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How on earth did we reach this point? The origins date back to the chief medical officer’s report in 2002. Its original principles clearly attracted widespread support. Self-evidently, there is a need for a modernised and focused career structure for trainee doctors. More standardised training based on competencies is the right way forward, and it is entirely reasonable to focus both on clinical skills and on the communication skills that I readily acknowledge are important for doctors. There were also legitimate concerns about patronage and bias in the old system. In any modern service those features are unacceptable and need to be challenged. Career advancement should always be based on merit, not on who a person knows or even the colour of their skin. I suspect that that has been a problem in the health service in the past.
What went wrong? The Royal College of Physicians points to two failures. The first was that modernising medical careers had become a straitjacket. It was too inflexible: it forced early career decisions on young doctors and from that point demanded a training schedule that gave them little opportunity to change direction to a different specialty. It shortened the training period, leaving many doctors concerned that their experience would be reduced as they went through the training process.
The second failure was the introduction of the medical training application service—MTAS—which was set up by the Department of Health to select junior doctors for MMC training posts. The royal college described the system as “deeply flawed, and unpiloted”—it had specifically requested that the system be piloted. Many concerns have been raised about how the unpiloted system has worked. It seems remarkable that so much emphasis appears to be placed on creative writing skills—we have heard about the number of points allocated for that competency—compared with clinical excellence. It seems that doctors who have undertaken research to prepare for a specialism could be disadvantaged. No CVs are considered and there is no proper acknowledgement of academic qualifications. The central question that the Minister of State, the hon. Member for Leigh (Andy Burnham), must answer when he responds is: how on earth did that happen? Is not it incredible that an entirely new, sophisticated web-based system was introduced without proper piloting?
Anne Milton (Guildford) (Con): As the taxpayer is likely to have to fund the reviews of the debacle and its repercussions, does the hon. Gentleman agree that it is important that we hear from the Secretary of State or another Minister exactly who was responsible? We have not yet been told.
Norman Lamb:
I am grateful to the hon. Lady for that intervention. I disagree with the right hon. Member for Birkenhead (Mr. Field), who seems to think that establishing who was responsible is a pointless exercise: it is essential if we are to hold the Government to account and learn lessons for the future. The hon. Lady made a point about the costs of the recovery exercise. I put that question to the Secretary of State during her statement last week. I did not get an answer, so I would be grateful if the Minister
of State could confirm what assessment has been made of the likely additional cost of the recovery exercise.
I was making a point about piloting. The terms of reference of the review highlight several features of the system. They include the assessment methodologies used in the selection process, including the relative merits of competency-based and more traditional methods of selection and recruitment; the level of choice on offer at application; and the lack of flexibility available to trainees on run-through programmes. They are all issues that would emerge from pilot programmes and the problems would be ironed out before a programme was rolled out nationally. How on earth was the system introduced without proper piloting?
Justine Greening: The hon. Gentleman is making some excellent points. Before I became an MP, I spent many years working in business and I cannot ever remember any company of any importance introducing an IT system without a full pilot and assessment of it afterwards.
Norman Lamb: The hon. Lady is absolutely right. Much smaller organisations pilot new programmes before they are introduced. We are talking about a system that is supposed to deal with tens of thousands of applicants across the whole country. It is bizarre and extraordinary that it was not piloted.
Warnings also went unheeded. The Royal College of Physicians warned but was ignored. The British Medical Association said that it tried to get the Government to listen, but it was ignored. During the Secretary of State’s statement last week, the hon. Member for Wolverhampton, South-West (Rob Marris) told the House that he had written several weeks ago to one of the Ministers at the Department—
Norman Lamb: The hon. Gentleman wrote in the autumn. He did not say to which Minister he wrote, but he said that he had not received a reply and that he had raised concerns about the introduction of the system. His warnings went unheeded.
Norman Lamb: As I understand it, the hon. Gentleman has still not had a reply. Perhaps he is going to tell us otherwise.
Rob Marris: May I clarify the position for the hon. Gentleman? I wrote last autumn expressing concern about the system and I was assured by the then Health Minister, Lord Warner, that it would be all right on the night. When it became apparent in the spring that it was not all right on the night, I wrote and asked who was being disciplined on account of this failure. After many weeks, I have still not received a reply to that question other than the answer that I received from the Secretary of State in the statement last week, when she said that no one had been disciplined.
Norman Lamb: I am grateful to the hon. Gentleman for that. Even if no one is disciplined, people could still be held to account for what has happened, but we have had no indication of whether that will happen.
Given that there was no piloting and that all the warnings from professional bodies were ignored, one is left with the sense that the Government have demonstrated total arrogance and total incompetence, or a pretty potent mix of the two. Who is responsible for the debacle? Will anyone be held to account? Surely, it is a pretty damning indictment when the former national director of MMC, Professor Alan Crockard, resigned stating that MTAS
“has lacked clear leadership from the top for a very long time”.
What does he mean by “from the top”?
