Examination of Witnesses (Questions 580-599)
MR PAUL
STREETS, PROFESSOR
ELISABETH PAICE,
MR BERNARD
RIBEIRO AND
PROFESSOR DAVID
GORDON
29 JUNE 2006
Q580 Dr Stoate: Before I bring Professor
Gordon in, the cardiac surgeons that you quite rightly brought
up, and I wanted to talk about, would not be required probably
at all. That may be a broad statement, but as we know them today,
in 20 years time, if it is foreseeable that cardiac surgery will
be a thing of the past, what in your view will happen to those
cardiac surgeons? Are they going to be trained today to have any
role in the future?
Mr Ribeiro: In fact, the Cardio
Thoracic Society has done a survey of its Fellows to find out
what they would actually do, and I have got the results tucked
away here somewhere, and what that actually showed was that 50%
of those surgeons would be prepared to continue in cardiac surgery
in non-consultant grades if necessary. That is the determination.
They have trained to this high level of expertise and they do
not want to throw that away. All of them would naturally like
to stay cardiac surgeons.
Q581 Dr Stoate: But is there going
to be any cardiac surgery for them to do is the point I am making?
Mr Ribeiro: Well, yes and no.
We talk about statins, we talk about stents, but stents can fail,
and we do not know what the long-term is. In fact, in terms of
research, we do not know what the long-term results are going
to be for cardiac—
Q582 Dr Stoate: Can I stop you there.
Are you hoping there will still be a role for cardiac surgeons
and that stents will fail and we will still need cardiac surgeons,
or are you—
Mr Ribeiro: No, no, no. Do not
forget, the explosion in cardiac surgeons came about through the
National Service Framework, I think it was under Milburn's time,
which suggested that there should be an expansion, and, unfortunately,
that expansion coincided with the drug treatment.
Q583 Dr Stoate: That is my point?
Mr Ribeiro: The point is that,
that workforce will now have to be redeployed. We should avoid
making those sorts of mistakes in the future by, as I said, making
sure people are light on their feet and can move into other services,
and it is quite clear that 20% of the people surveyed were prepared
to consider other surgical jobs and the rest would have had to
redirect themselves to radiology or whatever.
Q584 Dr Stoate: Professor Gordon,
what do you think about this?
Professor Gordon: I would very
much like to echo Mr Ribeiro's point about lightness on the feet.
I think medical knowledge and the practice of medicine change
unimaginably in a lifetime career, and the kind of medicine that
we saw in medical school is now history. The point I want to make
is that one of the places where innovation in clinical care comes
from is from the academic world. A good example is that when the
HIV epidemic began there was no-one who knew how to treat this
disease, and the first specialists in Aids all came from clinical
academic infectious disease who had the flexibility and the background
knowledge to be able to move into this new area. It is very important
that we maintain that scale and flexibility of academic activity.
We are very concerned, because the numbers of clinical academic
staff are declining. We have published this morning our annual
survey of clinical academic staff numbers, and we have enough
copies of this for the Committee, which we will leave, and it
shows that the total number of clinical academics has fallen below
3,000 for the first time. That is at a time when research is expanding
and medical student numbers are expanding and the world is growing,
and we are trying do what we do with fewer and fewer people, and
so it is very important that, whatever the root causes of that
decline, they are addressed because we will not be able to be
flexible on our feet in the future if we do not have these people.
Q585 Dr Stoate: A final point to
Mr Streets. Do you envisage that the Royal College exams in future
will be scrapped as a result of these competencies or will we
continue to have some sort of parallel system of Royal College
exams and competencies determining someone's fitness to practice?
