Access thebmj.com - The BMJ logo

We need to move towards a student-centred application process for foundation training

Close to 8000 final year medical students recently submitted their applications for their first employment as doctors in the National Health Service (NHS).1 The United Kingdom’s Foundation Programme Office’s (UKFPO) is responsible for administering and managing these applications through the online portal, Oriel.1,2 A series of technical and organisational oversights, compounded by what applicants perceive as inadequate and reactionary responses to issues,3 have resulted in some students feeling that the process is opaque, adversarial, and in some cases discriminatory, as well as lacking the rigour, candour, and fundamental commitment to equality that is central to their profession and the NHS.

The impact of recruitment practices on workplace culture, employee expectations, and workforce retention are well-documented.4 Crucially, recruitment marks the start of the ‘psychological contract’ students make with the NHS; mutual expectations which are developed in early employment that greatly impact on employee satisfaction.5,6 The impact of a breach in this psychological contract ranges from reduction of workplace citizenship behaviour to higher staff turnover (leaving the profession or moving abroad).6 These employer-employee relationships are being put under pressure by application processes that place undue stress upon applicants,7,8 and appear to lack clarity and openness. 

This year, Academic Foundation Programme (AFP) applicants experienced a series of errors on the Oriel webforms, including missing entry fields to document essential information relating to the hard-earned academic achievements which are used to shortlist applicants. Many students were required to duplicate their applications via email. Selection criteria were not advertised by all deaneries and some Academic Units of Applications (AUoA) even changed selection criteria after the application deadline.9 This lack of transparency created dilemmas for students regarding which achievements to declare, and where to submit their maximum of two applications.10 Furthermore, some students were required to provide specific documentation, such as evidence of previous degrees, which was unobtainable due to the covid-19 pandemic.2,11

As well as being time consuming, these hurdles were compounded by a lack of clarity from UKFPO and AUoAs. The UKFPO did not clarify the acceptability of documents prior to the application deadline,2 AUoAs did not accept appeals from students regarding credit for achievements,12 and they were criticised by students for not taking ownership and informing applicants of mistakes.13 These organisational problems were stressful for applicants and served to erode trust in the process from the outset.

The Situational Judgement Test (SJT) is a fundamental requirement of finalists’ employment process and is the greatest determinant on an applicant’s overall national ranking and allocated foundation post.2 Previously, UK students sat this at their institution, but this year they were required to sit the test at a Pearson Vue test centre, or at home via “proctoring”.14

Errors led to concerns from students that the process was discriminatory.15 Firstly, bookings becoming available twice in advance of the date and time advertised by the UKFPO,16,17 with the UKFPO later claiming they didn’t intend to advertise a time.18 Secondly, inequitable access to testing centres disadvantaged some students, such as those in Northern Ireland, forcing them to book their test and travel to distant cities and countries.7,17 Finally, due to an administrative error, students requiring reasonable adjustments (many of whom were prohibited from sitting the test at home) were unable to book their test when the booking window opened. Several weeks into the application window, many students were still waiting to be accommodated or were instructed to sit the test at a remote location or at home.7 Many students voiced concerns about whether the process met the obligations of the 2010 Equality Act, leading to the involvement of the BMA.15

Students later reported being told they were disqualified from the UKFPO application cycle this year for minor infractions when taking the SJT at home. These included making notes on blank paper, or putting on a jumper.20 Again students complained that advanced guidance was unclear and disadvantaged those sitting at home;21 those students who were able to sit the test at a test centre were able to make notes. Following negative publicity, the UKFPO reversed their decision not to allow these students to re-sit and stated they were working with affected students to offer them the opportunity to do so this academic year.21 The BMA have further called for the UKFPO to address Pearson Vue’s “unfair, unacceptable, and in some cases inhumane” treatment of medical students during the SJT, which appears to have disproportionately impacted students requiring reasonable adjustments.22

If the UKFPO’s aim is to “to help raise the standards of training”, the current process appears to be failing the future workforce.2 The process does not make the latest entrants to the medical workforce feel like valued individuals, whose achievements are recognised and respected. The authors recognise the importance of each new cohort of doctors and calls for a process that instils confidence that they will be welcomed and supported as they join the profession.

The GMC acknowledges that effective, fair, and supportive leadership is vital to reduce the current high level of “burnout” and job dissatisfaction among junior doctors.23 The experience of students this year suggests that the UKFPO need to develop a more welcoming, supportive, and student-centred application process which recognises achievements and individual characteristics and promotes equal opportunities. Student consultation must be at the heart of any decisions taken, and staff-student partnerships must lie at the centre of the change we need to see. This would allow the UKFPO, GMC, and the NHS to promote best practice by example, and improve morale among the incoming cohort of junior doctors.

