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RESEARCH: Kostas Mavromaras and Anthony Scott Promotion to hospital consultant: regression analysis using NHS administrative data BMJ 2006; 332: 148-151 [Abstract] [Full text]

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Worrying low levels of promotion to hospital consultant.

Mokhtar G E K N Isaac   (3 December 2005)

Only part of the story

J. Alastair Lack   (23 January 2006)

Overseas Graduates' UK qualification removed from GMC record

P K Tun   (23 January 2006)

Unfairness in Promotion to hospital consultant

Bhupinder Sandhu   (26 January 2006)

Outcomes Flexible Careers Scheme

S F Gray, Helen Goodyear, Jo Jones   (29 January 2006)

Promotion process for consultants needs examining

AJ Lindford, Amit Pabari, Phil Gilbert   (29 January 2006)

Re: Unfairness in Promotion to hospital consultant

Alastair Lack   (1 February 2006)

Outcomes of Flexible Careers Scheme

SF Gray, Helen Goodyear, Jo Jones   (4 February 2006)

Worrying low levels of promotion to hospital consultant. 3 December 2005
Mokhtar G E K N Isaac, Specialist Registrar Old Age andGeneral Adult Psychiatry East Sussex County Healthcare, eastbourne DGH, BN21 2UD Send response to journal: Re: Worrying low levels of promotion to hospital consultant.	Editor, I read with great interest this paper “Promotion to hospital consultant: regression analysis using NHS administrative data” by Mavromaras and Scott, being a final year specialist registrar myself. I have noticed with some worry that the percentages of promotion to consultant level per year were generally low (9.9% to 15.5%). Over the whole period (1993-2000), which is enough to finish most of higher training with exception of part timers, there were 32% promoted. These figures are worrying giving the fact that there has been a shortage in consultants in the UK according to the governments. I think there are some factors which might have affected the results of this study including: 1. The study looked at all registrars, senior registrars and specialist registrars, many of them would be still in training and not eligible for promotion to consultant level. It would have been more valid to review only doctors who have finished training and find out what percentage go on to be promoted to a consultant level. 2. Some of the doctors, particularly those who was graduated outside Scotland might have been promoted outside Scotland and not been accounted for in the study. 3. Women doctors are more likely to do part-time training and this might explain the lower percentage for their promotion. It would have been more valid if the study did sub-analysis for women who works full time compared with men who work full time. 4. The study looked only at Scotland and the results could not be generalized to the rest of the UK. The introduction of the new changes with MMC (Modernising Medical Career) and the new PMETB (postgraduate Medical Education and Training Board) will have an impact on the future levels of promotion. It would be of great interest to conduct a qualitative study looking at opinions, feelings and views of doctors in training about their future plans and promotion to a consultant level. Mavromaras k and Scott A. Promotion to hospital consultant: regression analysis using NHS administrative data. BMJ 2005; 0: bmj.38628.738935.3Av1 Competing interests: None declared
Only part of the story 23 January 2006
J. Alastair Lack, Retired SP54LX Send response to journal: Re: Only part of the story	There are several curious features about this paper from Melbourne about promotion in the Scottish NHS. It is not clear whether the authors understand the difference between 'promotion' - which they seem to think of here as in the armed services - moving up from Captain to Major, and appointment to a consultant post - as in applying in response to an advertisement for an appointment and obtaining it in open competition. Nor was it clear whether the authors understood that trainees are normally only eligible for appointment to a consultant post in their last year of a long training period. No figures for the changing proportions are given for different years in training. They also fall into the same trap as the paper they quote on distinction awards from Sir Netar Mallick and Elizabeth Vallance - they assume that all applicant groups in the eligible pool have the same proportions as the general population. They did not, for example, check to see whether the same percentage of females as males in training applied for consultant posts. Some specialties are naturally more attractive to different groups; orthopaedic surgery for example seems to attract fewer applicants for training posts who are female than anaesthesia. Do the authors propose some sort of allocation such that all groups are equally represented? The whole paper would have been much more convincing if it had been based upon the demographics of candidates applying for consultant posts, rather than the data about the whole training labour force which the authors appear to have used. Competing interests: None declared
