Assignment II: Modernising Medical Careers: A Human Resource Management

Perspective

Sadia M. Rajput

Submitted for deadline 8th March 2015

A report submitted in fulfilment of the requirements for Course MBAN-690DE, Masters of

Business Administration in Management, University of Nicosia-online.

An overall view of MMC’s HRM strategy and practices.

Modernising Medical Careers (MMC) is an online based programme set up to assist

postgraduate medical students find placements in hospitals for their medical training before

becoming specialised medical professional and practitioners. It is based on “seven pillars” to

enhance the medical care delivered to patients by providing doctors with necessary skills. The

new training system was intended to be “trainee-centred; competency assessed; service-based;

quality-assured; flexible; coached; and structured and streamlined” (DHET, 2004: 2-3). This

essay will draw on the article published by the DHET MMC: the next step in order to ascertain

the Human Resource Management (HRM) strategy and practices.

The medical training framework was intended to resolve outstanding issues with the medical

education in the UK and to support the medical work force. Some of these challenges were

arguably caused by the new deal and work time derivative set up many years prior and more

specifically to resolve the issue of the “lost tribe” of Senior House Officer (SHO) grade

(Executive, 2002). The SHO grade consists of postgraduate medical students who are

undergoing training in a specific area of specialisation in medicine under the supervision of an

existing consultant or registrar (Executive, 2002). This type of training was similar to an

apprenticeship that lasted at least two years if not more. The SHO grade were coined the “lost

tribe” prior to the reform because some doctors that did not specialise in fields recognised by

the Deanery, remain unaccounted for in the medical work force and others never moved out of

the SHO grade into any particular specialities (Executive, 2002).

Diliner (1993) has argued that this grade has the largest number of doctors however, there is

no distinct role that they play in hospitals as it is unclear what skills they have. With the

introduction of the work time derivative, a regulation on the working hours and training hours

of junior doctors, it became hard to ignore that there was a problem that needed to be resolved

within this grade (Diliner, 1993: 1550).

In light of this MMC was meant to reform specific aspects of the SHO as argued by the Scottish

Executive (2002). These were; the poor job structure of the SHO. The reason the SHO job

structure was poor was due to the fact that not all SHO’s are part of a training programme and

if they are, they have short term appointments (Executive, 2002: 4). Secondly, the training is

poorly defined. There are no clear objectives and thus no clear career path for SHO’s

(Executive, 2002: 4). Thirdly, the way junior doctors are selected and recruited is not done in

a standardised manner. The procedures do not establish whether a candidate possesses adequate

skills. As a result, most SHOs are overworked, are not given structured career advice or

appraisal and assessment (Executive, 2002: 4). Finally it can be argued that their training may

not be relevant to the Royal College examinations which are sat for after their training

(Executive, 2002: 4). Therefore, doctors in the SHO grade do not meet a satisfactory level of

competency necessary to deliver world class health care to patients.

Three HRM strategies can be identified within MMC and these are the revamping of the;

recruitment, selection and training processes. These strategies were restructured to address the

issues outlined in the paragraph above. This section will describe how each

strategy was carried. To begin with, the training structure was revised as follows.

Firstly, the previous pre-registration house officer (PRHO) grade after medical school and the

first year of SHO will be combined and compulsory for all post graduate students and will be

called the foundation programme (Executive, 2002: 5). The aim of this foundation programme

is to augment skills such as “team-working, communication, ability to produce high standards

of clinical governance and patient safety, expertise in accessing, appraising and using evidence

as well as time management skills” (Executive, 2002: 5).

Thereafter, doctors can enter into the second band of trainees, which is a broad, time specific

basic specialist training in one of eight areas. There are two options available for doctors here.

Doctors wishing to pursue general practitioner posts will carry out their specialised training for

three years and those who wish to become consultants will train in specialisation for six years

(Executive, 2002: 5). Unlike the previous SHO training, there will be individual programmes

available to junior doctors who feel that they need specific training in a different area other

than the eight broad areas of medicine (Executive, 2002: 5). Therefore, this reform would be

suitable to meet the needs of more doctors.

