Examination of Witnesses (Questions 545-559)
MR PAUL
STREETS, PROFESSOR
ELISABETH PAICE,
MR BERNARD
RIBEIRO AND
PROFESSOR DAVID
GORDON
29 JUNE 2006
Q545 Chairman: Good morning. I am sorry;
we are a few minutes late. Could I ask you, for the record, to
give us your name and the organisation that you are from?
Professor Paice: My name is Elisabeth
Paice. I am the Dean Director of London Deanery and the Chair
of COPMD, the Conference of Postgraduate Medical Deans.
Professor Gordon: I am David Gordon.
I am the Dean of the Faculty of Medical and Human Sciences in
the University of Manchester and I am here in my capacity as the
Chair of the Council of Heads of Medical Schools.
Mr Streets: I am Paul Streets.
I am the Chief Executive of the Postgraduate Medical Education
and Training Board.
Q546 Chairman: I understand our other
witness, Bernard Ribeiro from the Royal College of Surgeons, is
presently in a cab shortly to be with us. Could I, first of all,
thank you very much for coming along to give evidence to us today
on what is our fifth day of our evidence taken in the inquiry
into workforce planning. A question for Mr Streets and Professor
Paice: the new system of specialist medical training begins in
the summer 2007. Nine thousand five hundred specialist training
posts will be available, but the BMA estimate that 21,000 doctors
will compete for these posts. Why is there such an apparent shortage
of specialist posts and what will happen to those who cannot get
a training place?
Professor Paice: At the moment
the September 2005 census shows that there are 21,000 people in
SHO (Senior House Officer) level posts. Those posts are funded
one way or another. Many of them are educationally approved SHO
posts, some of them are locally funded, trust doctor posts, which
are not educationally approved, and the census is not able to
distinguish between the two; but do we know that there were 21,000
people in posts at that time. If you like, that is the stock.
Five thousand of those have been reconfigured into Foundation
Year Two posts, which start in August this year and will continue,
so actually the 21,000 is now reduced by 5,000 to 16,000. Of those
16,000 posts, as I say, it is not totally clear exactly what proportion
are locally funded, but the majority of those 16,000 are educationally
approved SHO posts, which would fit very nicely into the specialty
training programmes of the future at three levels: the first year,
the second year and the third year. It would, therefore, be possible,
with the existing resources, to fit all of those 21,000 people
into all of those four years of posts. The question then is whether
or not you have the specialist training opportunities and, indeed,
the requirement for all of those people in those posts to go through
to complete training, either to be a GP or to be a consultant,
and that is a decision which has to be made for the long-term
because you certainly cannot start people down a training pathway
if you cannot complete it. The likelihood is that the capacity
to train is there. It is a decision to be made whether the commitment
is there to take people through.
Q547 Chairman: Have you anything
to add to that, Mr Streets?
Mr Streets: It might be helpful
for the Committee to understand that it is PMETB's responsibility
to set standards, maintain standards and promote and develop Postgraduate
Medical Education. We have no due restriction over numbers, but
in terms of this debate we can work with the deans in order to
ensure that people can fit into training beyond the first year,
and that is one of the things that Professor Paice has referred
to.
Q548 Chairman: Basically, are you
saying, Professor Paice, that UK-trained doctors do not face a
genuine threat of unemployment?
Professor Paice: I do not believe
that there is any need for the output of the UK medical schools
to face unemployment and not be able to complete their training.
We have moved from a phase where we encouraged a great deal of
international recruitment, and I do not think that is sustainable.
Of that 21,000, we know that nearly half were not UK graduates,
so there is a balance to be struck there.
Q549 Chairman: You have mentioned
the issue about the new Foundation Training Programme. Will doctors
in all Senior House Officer posts have equal access to specialist
training posts or will it be reserved just for the new foundation
training programme?
Professor Paice: No, the idea
is that that body of people who are in the SHO posts will have
the opportunity to compete for the training as GPs and training
as specialists, not just the Foundation Two people.
Q550 Chairman: Could I just welcome
Bernard Ribeiro. We understand you have been spending some time
in a cab?
Mr Ribeiro: Thank you very much,
Chairman. My apologies for being late.
Chairman: No problem.