Overseas Graduates' UK qualification removed from GMC record 23 January 2006
P K Tun, Associate Specialist Royal Berkshire Hospital, Reading, RG1 5AN Send response to journal: Re: Overseas Graduates' UK qualification removed from GMC record	I am not surprised that Overseas Graduates have less chance of promotion to Consultant Posts on Scotland in this study because all the postgraduate UK qualifications(MRCP,FRCS,MRCOG etc) have been removed from GMC records around the time of Calmanisation. Only the primary degree MBBS with the year and name of the country are mentioned in the GMC records and certificates now. There must be a reason without any clear answers. Competing interests: None declared
Unfairness in Promotion to hospital consultant 26 January 2006
Bhupinder Sandhu, President MWF Royal Hospital for Children,Bristol.BS2 8BJ Send response to journal: Re: Unfairness in Promotion to hospital consultant	Dear Editor Members of the Medical Women’s Federation (MWF) will have read with interest the paper on ‘Promotion to hospital consultant: regression analysis using NHS administrative data’ which concludes that ‘Women are less likely to get promoted than men, even after experience, part time working, and other factors are controlled for. The authors found no explanation or justification why sex on its own should matter’ The authors findings come as no surprise to us but nevertheless represent an appalling indictment of the profession in the first decade of the 21st century. The Medical Women’s Federation has confronted this issue for much of its existence and this research merely reinforces the need for the MWF to maintain its role. Although major improvements have taken place allowing women a fairer deal this study suggests that not enough has been done. We agree that further research is required into variations in the criteria for promotion to see whether there is discrimination in the promotion process. There has recently been debate in the House of Lords (led by Lord Turnberg and Baroness Finlay,a past president of MWF) and considerable publicity about the fall in the number of UK medical academics. Various initiatives are taking place to address this, and related issues, including The Department of Health’s ‘Best Research for Best Health’ proposals ,which are aimed at enhancing UK Medical Research and make it a more attractive career. It is disappointing to read in this BMJ paper that in Scotland only 5.9% of women had honorary contracts (ie .are in academic posts) compared to 9.6% men. Having an honorary contract for the 2 years before promotion is associated with a higher probability of promotion to a consultant for men but, surprisingly, not for women. This state of affairs is not going to encourage young female medical doctors to go into academic medicine and needs addressing with some urgency . It should no longer be acceptable that doctors who work part-time are less likely to be promoted. As the proportion of female doctors increases we recognise that it will be difficult to meet the needs of our patients unless the promotion process is re-examined. We fully accept that weight should be given to individual skills and ability but the contract should allow the achievement of these through increased flexibility of working conditions. Recent news that funding for flexible training, both for the hospital doctors and general practitioners, may be in jeopardy is extremely worrying. MWF has written to Lord Warner and we very much hope that the Department of Health will ensure that the funding is available and ear-marked for flexible training. We endorse the view that all those involved including the Department of Health, the Royal Colleges, the British Medical Association and the Medical Women’s Federation need to work together to ensure that factors unlikely to be related to ability or performance such as gender, place of graduation or part-time working will not influence the chances of promotion to consultant grade. Professor Bhupinder Sandhu MBBS.MD.FRCP.FRCPCH President Medical Women’s Federation on behalf of MWF Officers PS MWF is delighted that BMJ in its 165 year history has its first woman Editor. Congratulations to Dr.Fiona Godlee Competing interests: President MWF
Outcomes Flexible Careers Scheme 29 January 2006