Additionally, there are five principles that govern the training strategy to ensure that the reform

achieves the objective of improving training and the quality of health care. The training should

begin with all postgraduate medical students and will firstly be based on a programme, tailored

as per the needs of a trainee, carried out within a specific time frame and finally, it should be

flexible enough to allow junior doctors to take a research or career break and resume training

when necessary. This concludes the training strategy and practices.

This next section will outline the recruitment and selection strategy and practices carried out

by MMC. The new strategy was to have postgraduate medical deans responsible for the

programmes with regards to training support, placement and appointment of junior doctors.

The recruitment and selection process of junior doctors was implemented by Medical Training

Application Service (MTAS). The system was designed to centrally receive and process

applications from doctors around the United Kingdom in the most efficient way possible

(House of Commons, 2007).

The selection process was based on an online application submission of 150 word responses to

a series of questions. All applicants were allowed to make four separate applications through

the online portal. The answers that the junior doctors wrote were then allocated score points in

order to shortlist candidates for the interview. The score points would indicate to the

consultants whether the candidate had qualities, attributes and attitudes they were looking for

to fill the posts (House of Commons, 2007).

Thereafter, shortlisted candidates would be interviewed by answering a series of questions that

were marked according to a rubric. The point of the interview was to assess whether the

applicant acquired specific traits. All successful applicants were then taken through a second

round of interviews before being accepted, confirmed and placed for training with a specific

hospital, depending on their speciality (House of Commons, 2007).

In conclusion, this essay has provided an outline of MMC HRM strategy and practices as set

out by the NHS and the Department of health. Three HRM strategies namely recruitment,

selection and training have been described.

Factors that may have contributed to the failure of MMC

In order to decide which factors affected MMC from being successful, this essay will draw on

the conclusions of stakeholders who were directly affected by the implementation of MMC.

The main stakeholders are the “trainee doctors, workforce planners, NHS employers, the

government, and patients” (Maddon and Maddon, 2007: 426). The reason there is an uproar of

failures is because impact of the failure of MMC to one stakeholder such as the junior doctors

has had a compounding rippling consequence to the other.

Maddon and Maddon (2007) argue that MMC has failed because it seems to have evolved into

something that stakeholders feel does not address the issues it was set out to resolve. It should

be noted that different stakeholders were affected by different factors. With regards to the

junior doctors, MMC failed to satisfy the “five principles” for reform. For example, one of the

principles that MMC failed to satisfy was a broad programme that is flexible. In addition, once

MMC kicked off the notion of a tailored program to suit an individual’s preference was

abandoned (Maddon and Maddon, 2007: 428).

The second aspect that MMC failed at was that it did not efficiently restructure the programme

so that it was producing consultants and general practitioners any faster that the old system. In

fact, they MMC was directly resolving the issue of having a large pool of SHO grade doctors

but the consequence of this meant that hospitals has fewer flexible doctors (Maddon and

Maddon, 2007: 428). With the additional pressure of the work time derivative (WTD) this

results in poor workforce planning.

Maddon and Maddon (2007) further argue that the effects on patients will not be favourable as

the doctors have less experience that previously trained doctors and this is a challenge as

patients’ needs are becoming more complex. However, there is no evidence to suggest how

significant this factor is as the difference in training between the previous consultants and is

between 1-2 years. This coupled with the advancement in technology and research available to

the doctors may cushion the extent to which this is a factor that caused MMC to fail.

An alternative perspective would be to look at the recruitment and selection carried out by

MTAS in conjunction with the security breach of the IT system which heightened the tension.

In addition to this, the organisation structure of MMC could be likened to a cobweb and the

move to allow foreign doctors to compete for a training place. These perspective have been

outline by the House of Commons (HC) over three volumes and will be discussed in detail

below.

