Select Committee on Health Third Report


For many years there have been concerns about the UK medical workforce, in particular the postgraduate medical training system. The most prominent of these centred on the poor training and indifferent career prospects experienced by some doctors at Senior House Officer (SHO) level and by many of those in Staff Grade and Associate Specialist (SAS) posts.

The Modernising Medical Careers (MMC) programme of work was established in 2003 to address these difficulties. A new Foundation programme was introduced in 2005, the Specialty Training system was reformed and the SHO grade scrapped in 2007. As a result of inadequate preparation during the implementation of the reforms, in 2007 the MMC programme plunged into crisis. The new centralised recruitment system, the Medical Training Application Service (MTAS), proved highly unpopular with both candidates and assessors. The number of applicants was also much higher than expected, creating fierce competition for posts in many areas and making thousands of doctors deeply anxious about their future prospects.

Following intense public pressure and major demonstrations by junior doctors, the Department set up the Douglas Review Group to make changes to the recruitment system. Several senior resignations, a legal challenge, two major security failures and a number of emergency statements by the then Secretary of State followed, however, as the crisis deepened. Elements of the MTAS system were subsequently abandoned and, although most training posts were eventually filled, the events of 2007 proved a disaster both for the Department of Health and for the medical profession itself.

The Government acknowledged that its new systems were flawed and apologised on several occasions to the thousands of doctors affected. The Secretary of State commissioned a major inquiry, led by Sir John Tooke, to examine the 2007 crisis. The Tooke Inquiry reported in January 2008 and called both for major changes to the structure of training and for the creation of a new body, NHS Medical Education England, to oversee medical education. The Department deferred decisions on whether to implement the Tooke Inquiry's most significant proposals.

Like the Tooke Review, the Committee's inquiry exposed serious problems with the management of the MMC reforms, and particularly the introduction of MTAS, by the Department of Health and its partners. A divided and inappropriate governance structure, flawed project and risk management and poor communication with junior doctors were the most serious failings. Co-ordination between the Department of Health and the Home Office on restricting medical migration was also woefully inadequate. These practical shortcomings were responsible for some of the direct causes of the 2007 crisis, including the defective application form and other aspects of the short-listing process, the unsafe computer system and the failure to limit the number of applications from overseas doctors.

Our inquiry also uncovered wider problems with policy development and leadership for MMC. The specific changes introduced by MMC often conflicted with the programme's stated aims, for instance through the universal introduction of run-through training in 2007, which created a more rigid rather than a more flexible training system. The leadership shown by the Department of Health was totally inadequate. Despite being the architect of the reforms, the Chief Medical Officer chose not to take on a clear leadership role and thus did not accept responsibility for the 2007 crisis. The medical profession was often more concerned by factional interests than by the common good. This confusion and incoherence exacerbated the 2007 crisis and prevented MMC from achieving many of its original aims, most notably increasing flexibility and reforming the SAS grades.

We make a number of recommendations for change and improvement in response to the shortcomings which undermined MMC. The Department of Health must address its weaknesses in project and risk management. It should strengthen and increase the independence of the MMC Programme Board and work more effectively with the medical profession on future education policy. A number of improvements to project management and to performance management of Strategic Health Authorities by the Department are also required. Employers and training providers should play a bigger role in decisions about the future of training while partnerships between the health and education sector must be revitalised.

The future structure of the training system itself must above all be made more flexible. This means allowing individual specialties to decide what length and type of training posts they offer, rather than continuing to impose one-size-fits-all solution from the centre. We therefore support the current "mixed economy" of specialty training schemes and recommend that this approach is maintained and extended. We suggest a similarly flexible approach to future recruitment processes and recommend that the Department devolve all responsibility for recruitment and selection to Postgraduate Deaneries and employers.

Devolving these detailed responsibilities to local level will allow the Department of Health to focus on more important policy questions affecting the medical workforce. Most pressing of these is how to restrict access for non-EEA doctors to UK training posts, a necessity in light of the recent expansion of UK medical schools. The Government has comprehensively failed to address this issue to date and its future policy is now reliant on a legal judgement by the House of Lords. The Department of Health and the Home Office must work together to resolve this embarrassing problem as a matter of urgency.

Finally, we recommend that the Department of Health address policy issues relating to the wider medical workforce, one of the unrealised ambitions of MMC. Reform of the SAS grades in particular is vital: the Department should aim to develop SAS posts into a genuine and valuable alternative to the formal training system, rather than the educational backwater in which they currently remain. We also propose the introduction of a hierarchy within the consultant grade. In addition, we call on the Department to resolve the key questions affecting the size and nature of the medical workforce, including whether care is to be consultant-led or consultant-delivered in future.

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Prepared 8 May 2008