The System As It Used To Be
Since time immemorial, the first year postgraduate year was as a Pre-registration House Officer (PRHO), or more commonly known as a House Officer.
Having completed this year as a PRHO, trainees applied for jobs as Senior House Officers (SHO). Most SHO posts were 6 months long and people often spent many years as a SHO, undertaking a variety of SHO posts in a range of different specialties. During this time as a SHO, there was often a requirement to undertake some postgraduate exams.
When an individual had decided on a chosen specialty, the next step was to obtain a Registrar post. As individuals progressed through their training and drew towards the end, they usually undertook a Senior Registrar (SR) post. Both registrar and senior registrar training was not a fixed duration and frequently individuals spent many years as registrars and SRs prior to becoming a consultant.
Given concerns about the structure of registrar training, both in terms of its length and content, a new system was introduced between 1995 and 1997.
It was named after the former Chief Medical Officer, Kenneth Calman. The new Calman Specialist Registrar (SpR) training grade was created, with the aim of providing structured training programmes within a recommended curriculum for each specialty, and progression through training based upon annual assessments. The result of the introduction of the SpR grade was a considerable shortening of training in most specialties.
Modernising Medical Careers
Modernising Medical Careers (MMC) was introduced with the aim of improving the quality and structure of postgraduate medical training. Since its introduction, there has been widespread criticism of both the aims and its implementation. The aim was to ensure a transparent and efficient career path for doctors, particularly to modernise the SHO grade, where all too often, doctors spent many years without a clear educational or career pathway and no defined educational goals.
One of the many problems with the introduction of MMC is that it has created a vast number of acronyms, used to describe various training posts, often at similar levels of training.
This programme was introduced in August 2005 to cover the first 2 years following medical school. The first year of foundation training (FY1) replaced the former post of Pre- Registration House Officer (PRHO) and is directly equivalent to internship. The second year of foundation training (FY2) replaced the former first year of Senior House Officer (SHO) training and is equivalent to a resident in Australia. All medical graduates are now expected to undertake this 2 year programme, aiming to provide them with supervised, structured training in basic clinical skills and management of patients.
The specialty training programme replaced the former SHO and SpR posts, combining the two, in the form of the new Specialty Registrar grade (StR). The original aim of specialty training was to provide a continuous ‘run-through’ training programme from the Foundation years right through to consultant posts. Unfortunately, in most specialties this has not proved to be a reality.
The total length of specialty training varies between the specialty chosen, taking 3 years for GP training and up to 8 years for some surgical specialities. As a consequence the early years of speciality training, (ST1 & ST2) replace the former SHO grades, whilst higher years of training (ST3 upwards) are equivalent to former SpR posts.
To confuse matters further, sometimes ST1 & ST2 posts are not called this, but instead are called Core Medical Training (CT 1 and 2). Core Medical Training aims to provide a solid background in the chosen speciality prior to subspecialisation.
Conversely, if a trainee intends a career in an acute medical specialty, core medical training is undertaken with acute care common stem training (ACCS) programmes. ACCS is essentially ST1 & ST2 training in acute medical specialties. It is a 2 year programme with six months in acute medicine and six months in emergency medicine in year one, followed by experience of anaesthesia and intensive care medicine in year two. Therefore a trainee in the first year of ACCS training, namely doing acute medicine or emergency medicine, may be called an ACCS1 or an ACCS ST1.
At the end of all these acronyms and when all the necessary specialty training has been completed, the successful StR receives a Certificate of Completion of Training (CCT). It is this certificate that makes the doctor eligible for entry to the GMC’s Specialist Register and so to apply for consultant posts.
A complete description of postgraduate medical training is contained within the book ‘A Reference Guide for Postgraduate Specialty Training in the UK “(The “Gold Guide 2010”)
How the UK training grades equate with the Australian system
FY1 is directly equivalent to internship in Australia, whilst FY2 is equivalent to a resident. Given that most specialty training is 6 or 7 years, the early years of the programme, ST1 – ST3 would equate to Basic training in Australia. As highlighted above, the early years of ST training may also be known as CT1 – CT2 or ACCS. The final few years of specialty training in the UK, ST5 – ST7, are equivalent to Advanced training in Australia.