According to a review by the HC in 2007, the fundamental triggers that led to MMC crisis was

the overall failure of the MTAS national recruitment system. They outline the combination of

the most significant failings as the shortlisting process, excess eligible applicants, design flaws

in the MTAS and MMC (House of Commons, 2007: 43). It can be argued that the shortlisting

process was designed to function as follows. Applicants had to submit their applications on a

web portal and wait to get called in for an interview, if they passed the first round, they would

be shortlisted and called in for a second round of interviews (House of Commons, 2007: 443-

44). However, due to poor MTAS design and lack of sufficient training given to consultants

and not enough time before going live, the selection process was disorganised and led to

devastating consequences.

The outcome was that it was difficult to assess a candidates competencies based on what they

had submitted on their application because there was no CV to verify their achievements

(House of Commons, 2007: 43-45). In addition to this, the scoring method for competencies

was flawed because for one, candidates of different levels of training were scored with the

same methodology and secondly, points were awarded to short answers rather than

qualifications (House of Commons, 2007: 43-45). Furthermore, there was a general weakness

in the IT system which consisted of not being able to cope with the demand as it would crash

often and finally there was a security breach on the website which immediately stripped MTAS

of any credibility (House of Commons, 2007: 43-45).

Moreover, Bach (2001) would argue that the scope of the HRM for MMC was too narrow only

focusing on workforce planning and the training. He argues that the role of HRM should be

widened and should include the external fit and internal fit i.e. alignment of MMC’s objectives

and the correct allocation of resources to ensure that the most effective outcome of the reform

is achieved (Bach, 2001). Since healthcare reform is driven by political and economic motives

and is aimed at solving macroeconomic issues and it is evident that the department of health

does not have the necessary skills or capacity to manage people, the implications on healthcare

reform is brittle (Bach. 2001: 2). Therefore it could be the lack of scope of the HR function that

caused MMC to fail.

Finally, the last perspective that will be assessed is the overall governance structure that had

multiple stakeholders and committees to review different aspects of the reform. This structure

was very complicated and disorganised. There were different boards and groups appointed to

handle different aspects of the reform, each with its own mandate. Most groups or individuals

reported to MMC strategy group who should have been accountable for the decisions made for

the reform, yet when the House of Commons did a review, no one was willing to take

ownership. Furthermore, there were a number of senior resignation on MMC side of the table

when the crisis broke out. This indicates that there is poor governance and this without a doubt

was the first sign of trouble for MMC (House of Commons, 2007). Below is a diagram to

illustrate the structures put in place.

Figure 1: (House of Commons, 2007: 7) illustrates all the groups associated with MMC

In conclusion this essay has demonstrated that there are several perspectives to argue which

factors caused the MMC crisis in 2007. It can be assessed from the point of view of the main

stakeholders, the governance structure and even the HRM strategy scope and practices set in

place to recruit doctors into the SHO grade. It must be stressed that it is a culmination of all

these factors to varying degrees that caused MMC crisis and not just one of them in isolation.

A recommendation of HRM strategies for MMC

This essay will recommend four HRM strategies for MMC given its complex structure and

how crucial it is to implement them in a timely manner so as to not interrupt the careers of

young doctors. The aim is strategically implement these practices in order to ensure the

objectives are met and that there is outperformance in the medical industry in terms of efficient

competent doctors and high standards of health care provision in the UK.

Before implementing any HR strategy, the first and vital step should be to increase the HR

capability so that the reform can achieve the objectives that it set out such as the “five

principles”. The reason this is crucial according to Bach (2001) is that, there is a knowledge

gap between what ought to be happening at a national level and what is actually happening in

practice. Once this gap can be narrowed then the correct HR structures can be put into place to

ensure that the reform is effective.

Secondly, it is likely that the Department of Health does not have the HR expertise and should

therefore consider outsourcing this role to HR professionals who will act as a strategic partner

to guide and recommend effective practices that will help the increase the effectiveness of the

reform. Armstrong (2006) points out that a HR partner is a long term investment as it is likely

that the organisations performance will improve if there is an alignment between HR practises

and MMC objectives.

