A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 


In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.


Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 


You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 


I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.


The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).


So what is the use of MTI posts? 


The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.


If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.

©M HEMADRI

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Yo BAPIO - What is that Moral Victory thing?

This article was first published in Sushruta Vol 7 Issue 1 by BAPIO

It is now very well known that BAPIO filed for a judicial review of the MRCGP examination, especially with regards to the CSA component; well there is no point beating about the bush, BAPIO lost the case.

That means that the MRCGP was ruled to be a fair examination, by indirect inference it may be assumed that other examinations were also likely to be fair. BAPIO members, BME doctors, IMGs can be reassured that things are rosy and live in joy. I was just about to do that when I found that Prof Rajan Madhok, Chairman, BAPIO tweeted ‘JR judge says: moral success but not legal victory! So our laws go against our morals? Crazy’ It is true. The judge said BAPIO had a moral victory.

So what is that moral victory thing? It is just a judge being polite?

Pause. Reflect.

To understand this, we have to go back to 7 June 1893. One Mr MK Gandhi who had a first-class ticket and was travelling in a first-class rail compartment was thrown off the train. He had a legal right to be on that train but he still lost his seat in the train; Gandhiji had a moral victory. The rest was history and what a history it was.

The judicial review has set off a number of changes which we are beginning to hear about. The GMC is now considering seriously introducing a common licensing examination for UK graduates and IMGs (similar the concept of USMLE). The GMC is introducing English language competency tests for EU doctors (where there is cause for concern). The time allowed for the AKT MCQ examination of the MRCGP is being increased. There could be changes to the way CSA is conducted and assessed. There are numerous other changes and many Royal Colleges and medical educational establishments are engaging with BAPIO and its partners.

The RCGP and GMC activities considered in the Judicial Review were ruled legal. Yet they and other institutions are making changes that further cause of equality. BAPIO contends that these changes would not have happened at this juncture and at this pace, without the Judicial Review? Are we beginning to understand the concept of a legal loss and a moral victory?

By the way, Gandhiji protested and was allowed to travel the next day by first class. In the continuation of the same journey he was beaten by a driver, banned from hotels and subjected to other forms of abuse.

BAPIO should be under no illusion that things are or soon will be rosy. The path is strewn with thorns and BAPIO should be prepared for its skin to be pricked in this journey. What does BAPIO want? BAPIO wants, what you have always wanted. A level playing field, no bias, high standards, fair assessment and equal opportunity to progress.

Here are some suggestions on the specifics that BAPIO should be asking for

1) Real patients rather than role players

2) Increased number of BME/IMG examiners

3) Two examiners on each station

4) Video recording of the session.

5) Improved training of the candidates.

6) Improved training of the trainers and holding to account of trainers with poor record of success of their trainees.

7) Feedback and mentoring for those who fail

8) Removal of hawk examiners/trainers (especially those who have negative impact on BME/IMG doctors)

9) Removal of dove examiners/trainers (especially those who have a negative impact on BME/IMG doctors)

10) Testing and continued monitoring of sub-conscious bias in examiners/trainers.

11) Examiners with extreme bias not to be selected, examiners with non-extreme bias to be provided training followed by monitoring.

12) Pass-fail threshold and other standard setting (such as ARCP/RITA progress) should be tested for impact on various populations with protected characteristics and where there is no evidence of impact on patient outcomes the thresholds should be adjusted to reduce any possible negative impact on doctors with protected characteristics.

13) Objective assessments/examinations for summative, pass-fail, high-stakes situations/examinations/assessments (with any subjective assessments reserved for formative processes)

There are many more ideas that will benefit the system.

If BAPIO decides to ask for these and more, you can be assured BAPIO will be vilified and denounced. The hope is, after the abuse is done, the changes would happen, even if they were slow.

A couple of thousand of years before Gandhi, we hear of one Jesus Christ, who lost a legal case and was crucified; he seemed to have won the moral case quite convincingly. Time will tell, but BAPIO’s moral victory may turn out to be a very strong force for change.

M HEMADRI

 

Revalidation - GMC must make it objective as soon as possible

The shortest overview of revalidation

GMC is commencing the process of revalidation for doctors in December 2012. The revalidation demands that we have evidence of 

1) Continuing professional development

2) Quality Improvement Activity

3) Significant events

4) Feedback from colleagues

5) Feedback from patients

6) Review of complaints and compliments

These six will populate the annual appraisal which apart from its main domains include the personal development plan, probity and health

Based on the above, the responsible officer will make a 'judgement' on whether the doctor can be recommended for revalidation. The GMC will then make a decision on whether the doctor has been successfully revalidated.