The Organisation of Specialty Training
In a system similar to Australia, each specialty has a college or faculty which dictates the syllabus of training and is responsible for the relevant postgraduate examinations. At a regional level, organisations called deaneries organise specialty training according to the guidelines and syllabi produced by the various colleges. Each deanery is responsible for the management and delivery of postgraduate medical education within its geographical area. Given that deaneries cover large geographical areas, each deanery will have overall responsibility of postgraduate education and training at a large number of hospitals within their region.
For example, there is a London Deanery, which manages training within London hospitals: http://www.londondeanery.ac.uk/.
Deaneries are essentially equivalent to Australian ‘training networks’.
Details of all the deaneries can be found via the MMC website: http://www.mmc.nhs.uk/colleges__deanery_recruitment/deaneries.aspx. This website has links to the individual deanery websites.
Recruitment to training posts occurs centrally, at either a national or regional level. Certain specialties, such as Obstetrics and Gynaecology and Paediatrics, organise their recruitment to specialty training programmes through their Royal College. Nevertheless, even though recruitment occurs at a national level, ongoing responsibility for the supervision and organisation of training will occur at a regional level via the local deanery. In most cases however, recruitment to training programmes does not occur at a national level and instead is organised by local deaneries.
Unfortunately postgraduate training in the UK remains in a state of flux and is liable to change in the future. The Postgraduate Medical Education Training Board (PMETB) was the regulatory body responsible for ensuring the standard of medical education were maintaining. To ensure maximal confusion, PMETB amalgamated with the General Medical Council (GMC), in 2010. Consequently, the GMC, the UK equivalent of the Australian Medical Council (AMC), is now responsible for ensuring the standards of postgraduate medical education and training within the NHS MMC system.
Whilst all training posts are managed at a regional level by the deanery, there are often several vacancies left within rotas at a local hospital level. There are frequently many of these jobs available, since, firstly there are ongoing problems with recruitment within specialty training programmes. Secondly, the European Working Time Directive (EWTD) has limited working hours to 48 hours per week, meaning that many rotas have been recently redesigned, requiring more trainees for each rota. All posts that are not within formal specialty training programmes, which, as described above are recruited at a national or deanery level, are considered to be non-training posts. The ‘non-training’ does not in any way reflect the day to day workings of the job or the training you will receive whilst in post, simply that the post is not part of a formal specialty training programme, overseen by the deanery. During normal working practice, it is impossible to distinguish a training from non- training post within a particular job role or department. Non-training posts exist at most, if not all, UK hospitals, including major teaching hospitals, simply as a reflection of vacancies on the rotas.
Such posts are broadly entitled ‘Specialty doctor’ posts. If a UK based doctor is unsuccessful in obtaining a post within the specialty training programme of their choice, they may opt for a non-training post. Furthermore, such posts potentially provide a short-term, often 6 month, introduction to a particular post or specialty, prior to an application to formal specialty training programme. Non-training posts will be particularly attractive to overseas trainees, who may be prevented from applying for training posts within specialty training programmes due to restrictions placed upon their visa. As is discussed in ‘Advice on Finding a UK ICM Job’, it is entirely feasible to have a UK ‘non-training’ post prospectively accredited for training, by the Australian Colleges.
Of particular note, instead of applying centrally, at a national or deanery level, as for specialty training posts, non-training posts are advertised and recruited by individual hospitals or trusts. Within job adverts, non-training posts are variously called Clinical Fellow, Trust Doctor, LAS (Locum Appointment to Service) doctors. Usually the advert will contain a description of the seniority of the vacant position, often in relation to training posts, for example ‘Trust Doctor, ST2 level’.