The first and most important HRM strategy would be to create a workforce plan. Knowing how

many doctors are currently required and how many will be required in the future is essential in

order to carry out a reform. This involves knowing how many doctors at any one time will be

undergoing training and at what stage of the training they are in. Structures need to be put in

place once a clear vision has been depicted by the MMC strategy group. As outline by the

Royal College of Medicine (2011), they stress that workforce planning ensures that we know

what is required in terms of medical services for the next decade or more and what it will take

to become a doctor in a socialist field of medicine.

In order to carry out an effective workforce plan, there needs to be accurate data available of

what the trends over the past have been in order to project for the future. This will also have

implications on the finance side. It will help prepare budgets in order to allocate funds to assist

the growth and refinement through the reform.

Thereafter, the second HRM strategy recommendation would be that MMC has a strategic

recruitment and selection strategy because doctors are the agents that will deliver good health

care and their interests need to be catered for in a professional manner if that is going to be the

outcome. A recruitment and selection strategy is said to be strategic when it is aligned with the

overall objectives of MMC (Stewart and Brown, 2009).

As a result of investing in HR capabilities and relevant practices, it is inevitable that staff will

have to be trained on how to carry out certain functions with competency (Bach, 2001). In the

case of MMC since it is the deans and consultants carrying out the selection process, they will

need to know how to assess the candidate’s competency by implementing a standard in order

for the process to be unbiased and fair.

The third recommendation would be a strategy to manage the quality of patient care given. The

focus should be on the wellbeing of the patient and their needs. Armstrong (2006) would argue

that this is attainable by instilling the value of attaining high quality during the training of the

foundation programme. This is essential because ensuring that there is overall good patient care

is the responsibility of each individual junior doctor. If each doctor takes ownership of his, then

the job will be half done. There are multiple quality management strategies available and a

suitable one will depend on several factors such as the area of specialisation of the doctor and

will need to be tailored accordingly.

The final recommendation would be to ensure that the training programme is centred on the

junior doctors and their careers. This means involving them every step of the way and getting

feedback on what they think of the reform, the restructured training, conducting user

acceptance testing with a sample of junior doctors and deans before going live on I.T systems

for example. The underlying premise of strategic human resource management is that people

are the most valued asset (Armstrong. 2006: 3). This will also serve to motivate the junior

doctors. In order for doctors to deliver high quality patient care, their needs also need to be

catered for as the quality of care they deliver is directly related to their treatment (Bach, 2001).

Therefore, the HRM recommendations offered to MMC have been focused on firstly ensuring

that there is a workforce plan, having a strategic recruitment and selection plan, delivering

quality patient care, and addressing the doctor’s needs because they are the individuals that will

provide the health care services. However, before jumping the gun, it is imperative that MMC

has a functional HR partner that it recognises as a strategic partner to help achieve an effective

reform of the medical workforce.

HRM practices that are likely to improve the function and publicity of MMC

This section will outline three specific HRM practices that will help improve the way the MMC

is viewed and how effective it is in establishing a career path for doctors. It will draw on

recommendations made by several inquirers in light of MCCs crisis such as the Tooke (2008)

inquiry and the inquiry made by the House of Commons (2007). This is not to say that these

are the only practices that will help, but they will definitely make a significant impact.

The first structural adjustment will have to begin with the governance structure of the MMC.

As argued in the House of Commons (2007) report, it was established that one of the ways to

save the MMC’s disaster was to fix what the crux of the problem was. As mentioned earlier

about the governance structure being complex and lacking accountability, the house of

commons ruled that “the governance systems for MMC have been simplified and improved

and a single line of accountability established” (House of Commons, 2007: 125).

This simply meant that the organizational layout needed to be simplified which involves a

number of realigning and streamlining activities of the different organisations and boards

involved in the reform. Tooke (2008) recommends there is a need to revisit the initial concept

of reforming the medical profession and reconstructing the framework form the basic principles

underline in Unfinished Business. These changes would improve the function of the MMC to

the extent that channels of communication would be simplified and thus making decisions

would be less bureaucratic. In addition to this, it would be easier to track which board is in

charge of what decision making processes. Therefore, it is likely the publicity of the MMC is

likely to positively benefit if people have faith in the governance structure.