There is plenty of guidance on GMC website : http://www.gmc-uk.org/doctors/revalidation.asp

Concerns about the background for revalidation

While the issue of periodic quality assurance of licensed doctors has been discussed for a long time, the common view is that the current revalidation efforts commenced after the Bristol enquiry and gathered momentum after the Shipman enquiry. Bristol was an outlier, there was no trend that many hospitals or many cardiac surgery units were having unacceptably bad outcomes. Shipman was an outlier, there was no trend that many doctors were behaving or beginning to behave in a Shipman like manner. Outliers need to be analysed properly so that outliers can be stabilised to a performance level compatible with other performers within the general system. Quality principles would suggest that outliers should not trigger a process change for the whole system. Process change for a system could be triggered by an unacceptable trend (there are other reasons to change the process as well, but outlier is generally not one of them). To create a process change on the basis of outliers is thought to result in unnecessary expense and wasted effort.

This does not mean that we cannot learn from outliers, undoubtedly there are extraordinarily important lessons to be learned from Bristol and Shipman.

Linking the background to current revalidation method

Bristol is about performance and Shipman is about behaviour. We can safely assume that this is what the GMC seeks to assure. Quality assurance needs to be demonstrated in an objectively measureable manner.

Revalidation criteria - Not Objective

The six areas of evidence that the GMC asks for seem to be mostly subjective.

Continuous professional development (CPD) is generally accepted as a reflection of time spent on courses and conferences or other learning opportunities. It is certainly not a measure of the knowledge or skills gained or updated though that might happen. Some professional bodies have not defined the time needed to be spent on CPD. Hence while CPD is often measured and entered as a number it is a measure of time spent rather than a number to show the knowledge or skills gained. It could therefore be argued that CPD is either subjective or fit for purpose for revalidation if the intention was to validate or assure knowledge and/or skills.

Quality Improvement Activity: within this areas a range of activity is included. Activity is neither outcome nor achievement. Therefore activity is again time spent rather than gains (or losses) measured. An important point in quality improvement activity is that people fail more often than they succeed, that is the nature of quality improvement. Doctors, hospitals and the GMC should be comfortable with that. This could be potentially be an objective criteria but currently it could probably be considered unsure.

Learning from significant events and review of complaints and compliments are about self-reflection and reflective writing. It is obviously subjective. Feedback from colleagues and feedback from patients though done through validated tools by external or independent service providers is essentially the conversion of subjectivity into a scale to be able to measure.

Are subjective criteria relevant?

Absolutely yes. But only when looked along with objective criteria. Any form of quality assurance process must include subjectivity. The current criteria for revalidation seems mostly subjective and hence the concerns.

Why are objective criteria important?

We are talking about doctors who are essentially already very highly qualified and doing an extremely complex job under phenomenally varying conditions. We are taking about professionals on whom we have already spent somewhere between half-a-million to a million pounds before they are employed to do their role. Revalidation is about making a decision about their careers which could potentially be halted. To make such major decisions on mostly subjective criteria would not make sense. Further, there are planet loads of data already gathered and analysed and hence objective criteria are possibly already available if we wanted to use them.

Next is the issue of who may potentially be adversely affected to a higher degree than most. When subjective criteria are used there is a risk that often the weak, the easy targets and usual suspects may be affected. This has been seen in a few exam situations where certain sections of candidates pass the objective knowledge and skill components but fail the subjective elements of vivas, communication, simulation etc. There is a fear that it is possible that IMGs and BMEs (and SAS) doctors  would be affected by the level of subjectivity involved in revalidation.

There are good reasons behind these fears which relate to the culture and history of healthcare institutions and the culture and mind-set of BME/IMG doctors which is not explored here.

Increasing objectivity

Testing knowledge has traditionally been done by examinations. Americans revalidate their doctors on the basis of an objective examination of knowledge. This while reducing bias increases the validity of assurance of knowledge. Skills assessment could quite relevantly be based on performance data. Speaking from a hospital doctor perspective, this should be quite easy to do with some minimal tweaking on how data is gathered. Operational performance data is either the best or as good as any other indicator of a doctors skill.

Increasing objectivity still would not resolve the underlying issue of a process change for all doctors based on outliers and not trends. The GMC also needs to resolve other issues. Is revalidation a quality assurance process or a quality improvement process? Because the theory and the tools for assurance are different from improvement

Revalidation is important. It is likely that as it stands the revalidation process is heavily subjective. Given the importance of healthcare of the nation it would be advisable to quickly move to mainly objective criteria. We are where we are, let us make it better and fit for purpose.

©M HEMADRI 

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