Mrs. Gwyneth Dunwoody (Crewe and Nantwich) (Lab): We have heard a fairly solid dose of hypocrisy about this issue in some parts of the debate. No one is suggesting that we return to the absolute chaos of the previous system, in which some doctors suffered considerably. However, may I point out to the hon. Gentleman that Professor Crockard was presumably in on the arrangement from the first and was also acting as a consultant?
Norman Lamb: I am grateful for that intervention, but I made the point that the principles of the system were widely supported at the start and I highlighted the concerns about the previous system. [ Interruption. ] I did highlight the concerns about bias and so forth; it was absolutely right to bring in a new system. It is the way in which it has been implemented that has caused so many people to be left totally frustrated by the Government’s incompetence. Professor Alan Crockard may be partly responsible for the debacle, but when he says that there has been a clear lack of leadership
“from the top for a very long time”,
we ought to listen to that concern.
Mr. John Leech (Manchester, Withington) (LD): Surely the difference is that the professor has fallen on his sword, whereas the Secretary of State has not?
Norman Lamb: I take that point. When the professor says that there is a lack of leadership from the top, we need to know whether he is referring to the Secretary of State, or a civil servant —[ Interruption. ] MTAS is a Department of Health initiative, so we need to know from the Minister to whom Alan Crockford—[Hon. Members: “Crockard.”] We need to know to whom Alan Crockard refers when he says that there is a lack of leadership from the top. Will the Secretary of State publish all the correspondence as part of a wider review so that lessons can be learned about what has gone wrong?
Will the Secretary of State publish any written submissions made by Professor Shelley Heard, who has also resigned? Professor Heard was the national clinical adviser and has been quoted as saying that the principles
“have been lost in the detail and acrimony of a recruitment process which should have supported and not driven it”.
“we are losing the goodwill of a generation of UK graduates who believed it when we said we wanted to train more UK doctors better and we are losing the goodwill of patients and senior colleagues”.
Professor Heard also fundamentally challenged the direction taken by the review group set up by the Secretary of State. She said that the group
“has become so immersed in the detail that it cannot see a way ahead which will be both equitable to doctors and support the aims of MMC”.
“able to support few of the decisions that the review group has taken since they undermine the principles which are at the core of MMC”.
Does the Minister accept that the review group’s direction of travel is undermining the principles at the core of MMC, as Shelley Heard suggests? That is a serious challenge to the direction that the Government are taking.
I am an employment lawyer by training, and before I became a Member of Parliament I advised employers on fair recruitment processes fairly regularly. This is not a fair recruitment process. It is fatally flawed, and once a process is flawed, one cannot satisfactorily remedy it. Will the Minister confirm whether the additional interviews for those candidates not hitherto given interviews will be conducted by differently constituted panels? However objective a scoring system, once different assessors are introduced on to a panel, objectivity is destroyed. Once something is flawed, it is always flawed, and that is why I have supported the attempts by Remedy UK to secure a judicial review of the process.
I want to explore the recovery process itself. I understand that all the additional interviews will take place over a four-week period in May. Will the Minister confirm how many extra interviews the Government expect will be required? Will that be logistically possible to achieve? When I put that question to the Secretary of State last week, she said that it would be achievable, but “only with considerable effort”. That suggests that there is a risk of substantial disruption to patient services and a possible impact on patients.
I understand that trusts are resistant to allowing consultants time off their clinical work to conduct the interviews. The hospital trusts are all under intense pressure to deliver on waiting time targets, yet they will lose a substantial number of clinical hours to conduct additional interviews. I understand that 10 candidates were originally interviewed for two specialty training level 3—ST3—posts in cardiac surgery in London, but that it is expected that an additional 50 applicants will be interviewed to comply with the review group’s new process. Will the targets with which acute hospitals must comply be adjusted to take account of the disruption that will inevitably occur, given that if a surgeon is interviewing, he or she is not operating? A question was raised about the cost of the recovery programme, and I hope that the Minister will give a confirmation of its cost.
What analysis has been undertaken of the impact of all junior doctors starting their new roles on 1 August? The Secretary of State, who I notice has disappeared from the Chamber, indicated that the turnaround had always taken place on 1 August, but I understand from my hon. Friend the Member for Oxford, West and Abingdon (Dr. Harris) and many others that that is not the case. It was a phased process; all junior doctors across the country did not change jobs on one day. It is hard to imagine a more crass arrangement than one in
which everyone is expected to start work under a new system at exactly the same time. Induction procedures will take doctors away from their duties, and I understand that many hospitals will, in effect, operate bank holiday working arrangements during that period, cancelling operations and clinics. Newly appointed doctors will find that their predecessors have already gone, leaving inadequate knowledge of the patients on the wards for whom the new doctors are supposed to be caring.
I suppose that it was inevitable that the changeover for the whole country would be planned for a peak holiday time, when so many consultants are away. That simply adds to the challenge. I have heard that some trusts are starting to suspend the right of consultants to go on holiday in the first two weeks of August. That suggests that acute trusts are anxious about the potential impact on patient care during that period.