S F Gray, Associate Postgraduate Dean Severn and Wessex Deanery, BS16 1LE, Helen Goodyear, Jo Jones Send response to journal: Re: Outcomes Flexible Careers Scheme	The Flexible Careers Scheme was launched by the Department of Health in England in 2002. The Hospital Scheme included a number of elements, including “pump-priming” funding for part time career grade posts and funding for six months whole time equivalent salary for those who had been out of medicine (a “returner”) package. For the first time there was a retainer package for those in training grades who were unable to work half time or more. NHS professionals stopped their involvement with the scheme on 31st December 2005 and the Flexible Careers Scheme is being now being devolved, possibly to Postgraduate deaneries or Strategic Health Authorities. The lack of clarity about funding arrangements mean that new applications are not currently being accepted, and the future of the Scheme is in jeopardy. We report on the experience in three deaneries of dealing with those returning to hospital medicine after a career break of two or more years. Between 1 Nov 2003 and 30 November 2005 in the Trent, South Western, and West Midlands Deaneries 18, 25, and 35 individuals respectively started on the scheme, a total of 78. A summary of the destination of those completing and leaving in this time is shown below (Table 1). The remainder are ongoing on the scheme. Table 1. Summary of destination of those leaving the hospital returner Flexible Careers Scheme in three deaneries. (Nov 2003- Nov 2005) Deanery Training GradePRHO/SHO GPVTS SpR/Consultant Non consultant career grade/trust grade Other/not known Total number completing in this time South Western 5 2 3 4 7 21 Trent 5 4 2 0 6 17 West Midlands 4 6 2 5 8 25 Total Number (%) 14 (22) 12(20) 7 (11) 9 (14) 21* (33) 63 (100) *includes 6 who left the deanery area prior to finishing the scheme The returner element of the Flexible Careers Scheme has been an effective way of helping those who have been out of medicine to return to practice. A short period of funded and closely supervised practise is invaluable in providing a route back to medicine. Some individuals in this scheme have tried other career paths in law or business, and a number have had their careers interrupted through illness, child bearing and/or moving to follow their partner’s career. This small audit demonstrates that a substantial proportion will go on to work within the NHS. It is inevitable that a there will be doctors who leave clinical medicine for a variety of reasons who will wish to return to practice and are capable of making a valuable contribution. In particular, as the number of women in the medical workforce increases, those taking short career breaks to have children or to follow their partner’s career will rise. Given the substantial investment required to fund individuals through medical training, the provision of a six-month attachment which allows individuals a route back to clinical practice is a highly cost- effective investment. It would be deeply regrettable if funding cannot be found to continue this valuable scheme. Competing interests: None declared
Promotion process for consultants needs examining 29 January 2006
AJ Lindford, SHO Plastic Surgery Queen Victoria Hospital, East Grinstead, Sussex, RH19 3DZ, Amit Pabari, Phil Gilbert Send response to journal: Re: Promotion process for consultants needs examining	Dear Sir, Mavromaras and Scott present a large amount of data relating to trainees in Scotland, and 'promotion' to consultant posts. Unfortunately all of this data, and the conclusions they draw from it are invalid because they have not considered how trainees actually become consultants; they are NOT promoted as outlined below. Between the years 1990 and 2000, to apply for a consultant vacancy, a trainee had to satisfy the Specialist Advisory Committee (SAC) that they had complied with the training regulations of their specific speciality and in some cases had also to pass an exit exam. Consultant vacancies are advertised, and those trainees who would like to fill the vacancy, apply for the post. If their training fulfils the regulations then thay are likely to be interviewed. In theory all interviewed candidates have an equal chance of being successful. To complete training, generally one had either to have completed 4 years as a Senior Registrar (although other training such as research or time abroad, could be taken into account) or 6 years as an SpR in Calman training (in some specialities, it is 5 years). If one is studying the fairness of the training scheme in relation to place of birth, place of training, length of training, gender etc. then what matters is firstly how trainees were selected for Senior Registrar or SpR posts, and secondly how consultants were selected from those who chose to apply for the post. Whether or not this would show any bias against particular groups of candidates we cannot say, but if it did then it would be relevant. Competing interests: None declared