Mr Streets: There is likely to
be both, in fact, because there is no doubt that within the CCT
as it stands there will be college exams as part of the assessment
process, but the arrival of PMETB has enabled people to be assessed
on competence, using a mechanism called Article 14 which has enabled
us to look at somebody's training experience, qualifications and
assess them as equivalent to a day-one consultant. In relation
to the broader point you made, I would just like to make a comment
on flexibility, because our belief would be that there is not
enough flexibility in specialist training at the present stage,
and we will work closely with the colleges on this. One option
for us would be to look at a core and options approach within
training so that people can flex what they do within a training
programme. We think we need to see training and education more
as a continuum and perhaps we need to look what is within the
CCT and what is after the CCT. There are contractual issues there,
because it is quite difficult at the moment for doctors to take
time out to train, from a financial perspective we need to look
at that, but most important of all, what we need at national level
is a strategic approach towards this that looks five, or ten,
or twelve years ahead. At the moment we do not have that, and
that is the missing link. It is very difficult thing to do. We
cannot predict the future, it is very evident in terms of technological
change and many of the things you have considered, but we do need
a strategic approach towards thinking about what the medical workforce
should look like in 10 years' time.
Q586 Charlotte Atkins: Professor
Paice, we saw the integration of the Workforce Development Confederations
and Strategic Heath Authorities back in 2004. What impact has
that had on the provision of postgraduate medical training?
Professor Paice: I do not think
that integration made a difference to postgraduate medical education
and training. I do not think that integration made a difference.
Q587 Charlotte Atkins: Obviously,
one of the issues as well is the whole issue of the number of
Strategic Heath Authorities being reduced down to 10. Do you feel
that that will have an impact, adverse or otherwise? I will bring
Professor Gordon after you have spoken.
Professor Paice: I think one of
the things which is a concern to anyone who is engaged in postgraduate
medical or undergraduate medical education is whether this reduction
in size, or at least a reduction in the number and increase in
the size, of the SHA will make a difference to where education
sits on the board or in the structure of the SHAs. It was a feature
of the 28 SHAs that there was an educational presence on those
boards, and clearly with the new structures that may well not
happen. I think it is absolutely critical that postgraduate medical
and dental education feature within that board structure.
Q588 Charlotte Atkins: Do you think
that the postgraduate deaneries will not have the same sort of
relationship with the SHAs given that they are going to be reduced
to ten? Is that your concern?
Professor Paice: I do not think
it is necessary for that to happen. I think it could be, and,
indeed, certainly in London, where we had five SHAs and one London
Deanery, I am extremely hopeful that the relationship may improve
as a one-to-one relationship. So, I do not think that is necessary
at all, it is just a question of making sure that education is
up there.
Professor Gordon: We are actually
very concerned about these changes in the documentation about
the strategic objectives of the new SHAs. There is not a single
mention of education or of research, and I should mention parenthetically,
and you may note, that the Healthcare Commission also makes no
mention of education or research in its core developmental standards.
To echo Professor Paice's point, there is now no obligation to
have a representative from higher education on the board of an
SHAs because there is actually a statutory instrument before Parliament
at the moment removing that, and that means that there will be
no membership as of right on each SHA making sure that tri-partite
mission of education and research alongside patient care is fully
met, and I think this is very important indeed. We cannot really
sensibly leave decision-making about how much resource and how
much effort goes into education to local decision-making in SHAs
where there is no-one with a flag, so it is a very serious problem.
Q589 Charlotte Atkins: Mr Streets,
do you want to come in on that?
Mr Streets: Yes. We would welcome
moves towards integration if it really means that chief executives
of strategic heath authorities are going to prioritise training
and education, and the proof of the eating will be in the pudding,
and actually it is difficult to see how they will, given the other
priorities they are going to be facing. We need strong deaneries
if we are going to have good education, but the key goes back
to the point I made earlier about national strategic leadership
for medical education looking beyond the next year or two, and
it will be fine for them to be integrated locally within SHAs,
providing it was in the context of national leadership of medical
education, really thinking beyond the next year or two, and it
is difficult to see how strategic heath authorities will be able
to do that. Indeed, one would not want 10 different approaches
towards that, you need one national approach to that.
Q590 Charlotte Atkins: Interestingly
enough, you made a comment about ISTCs and the fact they were
going to be training in phase two. I think some evidence we received
yesterday indicated that that was very much down to the deaneries
and it would not necessarily be a contractual obligation?
Mr Streets: There is no doubt
that deaneries are absolutely critical to the delivery of medical
education, and they must ensure that training provided in ISTCs
is equivalent to that that would be provided in an NHS hospital.
Q591 Charlotte Atkins: Do you think
that will happen?
