Flexible training? What are the opportunities?BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7144.2 (Published 23 May 1998) Cite this as: BMJ 1998;316:S2-7144
- Barbara Clay, Associate dean (postgraduate studies)
Know your administrator. Associate postgraduate dean Barbara Clay is your guide through the regulations that govern flexible training
In 1995 the Junior Doctors Committee of the BMA ((1)) called for renegotiation of the framework for flexible training in the wake of the proposals for a unified training grade. While there was a target for 5% of doctors to undertake flexible training, there was an indication that 40% would like it. So what is the reality in 1998?
Since 1995 flexible training has achieved a much wider recognition, with more uniform opportunities throughout England and Wales. The Committee of Postgraduate Medical Deans (COPMED) has established a Flexible Training Working Group to advise it specifically about the issues. Opportunities are also available in both Northern Ireland and Scotland. With the Scottish deaneries now being represented as full members of COPMED, it is expected that there will be even greater uniformity of the administration of the scheme nationwide.
Provision for flexible training was started in 1969 with the HM(69)6 notice providing for part time training. This was specifically for women with domestic commitments, and, although some posts were established in Oxford through the hard work of Rosemary Rue, the scheme was little used in other regions. The PM(79)3 scheme was specifically directed at senior registrars, and regions remained able to set up flexible posts at other grades at their own discretion. Candidates had to show ‘well-founded personal reasons' for requesting a flexible training opportunity, and senior registrars had to enter a national competition to get manpower approval.
Funding was not always quickly available, and there was an average delay of 18 months between application and taking up a post.((2)) For other grades, implementation was patchy until EL(91)5 introduced a new scheme for career registrars. Manpower approvals and funding for the posts were provided centrally, and interviews carried out locally. This scheme increased the number of people training flexibly. Further administrative changes resulted in all funding for flexible training being the responsibility of postgraduate deans. No specific scheme was introduced for senior house officers, but deaneries were allowed to continue to provide for this grade locally. They were also allowed to provide for pre-registration house officer posts, although this grade seemed to have less need of the scheme, mainly due to doctors' ages at marriage or forming permanent relationships. The royal colleges agree that flexible training schemes must be available in all specialties, including general practice.
The next important change was the introduction of the unified training grade through ‘Calmanisation.' With the introduction of the specialist registrar grade, appointments for flexible training have been integrated within the appointments systems in each deanery so that there shall be seen to be equal criteria for appointment for full time and part time posts. For other grades deaneries have made local arrangements to ensure that appointments are seen to be fair.
The Flexible Training Working Group of COPMED comprises associate deans who have responsibility for administering the flexible training schemes in each deanery. Discussions within this group have identified common interpretations of the ‘well-founded personal reasons' necessary for a candidate to be eligible to join the scheme. It is arguable that any candidate who is prepared to work for half pay (or thereabouts) must have well founded personal reasons for wishing to join the scheme. Given that there is a limited budget for the scheme in all deaneries, eligibility may be easily agreed but funding may be more difficult in some deaneries, and these may have various criteria for assessing priorities in place.
Both men and women can apply. Candidates should be unable, for the well founded reasons, to work full time. The commonest reasons given are the care of young children or dependent relatives and ill health, but others are accepted-for example, an athlete of international standard needing to keep up a schedule of fitness training, or a former full time researcher wishing to return to clinical medicine and needing to update skills while completing outstanding research. The commonest health reason given is psychiatric illness, usually stress related. There are also cases of malignant disease, multiple sclerosis, chronic fatigue syndrome, and others. Criteria used in assessing priorities for funding will include such factors as the sudden onset of stress related illness making it inappropriate for the trainee to remain in full time employment and transfer from another region of a trainee already on the scheme in the original deanery in order to remain with his or her family.
It goes without saying that the training goal must be realistic. It is simply not practical to suggest that, on returning to training after a gap at the age of 36, flexible training could lead to a career in paediatric cardiac surgery when both national training places and consultant opportunities are limited.
How flexible is the scheme?
EC directive 75/636 requires that part time training shall be for a minimum of 50% of full time training or, in the case of general practice, 60%. Although most deans and college advisors would agree that the amount of actual training and learning acquired by a part time trainee exceeds these percentages in terms of experience, the directive insists on precise lengths of time in training being pro rata that of full time trainees in the discipline, including emergency or on call experience. There is also a requirement that training times be increased to account for any ‘interruption' in training. Thus, for specialist registrars, for example, the date of the certificate of completion of specialist training may be put back by a period of illness or maternity leave for both full time and part time trainees. However, the Specialist Training Authority has recently advised that an absence of up to three months may be allowed within the training period (Sir Leslie Turnberg, personal communication).
With these limitations, however, the scheme can be very flexible. It is possible for a trainee to take some unpaid leave in order to coincide with school holidays if this is negotiated with the deanery and educational supervisor in good time. Although part time trainees must undertake rotation of placements equivalent to that of full time trainees, efforts can be made to place trainees close to home. The programme must mirror that of the full time trainee but be appropriate to the training needs of the trainee, and the educational programme for an individual must be approved through the regional advisor, and in some cases by the College Education Committee.
National trend in uptake
As the table shows, there has been a steady increase in the overall provision of flexible training places in the past four years. While the number of specialist registrars seems to have steadied in the past two years, this is difficult to assess accurately as many psychiatry trainees, previously shown as registrars, are now included in the senior house officer grade. As to the proportion of all training posts, a recent survey by Professor C L Welsh of Sheffield deanery (who supplied the figures) showed that only 3.7% are flexible, including 6.9% of specialist registrar posts and 2.0% of senior house officer posts. These figures are disappointing although the proportion of flexible specialist registrar posts exceeds the old target of 5%. Most deaneries report waiting lists for flexible training: funding is the limiting factor, and there is also delay because of the need to negotiate with trusts for the payment of the additional duty hours component of part time trainees' salaries. Some trusts are now telling deans that they are unable to support further part time trainees.
How to apply
Once you think that you may wish to take up the flexible option, you should contact the responsible associate dean in your deanery at the earliest possible momentÑyour postgraduate clinical tutor or postgraduate education centre manager will know who this is and how to get in touch. You will be invited for a formal interview, where your eligibility will be assessed and the mechanism for arranging a suitable programme discussed. If you are a senior house officer this will usually involve you meeting the appropriate regional advisor and a suitable consultant who will become your educational supervisor.
If you have not previously held senior house officer posts you will usually have to attend a formal interview in the appropriate specialty: for example, prospective general practitioner trainees will submit their curriculum vitae and be interviewed at the next appointment committee for the local general practice vocational training scheme. If you are replying to an advertisement for your first specialist registrar post you will not be expected to discuss your intentions with anyone else at this stage. In reality, if you are already a senior house officer training flexibly, the regional adviser and others on the education committee in your deanery may well think that you are likely to continue to train flexibly. However, they are not allowed to make any assumptions and you must not be asked questions about your intentions at the interview.
Candidates are considered on exactly equal terms and ranked in order of merit. When you are offered an appointment, you then disclose your eligibility and wish to train flexibly. Provided you have discussed the situation with your associate dean it is most likely that funding has been allocated for you. If funding is not yet available for the date when you are due to take up your appointment you could retain your present contract until funding and a suitable training slot become available, or take up the post on a full time basis until the money for part time training arrives.