On the mismatch between the number of applicants and the number of posts advertised, the Secretary of State indicated that there were about 23,000 training posts, but of those 23,000, she said that 3,000 were general practitioner posts. She then said that the net figure for hospital posts was something over 19,000. I do not quite understand the maths, but that is what she said. She also said that 700 extra posts were being added. I do not understand where that figure comes from, and I would be grateful if the Minister of State could explain when he winds up the debate. Are those 700 extra posts the additional training jobs that the Government said that they hoped to provide, or are we expecting more training posts on top of that 700? The people affected by the problem, many of whom are in the Gallery today, deserve clarity and answers from the Government on that point.
The Secretary of State was right to point out that some, but not all, of the people who do not get training jobs will continue in their existing posts. Will the Minister give his assessment of the number of junior doctors who are likely to be unemployed come the summer? The hon. Member for Wolverhampton, South-West had a stab at providing a figure, but he was told by the Secretary of State that he had overstated the numbers because many people would remain in their jobs, so what is the figure? We know from the document leaked last week that Government planning is proceeding on the basis that thousands may be unemployed. It is incumbent on the Government to tell us the estimated number of junior doctors who will be unemployed this summer.
The document referred to the possibility of junior doctors being sent off with Voluntary Service Overseas. VSO is a fantastic concept and I applaud all the junior doctors and the many other professionals who do voluntary work overseas, but as a human resources solution for a Government who have got themselves into a hole, it is hardly an appropriate way forward. Will the Government publish the document that was leaked last week? I have not seen it. Is it available, and may we see what the Government are planning to do with all the unemployed doctors this summer?
We are told that it costs about £250,000 to train a junior hospital doctor. How many are likely to end up heading overseas or leaving the profession as a result of
the crisis? What is the scale of the resources that will be wasted on all that training?
The hon. Member for Wolverhampton, South-West raised the issue of the two cohorts coming together, as did my hon. Friend the Member for Somerton and Frome (Mr. Heath) in an intervention on the Secretary of State. We still have not had a satisfactory answer on why the Government did not expect that to happen and why they do not appear to have planned for it or its consequences.
I suspect that the right hon. Member for Birkenhead might disagree on this point, but one sensitive, but important, issue is the way in which we treat foreign doctors who work in hospitals across the country, many of whom have given dedicated service to the NHS. How will they be treated as a result of this debacle? My hon. Friend the Member for Oxford, West and Abingdon made the point that, historically, staff grades that are often filled by ethnic minorities and women are, in a sense, dead-end jobs, with no prospect of career advancement. Why can the Government not plan to convert those jobs into training posts, to give the occupants the chance of career enhancements?
Dr. Evan Harris: Does the Minister accept that the key to the mismatch between the number of juniors looking for training posts and the number of training posts available is the question of consultant expansion? It begins and ends with that, because what patients want—we must remember patients—is a consultant-provided service. The Minister must explain whether medical schools were expanded in order to fill an expanded consultant grade, or whether they were expanded in order to fill trust grades, clinical fellowships and staff grades—all non-training posts, which many people do not want to occupy even though they are in such posts? Does he expect that the consultant expansion we need will take place? In 1997, a British Medical Journal editorial noted that “consultant expansion was insufficient”. That editorial was written by a Dr. Evan Harris, but 10 years on, I see that there is still no expansion—
Mr. Deputy Speaker (Sir Michael Lord): Order. I think that that doctor’s intervention is long enough.
Norman Lamb: It has never been known in the past, Mr. Deputy Speaker. I endorse the question that my hon. Friend put to the Minister and hope that he will be able to respond.
In conclusion, the scale of incompetence is quite remarkable. We need belated recognition from the Government that the problems this year have not been resolved and that the system remains fatally flawed. Remedy UK is seeking judicial review this week and I hope that it succeeds in that challenge to the Government, because the process, as we have all said, is fatally flawed.
Mr. John Gummer (Suffolk, Coastal) (Con): Will the hon. Gentleman add to his questions to the Government a question about how bad the next disaster has to be before any Minister thinks that they ought to resign, so that we have a picture in advance?
Norman Lamb: I have a great deal of sympathy with the right hon. Gentleman’s intervention. We heard earlier that the departing director said that the system had been mismanaged and that there had been a lack of direction “from the top”. Where is the top? Is it Ministers? The Secretary of State has left the Chamber, as we have heard, but who will take responsibility? That is the critical issue. I fundamentally disagree with the right hon. Member for Birkenhead. If we are to hold the Government to account, it is right to find out what has gone wrong, who was responsible for it, and for that person to be held to account.
Mr. Heath: On a point of order, Mr. Deputy Speaker. Is it not customary in the House for a right hon. or hon. Member who has made a contribution to remain in the Chamber long enough at least to hear the subsequent contribution from another hon. Member? Is that still the normal practice in the House, and does it apply to Secretaries of State?
Mr. Gummer: Further to that point of order, Mr. Deputy Speaker. Is it not true that the Speaker recently circulated a note on that very point, not just to Back-Bench Members but to all Members, saying that it was courteous to listen to the following two speeches after making a contribution?
Mr. Deputy Speaker: The first point of order and the subsequent point of order are both accurate reflections of the Speaker’s views about how Members should behave in the House. It is not the Chair’s responsibility as to whether Ministers remain for the debates.
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