Reply

We thank Rogers et al for their valuable contribution to the debate. ¹ In our original letter, we highlighted the inherent difficulties with meritocratic systems and the risk of perpetuating elitism when applied to medical specialty training. ^{Reference Howarth, Kennedy and Berelowitz2} We offered two possible solutions, the first a system of admission by lottery as proposed by Michael Sandel, Professor of Political Philosophy and Justice at Harvard University. ^{Reference Sandel3} We acknowledge the criticism of this course by Rogers et al, who highlight that a Sandelian system in the UK Foundation Programme has been met with feelings of ‘injustice’ and ‘powerlessness’ by prospective trainees. ^1,4

We agree that a lottery is far from the best option. The population needs and deserves good doctors, and doctors want to practise safely and to a high standard. The best way to ensure this is for all training schemes to be of high quality. We believe this might be achieved by following Marmot’s principles of proportionate universalism. ^{Reference Marmot, Allen, Goldblatt, Boyce, McNeish and Grady5} Neither NHS England nor the Royal College of Psychiatrists can readily control what happens before trainees enter their ranks, but once they do, there is an opportunity to balance the scales. By developing the poorest-performing training programmes the most, and in a graded way towards the best performing programmes, we might truly achieve some sense of equity in training. In the future, trainees may choose to serve the communities they grew up in and do so knowing they can still be among the brightest and best.