Select Committee on Health Third Report

4  2007-08: Fall-out

Introduction

78. Despite the many problems experienced during Round 1 of recruitment, the majority of training posts were filled by 1 August 2007. The chaos and confusion of the previous six months, however, and the obvious inadequacy of the selection process, had raised serious questions about the future of the MMC programme. A new round of selection was set to begin in January 2008 and it was unclear how this would be managed in light of the woeful performance of the recruitment system in 2007. In this chapter we look at how the Department of Health and others responded to the fall-out from the 2007 crisis. We then examine the findings of the independent Tooke Review into the implementation of MMC, which published its interim conclusions in October 2007.

Aftermath of the 2007 crisis

NEW GOVERNANCE ARRANGEMENTS

79. One of the Department's immediate responses to the problems of 2007 was to make significant changes to the governance arrangement for MMC. The Douglas Review group, which had been the main decision-making body for both MMC and MTAS since its creation in March 2007, published its final report on 12 July, after which it ceased to exist.[89]

80. On 25 July, a newly constituted MMC Programme Board met for the first time, chaired by the Deputy Chief Medical Officer. The new post of Chief Operating Officer for MMC was also created at this time. The new Programme Board contained representatives from a range of interested parties including the Royal Colleges, the BMA, NHS organisations and the Department of Health. Many of the Board's members had sat on the Douglas Review group and the medical profession and junior doctors themselves were well represented.

81. The Secretary of State described the introduction of the new Programme Board with significant professional representation as "the most important innovation" in the immediate aftermath of the 2007 crisis.[90] Others were more doubtful: Dr Ian Wilson, a BMA representative on the Programme Board, told us that the new Board risked repeating the mistakes of 2007 by ignoring the views of the medical profession. Such doubts appeared to be confirmed in January 2008 when several Programme Board members from the Royal Colleges wrote to The Times to complain about the allocation of training places for 2008. The continuity of Department of Health representation on the Programme Board was also affected when MMC's Senior Responsible Officer, Martin Marshall, resigned in late 2007.[91]

82. The main immediate tasks facing the new Programme Board were to oversee the completion of Round 2 of the 2007 recruitment process and to advise Ministers on arrangements for the 2008 recruitment process. Longer-term decisions about the future of the MMC programme were largely deferred until after the publication of the Tooke Review. On 11 October, the Round 2 interview process was further extended with the current jobs of Round 2 applicants guaranteed until 31 December.[92] Thus the Round 2 process was only finally completed a few days before the 2008 selection process began.

THE STATUS OF NON-EEA DOCTORS

The situation in 2008

83. The new Programme Board also had the task of addressing the future of non-EEA applicants. As described in Chapter 3, the failure to resolve the status of overseas applicants prior to the start of recruitment was one of the main causes of the 2007 crisis. In an attempt to prevent this problem from recurring, the Department of Health published a consultation paper on 8 October 2007, setting out options for managing non-EEA applications in 2008. In spite of BAPIO's ongoing legal appeal, the Department's preferred option was to restrict applications from overseas doctors in 2008 by enforcing its guidance to employers:

The Department's preferred option is to re-implement the long-standing policy guidance, that doctors from outside the EEA with limited leave to remain in or enter the UK should be considered for post-graduate medical training places in the NHS, only if there is no suitable UK or EEA applicant.[93]

84. The Department's consultation paper estimated that the decision not to implement its guidance in 2007, which we describe in Chapter 3, would eventually leave 1,200 UK medical school graduates without a training post.[94] This was the first time that the impact of open competition in 2007 had been quantified; the Department later increased its estimate to more than 1,300 UK-trained doctors "displaced" in 2007.[95] The Department went on to predict that if its guidance was not applied in 2008 and subsequent years "around 1,000 to 1,500 UK medical school graduates are likely to be displaced and unable to secure a training place".[96]

85. Thus the Department's plans for 2008 were reliant on the Court of Appeal upholding the legality of its employment guidance. BAPIO's case was heard in October 2007 and on 9 November the Department's guidance was declared unlawful. Lord Justice Sedley concluded that the guidance contradicted existing Immigration Rules and should not have been promulgated without Parliamentary approval. He concluded:

Very properly, the guidance has been put on hold pending these proceedings. I would declare it to be unlawful and of no effect.[97]

86. The Department subsequently requested a review of the Court of Appeal's decision by the House of Lords. The House of Lords' verdict was scheduled for publication in May 2008, however, meaning that the Department was again unable to apply its guidance when the 2008 selection process began in January. Just as in 2007, non-EEA doctors who had gained HSMP status were free to apply on an equal footing with UK and EEA doctors in 2008. According to the Department itself, this would mean there would be three applicants for every available training post in 2008, a higher competition ratio than in 2007, and up to 1,500 UK graduates displaced from the training system.[98]