Mr Streets: It is a question you
could ask Professor Paice about.
Professor Paice: Only if there
is the funding for it, because there is one thing that is absolutely
clear about ISTCs and that is that they will do what it is that
they are incentivised to do financially.
Professor Gordon: I think it is
important to point out that it is very difficult when the education
and training levy within the SHA budget is not actually really
ring-fenced, as we think probably it should be.
Q592 Mr Campbell: As we know, education
and training funding is basically supplied by the Strategic Health
Authority, but last year it had a surplus of 500 million. You
have got to wonder why. Did this really affect any training and
education, and the second question which follows on from that,
was it prevented from spending that money because of the defects
in the health economy elsewhere?
Professor Gordon: That is a question
for the Department of Health, but I think it is quite likely that
financial problems in the delivery of patient care may have to
be bailed out, in the present circumstances, using money that
should be for education and training, not just for postgraduate
education and training but also the money that underpins the additional
hospital and primary care costs of training medical students.
The Department of Health has recently very clearly ring-fenced
its R&D money and we believe strongly that the education and
training money should be equally firmly ring-fenced, because if
it is not it will be raided, and that is actually eating the seed-corn
for the future.
Q593 Mr Campbell: The big question
is: is it being raided now or is it going to be raided?
Professor Gordon: We believe has
been raided now.
Q594 Mr Campbell: It has been?
Professor Gordon: My information
is that it has been.
Q595 Mr Campbell: So it is going
to affect training and education?
Professor Gordon: Yes. Certainly
there is evidence in the reduced number of places commissioned
in nursing. You have got Dame Jill Macleod Clark coming later,
so you may be able to ask her about that.
Q596 Dr Taylor: We have had evidence
about nurse training, but, as far as you are concerned, the deficits
have not yet affected medical training.
Professor Gordon: No, but there
is a process going on to look at the scale of the element of SIFT
(Service Increment for Teaching) that actually supports undergraduate
medical training to suggest that there might be a common rate
and that rate might well be much less than the true cost, we believe.
Certainly in many centres it will vary from one centre to another.
So, we are very concerned about the process that is going on to
review the levels of SIFT, and we believe that that could have
a severely adverse effect on undergraduate medical training.
Q597 Dr Taylor: Somehow the Government
have found £765 million to lesson their deficits, and that
would appear to have possibly come from the training budgets.
Have you any evidence that that is the case?
Professor Gordon: Not directly,
no, I have not.
Q598 Dr Naysmith: We are going on,
finally, to the question of diversity. It seems to be fairly well
recognised that a disproportionate number of doctors are female,
white or Asian and middleclass. How can we encourage more working
class men into the medical profession?
Professor Gordon: The Committee
members probably do not know the huge amount of work that medical
schools do in trying to ensure the appropriate diversity of their
intake. We have teams of staff and our students go out into primary
and secondary schools. In my own centre we are involved in every
school within a certain radius in Greater Manchester and we talk
to children, we endeavour to find those who would have the aptitude
and the ability and encourage them to come in. Sometimes they
are dissuaded by other factors, particularly financial ones. It
is very difficult if your parents are looking forward to you entering
the paid workforce very early on and you are going to be a student
for many years, and there, I think, obviously bursaries and other
things can help in that way. The other development with which
the Council of Heads and Medical Schools is involved is that of
the UK clinical aptitude test. This is designed to test innate
ability rather the kind of abilities that can be trained for and
shown in public examinations, and it will also be looking for
qualities such as integrity, empathy and resilience. So, we are
looking for the basic qualities that the young man or woman has
rather than what they have been coached to do in school, and about
75% of all medical and dental schools will require students to
take UK CAT, and we believe that this will be a great help in
picking out young people from all backgrounds who have the right
ability and then we are very keen to get them through.
Q599 Dr Naysmith: The Chief Medical
Officer told us when we were discussing this subject that new
medical schools had been more successful in this than other medical
schools, the older, more established traditional ones. Should
it not be those ones that they were really trying to get the sort
of people you were talking about?
Professor Gordon: I would be interested
to know Sir Liam's data on that point. I come from quite an old
medical school and we are working very hard.
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