Re: Unfairness in Promotion to hospital consultant 1 February 2006
Alastair Lack, Retired SP54LX Send response to journal: Re: Re: Unfairness in Promotion to hospital consultant	Dear Madam, The response from Professor Bhupinder Sandhu seems totally to ignore the apparent flaws pointed out both by myself and by Dr Lindford regarding this study. It would be very much in the interests of equity if the Medical Women’s Federation, who Professor Bhupinder Sandhu represents, performed a proper study which looked at the ambitions of women, men, british-born ethnic minorities and foreign-born ethnic minorities at each year of their progress through training, and how they were fulfilled or frustrated. The publication of apparently flawed studies like the one we are discussing does no favours to anyone, including the BMJ. A soundly based study would be invaluable. I think it very likely that it would yet again be rediscovered that as training progresses many women come to realise that the goal they thought they were pursuing when they started is not nearly as golden as they had imagined. That is the problem that needs sorting, not any unfairness of appointments committees. Competing interests: None declared
Outcomes of Flexible Careers Scheme 4 February 2006
SF Gray, Associate Postgraduate Dean Severn and Wessex Deanery, BS16 1LE, Helen Goodyear, Jo Jones Send response to journal: Re: Outcomes of Flexible Careers Scheme	The Flexible Careers Scheme was launched by the Department of Health in England in 2002. The Hospital Scheme included a number of elements, including “pump-priming” funding for part time career grade posts and funding for six months whole time equivalent salary for those who had been out of medicine (a “returner”) package. For the first time there was a retainer package for those in training grades who were unable to work half time or more. NHS professionals stopped their involvement with the scheme on 31st December 2005 and the Flexible Careers Scheme is being now being devolved, possibly to Postgraduate deaneries or Strategic Health Authorities. The lack of clarity about funding arrangements mean that new applications are not currently being accepted, and the future of the Scheme is in jeopardy. We report on the experience in three deaneries of dealing with those returning to hospital medicine after a career break of two or more years. Between 1 Nov 2003 and 30 November 2005 in the Trent, South Western, and West Midlands Deaneries 18, 25, and 35 individuals respectively started on the scheme, a total of 78.   A summary of the destination of those completing and leaving in this time is shown below (Table 1). The remainder are ongoing on the scheme.    Table 1.            Summary of destination of those leaving the hospital returner Flexible Careers Scheme in three deaneries. (Nov 2003- Nov 2005)   Deanery Training Grade PRHO/SHO   GPVTS     SpR/Consultant     Non consultant career grade/trust grade   Other/not known       Total number completing in this time South Western 5 2 3 4 7 21 Trent 5 4 2 0 6 17 West Midlands 4 6 2 5 8 25 Total Number (%) 14 (22) 12(20) 7 (11) 9 (14) 21* (33) 63 (100) *includes 6 who left the deanery area prior to finishing the scheme   The returner element of the Flexible Careers Scheme has been an effective way of helping those who have been out of medicine to return to practice. A short period of funded and closely supervised practise is invaluable in providing a route back to medicine. Some individuals in this scheme have tried other career paths in law or business, and a number have had their careers interrupted through illness, child bearing and/or moving to follow their partner’s career. This small audit demonstrates that a substantial proportion will go on to work within the NHS. It is inevitable that a there will be doctors who leave clinical medicine for a variety of reasons who will wish to return to practice and are capable of making a valuable contribution. In particular, as the number of women in the medical workforce increases, those taking short career breaks to have children or to follow their partner’s career will rise. Given the substantial investment required to fund individuals through medical training, the provision of a six-month attachment which allows individuals a route back to clinical practice is a highly cost-effective investment. It would be deeply regrettable if funding cannot be found to continue this valuable scheme.      Competing interests: None declared