Adrian Paul McGrath, Final Year Medical Student at Warwick Medical School, University of Warwick, UK

Andrew Gadie, Final Year Medical Student at Warwick Medical School, University of Warwick, UK

Charlie Cunningham, Senior Careers Consultant at Warwick Medical School, University of Warwick, UK

Jean-Pierre Laake, Final Year Medical Student at Warwick Medical School, University of Warwick, UK

Emily Róisín Reid, Director of Student Experience, Employability and Progression and Senior Teaching Fellow at Warwick Medical School, University of Warwick, UK

This manuscript represents the perspectives and opinions of the authors and not necessarily those of Warwick Medical School or the University of Warwick. 

Competing interests: none 

References:

    1. ‘Key Stats and Facts Report’. 2020. UK Foundation Programme Office (accessed 12 November 2020)
    2. UKFPO Applicants’ Handbook 2021. 2020. UK Foundation Programme Office. (accessed 12 November 2020)
    3. Dusoye A. 9 November 2020. “The issue of no extra time was brought to your attention on Friday by email when booking opened accidentally and candidates with approved ET didn’t have it when they made the booking (before being cancelled). How did that not show up any red flags and get fixed over the weekend?”
    4. Spooner S, Pearson E, Gibson J, et al. How do workplaces, working practices and colleagues affect UK doctors’ career decisions? A qualitative study of junior doctors’ career decision making in the UK. BMJ Open 2017; 7:e018462. doi: 10.1136/bmjopen-2017-018462
    5. Hartwell, J. Psychological contracts: a new strategy for retaining reduced-hour physicians. J Med Pract Manage 2020; 25(5):285-97.
    6. Hoff T, Dopson S, Mitra M. BMJ Opinion 2020. The medical profession is breaking its psychological contract with medical students and trainees (accessed 12 November 2020)
    7. Nabavi N. Students forced to travel across UK to sit compulsory exams. BMJ 2020; 371:m4452 doi: 10.1136/bmj.m4452 
    8. Miah R. 6 November 2020. “Unacceptable error from UKFPO to open up SJT sign ups before the start date. On top of Oriel errors, changing AFP guidelines AFTER submission, final years are SO stressed – PLEASE act with more care @UKFPO @TheBMA @BMAstudents”
    9. General Medical Council (2014) Good Medical Practice; Maintaining Trust. London: GMC pp18-24 (accessed 12 November 2020) 
    10. Smith C. 6 November 2020 “REALLY disappointing that LAKSS AUoA shifted the goalposts for longlisting AFP applicants, 2 days AFTER Oriel closed Removes EPM from how candidates are assessed. With only 2 AUoA choices knowing selection process is KEY to tailoring applications Why now? Nothing has changed??”
    11. King’s College London. Certificates. (accessed 12 November 2020)
    12. Health Education West Midlands. West Midlands Deanery. AFP 2021 Applicant Guide Final. Version 1. August 2020 (accessed 12 November 2020)
    13. Scott M. 9 November 2020. “How does that help people who aren’t looking at your website? This should be communicated directly to all candidates.”
    14. UKFPO. 30 July 2019. “**UKFPO are pleased to announce the #SJT Contract has been awarded to @PearsonVUE and @WorkPsychGRoup ** Representatives from #UKFPO and FSMs welcome a more sophisticated means of selection for #Foundation Press Release”
    15. BMA Students. 13 November 2020. “Of particular concern is the allocation of places that may discriminate against candidates who require reasonable adjustments and who will have not been given first priority for choosing the time and the place of their SJT”
    16. Mahomed Z. 9 November 2020. “possibly the *only* thing worse than not giving a time is giving an INCORRECT time (photo taken of a slide from the final official UKFPO webinar on 29th October) #sjt #ukfpo #MedTwitter #medstudenttwitter”
    17. Gulati R. 9 November 2020. “Having to fly back to London too! Not fair for @UKFPO to open up slots in the middle of the night – final year is stressful enough without all these mistakes with Oriel/London AFP and now SJT”
    18. UKFPO. UKFPO Statement–UKFP 2021 Applications and SJT Booking Process. (accessed 30 November 2020) 
    19. Bishop P. 18 November 2020. Twitter
    20. Anonymous Med Student. 21 January 2021. “Final year UK med student here. Going public with some experiences of a compulsory online exam. Summary: students threatened with disqualification from becoming doctors (in a pandemic) due to problems with online exams (incl. some being forced to urinate in their seats)”
    21. Turnnidge S. NHS U-Turns Amid Anger Over ‘Inhumane’ Exam Conditions For Medical Students. Huffington Post. 
    22. BMA Students. 26 January 2021. “SJT LETTER TO @UKFPO This afternoon we’ve written to UKFPO to raise the distressing experiences of our members and medical student colleagues sitting the SJT remotely.” (1/5) 
    23. General Medical Council. What we do and why. 2020. (accessed 12 November 2020)