Q551 Dr Stoate: I would like to explore
one final point. The BMA is saying, openly, that there will be
significant unemployment amongst doctors because of these new
changes and they are predicting that vast numbers will emigrate
to other countries. Is this realistic or simply crying wolf?
Professor Paice: It depends how
you describe "doctors". At the moment there is unemployment
amongst doctors in the UK, and it is something which is very concerning.
A lot of the unemployed doctors are doctors who have come to this
country to train, have taken PLAB and are unemployed, and that
is a situation which I do not think anyone finds acceptable. It
would be quite wrong to say there is not unemployment amongst
doctors in the UK, there is, but that may be a different thing
from saying that looking to the future, with the changes which
have already been put into place about access to permit free training,
there is a plan in the future to organise things so that there
are unemployed UK graduates, which there is not.
Q552 Dr Stoate: I still do not feel
much happier, because the BMA are saying that there will be large
numbers of unemployed doctors as a result of these changes. Are
you saying that this is not going to make much difference or is
going to make much difference?
Professor Paice: As I say, I think
that it is important to say what you mean by "doctors".
There is not enough training capacity and, indeed, need in the
UK to train every doctor who has come and taken PLAB and has come
to this country looking for training to offer training to everyone.
It just is not there. If you are saying, is there going to be
unemployment amongst doctors? The answer is, no, there is no intention
to train every doctor that comes to the country seeking training,
but I am having to make a distinction between plans for the output
of UK medical schools and plans for the very, very intense interest
there is in coming from various parts of the world to seek training
in the UK, and there is not the capacity to meet that demand.
Q553 Dr Stoate: So you are saying
that UK trained doctors coming out of our medical schools in this
country will not face unemployment but many people who are coming
into the country who are given training might? Is that a better
way of putting it?
Professor Paice: I would have
to say that those people who are unable to compete in that market,
those UK graduates who find themselves unable to enter into open
competition successfully, as the vast majority of UK graduates
would, may be unemployed. Nobody could guarantee that every UK
graduate will be offered a training programme—that is not
possible—but the plans are being based on the intention
to offer an appropriate number of training programmes for the
UK output. Is that a reasonable way of putting it?
Dr Stoate: That is much clearer. Thank
you.
Q554 Sandra Gidley: You seem to be
saying that it is unacceptable that a doctor would do a degree
course and then not be able to access further training.
Professor Paice: No. I guess what
I am saying is it would be wrong to plan to produce medical graduates
and to say, "The plan is we will have a cull and we are not
planning for a third of them to progress." After a six-year
undergraduate training programme, which is broad and deep and
expensive, it would be wrong to plan for people not to be able
to train further in the postgraduate field and make themselves
useful.
Q555 Sandra Gidley: So we actually
need fewer university places?
Professor Paice: No, I do not
think so. I think we need all the doctors that we are currently
training. There has been a recent review of this looking at the
projections over the next ten, 20, 30 years, looking at the demographics
of the doctors being produced, looking at the participation rates
that are predicted, looking at the skill mix for the future and
the needs of the country for the future, and careful discussion
as to whether we needed more medical schools or fewer medical
schools, and the conclusion was actually at looks as if we have
probably got it about right at the moment.
Q556 Dr Naysmith: I am going to turn
to another aspect of this training. There has been a recent survey
in which 62% of doctors who were surveyed (and it was a large
survey, more than a thousand doctors of all different grades and
skills and so on) felt that patient safety had worsened as a result
of the recent changes to postgraduate training. What are your
comments on that? Do you agree that is a valid judgment?
Mr Ribeiro: We presented evidence
last time on the basis of what we had surveyed following the European
Working Time Directive, and it really is a combination of the
impact of what the EWTD has done since 2004. What we found for
our survey was that 83% of the respondents felt there had been
a reduction in the continuity of care and, as a consequence, in
the quality of care which they felt they were able to provide
to their patients, and that was our college survey. When you talk
about patient safety, doctors in a professional sense have a real
desire to see the job done and not to leave a case until they
are satisfied it is properly done. The restriction imposed by
time-based working, which what the European Working Time Directive
does, leaves many doctors with the unsatisfactory situation of
having to hand over to somebody else to manage the case, and I
think it is this sense that gives rise to the question of patient
safety. In terms of risk to patients per se, I suspect
that that would be subjective in terms of how that is reported.