Secondary to the above, but the most significant factor are the doctors themselves and what

they want out of their medical careers. A lot of the reform was centralised around the different

stakeholders and their interests but what was most striking was that decisions about the

specialist training and a doctor’s career was never consulted with the actual doctors themselves.

The underlying premise of HRM is that people are an organisations most valuable asset

(Armstrong, 2006: 3). Therefore the doctors should be at the centre of the reform and they

should be engaged with matters concerning medical reform. After all, they are the ones who

will determine the extent to which MMC is a failure or a success.

To demonstrate the relevance of the above argument, this paper will draw on a survey

conducted by Allen (2008) at the University of Manchester that tried to establish the factors

that influence a medical student career choice. The results were simply that the MMC reform

had made career choice issues an important factor to look at. What they discovered was that.

The “views of undergraduates are important as they are trained to be doctors of the future”

(Allen, 2008: 166). Such findings are crucial because they highlight the fact the doctors will

determine or at least try to dictate the terms of their career and therefore the MMC should use

such information to reform the medical profession. This would have been useful had this

approach been implemented in the beginning however, a doctor’s medical career must continue

and hence the second recommendation entails involving the young doctors in reform decisions

for an effective outcome. In support of this view, they concluded that “continuing research and

exploring the needs and expectations of our future doctors are likely to be essential tools during

this period of uncertainty and transition in medical training” (Allen, 2008: 166). This is also

one of recommendation offered by Tooke (2008). It is therefore without a doubt that such an

approach can restore the publicity and functioning of the MMC.

Moreover, the third and final recommendation is to restructure workforce planning. This entails

understanding the capacity and capabilities of the current medical workforce and making

provisions for the future and also using information of the past trends in order to make informed

decisions about the future of workforce planning. The Tooke (2008) report gives a number of

ground-breaking recommendations that will be discussed in the section below.

The Tooke (2008) report highlights the fact that the MMC reform was never going to resolve

the current issues of the “lost tribe” with the framework it was operating under because it was

not based on a model of workforce supply that was relevant to the current situation and the

future requirements of the medical profession. A quick fix is not the solution to the

longstanding structural problems of the medical profession. The report therefore makes the

following recommendations.

Firstly, there should be a model of workforce planning and this can be derived by seeking the

assistance and expertise of universities, in particular health economist and epidemiologist

modellers for example and regular reviewing their projections in order to make informed

decisions (Tooke, 2008: 26). Furthermore, the MMC would have to publicly declare and the

eligibility of foreign students for the postgraduate training and use this supply of doctors to

compensate for the gaps rather than have this group compete against local doctors (Tooke,

2008: 25). Lastly, the Department of Health should invest in having a database of the existing

skills and certifications of all the doctors in different regions. This will be useful in determine

what specialities have less doctors and what needs to be done to increase those numbers but

more importantly to the medical students to make informed career decisions (Tooke, 2008: 26).

However, Wright and Haggerty (2005) in their research bring out an important argument that

needs to be taken into consideration. They argue that there are three variables: time, cause and

the individual need to be taken into consideration when evaluating the extent to which HRM

affects the organisations performance. More specifically the time lag between coming up with

a policy framework, implementing and then executing training will impact on how successful

the MMC is guaranteed to be. Thus, revisiting the reform is time sensitive and hence a

comprehensive plan needs to be made and executed within the stipulated time frame.

In conclusion this essay has demonstrated 3 possible recommendations for the restoration of

the publicity and functioning of the MMC. These recommendations are not the only options

available but merely a glance into the direction needed and it should be stressed that they are

to be taken in conjunction with one another and any other recommendation. The independent

inquiries done by Sir Tooke (2008) and the House of Commons (2007) to name a few have a

wealth of insight.

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