Eligible for flexible training?BMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7108.2 (Published 06 September 1997) Cite this as: BMJ 1997;315:S2-7108
- Ilfra Goldberg, associate dean for flexible training,
- John Maingay, research assistant
Part time training used to be for women with “domestic difficulties.” Now the individual wishing to train flexibly must have “well founded reasons.” Ilfra Goldberg and John Maingay discuss the evolution of eligibility criteria
The need for part time training and work opportunities for doctors unable to train on a full time basis was identified nearly 30 years ago.1 At that time it was noted that most of these doctors were women prevented from practising by domestic or other difficulties.
Developing part time opportunity
In 1979 opportunities for part time training were redefined by a Department of Health memorandum,2 reflecting the Equal Opportunities Act of 1974, the sharp increase in the total number of women doctors graduating, and the increased number of women in the workforce. The memorandum sought to ensure that the calibre of part time trainees was comparable to that of full time trainees and that the training posts they occupied had educational approval from the appropriate royal college. The training scheme was specifically for doctors and dentists “able to work only part-time because of domestic commitments, disability, or ill health.” Undertaking other paid work, medical or not, precluded doctors from training part time. Responsibility for assessing these criteria was sometimes assumed by the postgraduate dean and sometimes by the regional health authority. There was competition for part time opportunities; often insufficient staffing approvals were available, and also insufficient funding for many of the required posts. This meant that the eligibility criteria tended to be scrutinised more closely, with those deemed to be more in need being given preference over others. Arrangements varied considerably from region to region and this was reflected in the uptake of part time or flexible training opportunities across the country. Meeting the eligibil-ity criteria was the first step for trainees in a long drawn out bureaucratic process of establishing a training post.
In 1993 a further report was published by the NHS Management Executive, the report of the Joint Working Party on Flexible Training.3 “Part time” training became known as “flexible” training. During the 1980s various European directives concerning medical education were consolidated, culminating in the 1993 directive 93/16/EEC, whose purpose was to facilitate the free movement of doctors and the mutual recognition of their diplomas, certificates, and other formal qualifications. Article 25 of this directive permits part time specialist training “when training on a full time basis would not be practicable for well founded individual reasons.” This is a somewhat broader interpretation of eligibility than the previous British requirements. Specifically, it no longer excludes doctors who may wish to take other paid or unpaid work. It focuses instead on the high quality of the part time training and on the total duration of such training.
This support, and the devolution of decision making to regional postgraduate deaneries, have changed the way decisions are made. Decisions are influenced by a perceived need to avoid wasting the investment in doctors' training, and by a recognition of the potential shortage of NHS medical manpower.
Trends in eligibility
The records of all doctors accepted for flexible training in the Thames regions from 1993 to 1996 inclusive were reviewed. The numbers of new doctors each year entering flexible training were noted and the main reason for their being eligible for the scheme was categorised.
The records of 380 doctors seen in the flexible training office of the Thames regions between years 1993 and 1996 were examined. Eligibility for flexible training was one of the factors considered at each interview. The total numbers seen and beginning flexible training each year is shown in table 1. The broad categories of their reasons for wishing to continue their training on a flexible basis are illustrated, together with the numbers in each category.
The total number accepted on to the flexible training scheme has increased in each of the four years under review, although the rate of increase was smaller in the last year.
Since the introduction of part time training in 1969 eli-gibility for this pattern of training was regarded as a controlling mechanism. The prevailing view then was that if flexible training was too readily available there would be floods of applicants waiting to take it up. A more recent view is that medical training is already long and that no one without a very good reason would wish to double the length of training at half the rate of pay. The criteria by which doctors may be considered eligible for flexible training are not necessarily the same as the reasons they have for wanting this pattern of training, and there may indeed be more than one reason influencing the decision to seek flexible training.
Adapting training to trainees' needs
The introduction of the specialist registrar grade emphasises the needs of trainees and the importance of adapting training programmes to needs rather than forcing the training to be subservient to service needs. This approach has always been the case with flexible training programmes and has been their great strength. However, because the programmes differed from full time training in this respect, the trainees and their training tended to be marginalised. Now, both full time and intending flexible trainees are assessed equally by an appointments committee and only after the appointment to the grade does the trainee indicate their preferred pattern of training.4 There is pressure to focus on the calibre of the trainees and the quality of the training programmes. (Eligibility will need to be considered according to the EC directives but will also be part of overall advice and career planning.)
The Thames regions account for about a third of all full time trainees, and about one fifth of the total of flexible trainees in England and Wales. There has been a progressive increase over the 4 year review in the number of flexible opportunities implemented. All hospital trusts and all major specialties in the Thames regions have had responsibility for flexible trainees and understand the scheme and the issues involved.
Policy for eligibility criteria
The Thames regions have produced a policy paper on eligibility for flexible training, where the various criteria are categorised. All the doctors in the different categories are eligible for flexible training, but they are grouped according to priority for funding. Doctors with domestic commitments and disabilities would be regarded as high priority. Have doctors been refused flex-ible training on the grounds that they are not eligible?
In the first year of our survey, the decision over eligibility rested with the Department of Health, although the scheme was managed by the postgraduate deans' offices. Two doctors, regarded as eligible by the postgraduate dean, were refused flexible training by the department: one who had wanted to do a part time fine arts course, and the other whose husband was in the army and was therefore subject to frequent moves. She appealed, her appeal was allowed, and she successfully took up a flexible senior registrar post.
In the past three years the decision over eligibility has been vested in the postgraduate dean. Four doctors who applied for flexible training and were regarded as eligible were asked to reconsider their plans and to take further advice as their reasons did not make good sense in the context of their career intentions.
A further group of doctors, although complying with eli-gibility criteria, were not able to proceed with training because the appointments committee did not regard them as competitive applicants in their intended grade and specialty.
Funding restriction and staffing controls affect all aspects of medical training and should not be confused with eligibility requirements. Funding for flex-ible training in the Thames regions has been sufficient to respond to the demand, although occasionally doctors have had to wait a few months for their posts to be established, and many would like to train for more sessions each week than we can currently allow.
The interpretation by departments of postgraduate medicine as to what constitutes a “well founded individual reason” is being interpreted more broadly. This is occurring as a result of increased awareness of flexible training opportunities by junior doctors and therefore increasing demand, and the recognition of the need to use the trained staff within the NHS effectively and efficiently. The emphasis is on candidates meeting the entry criteria for the various training grades rather than on eligibility being used as a barrier to flex-ible training. The implications of a doctor's decision to train flex-ibly are considerable, and these should be discussed as part of career advice and planning.