Professor Paice: I think it is
very difficult in a period of change for people to see how things
can work in a new world. People are very used to what they do
and change seems risky. My own personal view is that the reforms,
particularly the reforms around the Working Time Directive, which
will hopefully put an end to sleep deprived doctors, will do nothing
but good for patient safety. I strongly believe that doctors do
not learn well when sleep deprived, nobody else learns well when
sleep deprived, and there is good evidence to show that what you
do learn at night when sleep deprived following that learning
experience is not retained. So, the first thing I would say, putting
an end to sleep deprivation can do nothing but good for patient
safety. The second thing I would say is making sure that the training
is structured, that competency is assessed, that supervision is
in place before people are allowed to do things unsupervised can
do nothing but good for patient safety. What is absolutely critical
is that people get the experience that they need, and one of the
things I think that we have to do with the new reforms is to make
sure that that happens, because there is no doubt about it, surgeons
cannot learn unless they are able to practice and see what needs
to be seen, and that means moving away from a system in which
trainees have been seen perhaps as deliverers of service that
you have to train in order to get them to come and work for you
and into a system where trainees are there to learn, where the
learning is available, at the times when it makes sense for them
and in the centres where the clinical cases are there for them
to learn on, so that when their learning is done in a streamlined
way and a little bit quicker than we do it now, they come out
as specialists and general practitioners who are competent, experienced
and able.
Q557 Dr Naysmith: I am not sure whether
you are saying that the judgment expressed by these doctors was
correct and you are doing something about it or whether you disagree
with that judgment?
Professor Paice: We are talking
about reforms which are still in the pipeline, and so I am saying
I think they are wrong, I am sure they are wrong, that patient
safety will suffer in the future if we get the training right,
but if left to serendipity and opportunism, I have absolutely
no doubt that there will be problems.
Mr Ribeiro: Can I come back on
that. I entirely take that aspect. I think where we have been
concerned in our projections is over the time that will be available.
Currently trainees are clocking up something of the order of about
17,500 hours in the current Calman system of training that they
have towards the end of the training. Our calculations were that
with the onset of the EWTD (48 hours by 2009) that will lead to
a reduction down to something like 6,000 hours of training time.
As a consequence of that, our college has actually extended the
period of training with this new arrangement to anything between—
Q558 Dr Naysmith: That aspect has
been sorted out?
Mr Ribeiro: Part of that aspect
has been sorted out by virtue of the fact we have extended the
training from six years of specialty training to about seven to
eight years, but it is important to realise that a lot of practice
and experience that we have is going to be based on competences,
and those competences will determine that somebody is competent
to practice, but it actually needs a lot of experience before
somebody can practice independently and in a professional and
safe way.
Q559 Dr Naysmith: So there is a danger
that people will not get that experience unless you make absolutely
sure?
Mr Ribeiro: While I accept everything
that Professor Paice has said about working at night and the problems,
and we have looked at that, and perhaps I could return to that
later and the work that we are doing in the college on the separation
of emergency/elective care, what I would say is that, recognising
that problem, we have extended the period of training to take
account of that. We are also, within our college, developing courses
for our current trainees which will look at some of the problems
that come in delivering care. Trainees as well as consultants
need to have training in the effective handover of the skills
that they have acquired, and these are part of the things that
we are doing, and we are developing courses to make sure that
they are fully aware of this.
Mr Streets: Clearly, we cannot
bury our heads in the sand. The Working Time Directive is with
us and it will have an impact on training, and you can juxtaposition,
as Professor Paice has, the past, where people worked 120-hour
shifts, with the future where they will be not be able to that
and question whether actually that was safe for patient safety
too. The key for us is that we must make more explicit some of
the things that have been implicit in training, and that is about
standards for curricula, standards for assessment and the standards
in which training is taking place, and PMETB is a part of that
working alongside MMC and the colleges and the deaneries. The
danger is that if we do not do that, we will just need to continually
extend the length of time that people train, and that will probably
lead to less flexibility, and, as this Committee has considered
previously, one of the things that we need to more towards is
more flexibility. We think there needs to be a move towards much
more explicit standards for the situation in which training takes
place, and PMETB is a part of that.
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