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Rheumatology 2001; 40: 1413-1415
© 2001 British Society for Rheumatology
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Research and training review of the use of LAS, LAT and flexible training positions
Department of Rheumatology, Princess Margaret Hospital, Swindon,
1 Staffordshire Rheumatology Centre, The Haywood, Stoke-on-Trent and
2 Centre for Rheumatology Research, University College London Hospitals, London, UK
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Background |
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 Top Background Results and discussionSummary |
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Concerns have been raised recently at the Research & Training Committee of the British Society of Rheumatology (BSR) about the differential use of LAT (Locum Appointment for Training) and LAS (Locum Appointment for Service) appointments in different regions of the UK. It is worth considering why LAS and LAT appointments become available. In some cases it is because individuals, having completed their training, have received Consultant appointments and a gap occurs before a replacement can be appointed. In other cases, trainees with an NTN (National Training Number) leave a gap for a finite period as they wish to undertake a period of research training in order to obtain a MD or PhD degree. Other NTN holders wish to take time off to start or raise a family. There are also a variety of other reasons (e.g. to accompany a spouse overseas for a short period). At present the rules are that LAT posts which can be counted towards CCST (Certificate of Completion of Specialist Training) can only provide up to 1 yr of accreditation. These posts have to be advertised and formally interviewed. In contrast, LAS appointments do not have to be advertised or formally interviewed for but they provide no time towards accreditation. In addition, it is not clear how often flexible trainees with NTNs are being appointed.
In order to try and answer these questions, a questionnaire was devised and sent to the Chairs of the Specialist Registrar Training Committees in Rheumatology across the UK (representing England, Wales, Scotland and Northern Ireland) during spring and summer 2000. The opportunity was also taken to explore the more general question of how many specialist training positions have been established in the different regions; the time spent by the chairs in managing the rotations and how the registrars in training are appraised throughout the country
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Results and discussion |
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TopBackgroundResults and discussionSummary |
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It is clear from reviewing the accompanying table that different regions have indeed developed different strategies for using LAS and LAT positions.
The highest proportion of training positions occupied by non-NTN holders is found in the East Anglia (four LATs to five NTNs), Wessex (two LATs+two VNTNs to six NTNs), North Western (four LATs to nine NTNs) and Mersey (three LATs to eight NTNs) regions. The North and South Thames regions, which had the largest number of specialist training positions at the time of the survey, had just one LAT position. The possible explanations for the differences would seem to be the following.
- That a policy decision has been made by the smaller regions that when trainees take time out from their rotations they will invariably be replaced by LAT rather than LAS appointments. This must produce some difficulties, for example with a trainee who obtains funding to undertake a PhD, in which case three LAT appointments will be required to cover the 3-yr gap.
- The Thames regions, by virtue of having had more research posts at the time of Calmanization, have managed their rotations by utilizing a larger pool of ‘players’. An analogy might be the squad system in the country's leading Premiership clubs. The Thames regions manage any gaps that appear in their rotations by the use of short-term LAS appointments.
- The extensive use of LATs in the regions appears to be a permanent situation in many cases and it is apparent that they are being used to ensure continuity of service provision. It is not clear why at least some of these posts did not receive an NTN in the initial Calmanization process, as many such posts are long-standing and not new developments.
- Specialist training committees may be unaware that it is possible to create a temporary extra NTN to cover for trainees leaving the rotations for 2 or more years for bone fide reasons, such as research.
Is one system to be preferred to another? The use of many LAT appointments must clearly provide more trainees with the hope of obtaining a full NTN and the knowledge that, if they do obtain one, the work they have done will count towards accreditation. However, it is also likely to create false expectation and not everyone who obtains an LAT appointment will go on to get a full NTN-approved position.
The majority of chairmen spent an average of one session per week managing the rotations, and many commented on the huge amount of administration required to run the STC. It may be that in the future, in order to organize the rotations efficiently, Trusts will have to provide administrative support for the chairmen of these committees.
Only the West Midlands region attempts a true assessment of clinical competence, although at least one other region is in the process of adopting a similar approach. The remainder of the regions rely on written reports from supervising consultants and trainees together with a panel interview. In discussion, many regions currently experience problems with assessments—both assessments within region and Royal College of Physicians Specialist Advisory Committee General Internal Medicine/Rheumatology assessments. Would the current annual assessments within the regions stand up to external scrutiny? Only one region currently attempts an objective measurement of clinical competence and there may be an argument that this approach should be more universally adopted. Certainly the curriculum now seems to be recommending a more formal assessment. Simply counting time served as a measure of readiness for accreditation seems likely to be considered inadequate in the future with the advent of clinical governance. Some chairs commented that strict adherence to a time parameter for measuring training did not take individual variation into account. Clearly, some trainees may need more or less time to reach the same level of competence, and some jobs may provide more or less intensive experience than others. There may be conflicts between the region's assessment of a trainee’s readiness for full accreditation and the SAC GIM/Rheum assessments, and better liason between the regions and the central committees is essential if we are to achieve an idea of what the training programmes are providing and what is expected of trainees prior to accreditation being granted.
Nineteen flexible trainees were identified, 10.4% of the total. The highest proportion was in the West Midlands region (four flexible to 13 NTN). In all cases the flexible trainees were assessed in the same way as full-time NTNs.
It seems likely that an increasing number of specialist trainees will opt to train flexibly. However, this is likely to have knock-on effects, i.e. part-time trainees will probably want part-time consultant jobs, at least in the first instance. Will these posts be created? This point and a number of others raise the critical problem faced by everybody involved in both training and service, namely that those responsible for training the country's future consultant rheumatologists, i.e. specialist advisory training committees, the British Society of Rheumatology and the Royal College of Physicians, do not necessarily have the same agenda as the Trusts, which actually create and pay for the Consultant posts. This is not an issue which will be easily resolved.
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Summary |
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TopBackgroundResults and discussionSummary |
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From this survey, it is evident that there is wide variation in the numbers of NTNs across the regions, with similar variation in the use of LAT and LAS appointments. There is concern that the 19 flexible trainees do not have a clear-cut career structure and continuing concern about the assessment of clinical competence, which seems to be variable and may be inadequate in some cases.
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Acknowledgments |
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We wish to thank all the regional chairs whose comments and replies form the basis of this paper.
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Notes |
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Correspondence to: E. Price, Department of Rheumatology, Princess Margaret Hospital, Okus Road, Swindon SN1 4JU, UK
Submitted 11 May 2001; Accepted 17 May 2001
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