The situation in 2009 and beyond

87. Undeterred, the Department released a further consultation paper in February 2008, examining options for managing non-EEA applicants in 2009. Once again, the Department proposed to implement its employment guidance, provided that the House of Lords declared it lawful in May 2008.[99] The Secretary of State told the Committee that he was "quite confident" the House of Lords would uphold the Department's appeal.[100] He also stated, however, that the guidance would not be applied retrospectively if it was found to be lawful, meaning that its full impact would not be felt until 2009.[101]

88. The Secretary of State also described some of the other options available for managing non-EEA applications in 2009 and beyond:

If it [the guidance] is upheld I doubt whether we will need any further requirements… If the guidance is not upheld then we will continue to look at other options… I mentioned one, which is a fees regime. The other is to see whether we could pass into legislation from my Department something that would cover this…[102]

89. To ease the situation, the Home Office introduced restrictions to its new immigration system in February 2008, preventing any overseas doctors acquiring HSMP status in the future from applying for training posts. This change, to be implemented gradually in 2008, would not affect existing HSMP doctors but would prevent non-EEA doctors from applying through the HSMP route from 2009 onwards.[103] The Department of Health stressed, however, that this represented only a partial solution: the applicant pool in 2009 would be reduced by 3,000 to 5,000, but the 10,000 HSMP doctors already in the UK would be unaffected.[104] The Home Office also emphasised that the change represented a "stop gap" solution to allow the Department "to find its own sustainable solutions to workforce planning problems".[105]

THE 2008 RECRUITMENT PROCESS

90. Alongside these faltering efforts to resolve the status of non-EEA doctors, the Department set out detailed plans for the 2008 recruitment process, strongly influenced by recommendations from the new Programme Board. A consultation paper published on 12 September 2007 proposed a recruitment process delivered largely by local Postgraduate Deaneries and without using the national on-line computer system.[106] Other features of the 2008 system included:

• Candidates were permitted to make as many applications as they wished;
• New applications forms and short-listing systems were used, designed locally by Deaneries and giving more prominence to CV-based questions, and with different forms for candidates applying to different levels of the training system;
• Local timetables for completing the main selection process were established, within a national timetable running from January to May 2008, with two further small recruitment rounds thereafter; and
• Variation between the selection processes used by different specialty areas with a small number, including General Practice, Histopathology and Public Health, running a national recruitment system.[107]

91. Representatives of Postgraduate Deaneries told the Committee in January 2008 that the recruitment process was running more successfully than in 2007. Professor Elisabeth Paice, Dean Director for the London Deanery, even commented that in spite of the inclusion of non-EEA doctors, the number of applicants had not overwhelmed the selection system:

…one might have feared a tidal wave of applications, but that has not happened. Obviously, people are targeting the post they want…they are spreading their applications so that across the country people are getting applications in the thousands, though not tens of thousands. Therefore, so far so good…[108]

The Tooke Review

92. At the same time as the 2008 recruitment process was being planned and implemented, the independent Tooke Review published its findings and recommendations for the reform programme for 2009 and beyond. The Tooke review panel published an interim report, Aspiring to Excellence, in October 2007.[109] Following a consultation period, a final report was produced in January 2008. The inquiry's findings, which have significant implications for the MMC programme, future recruitment systems and the wider medical workforce, are set out in more detail below.

THE DIAGNOSIS

93. One of the key tasks of the Tooke Inquiry was to establish why the crisis of 2007 occurred. The review looked widely at the development of the MMC reforms, as well as specifically at the MTAS recruitment process, in order to answer this question. Its main conclusions were:

• The policy objectives for MMC were poorly defined with "no definitive description of MMC and what it embraced". The original principles of Unfinished Business "were eroded and over time subsumed by workforce objectives" during implementation. For example, the creation of run-through training programmes contradicted the principle of increasing the flexibility of the training system.[110]
• Governance structures for MMC were inappropriate "with complex and ambiguous accountability structures for policy development and very weak governance and risk management process". Crucially, responsibility for the national recruitment system and for resolving the status of non-EEA doctors "lay outside the MMC management framework".[111]
• The implementation of MMC, and particularly MTAS, was hampered by poor project management, including unrealistic timescales, a failure to pilot, poor risk management and the over-ambitious decision to introduce all the changes in the same year.[112]
• These problems were compounded by weak leadership on the part of both the Department of Health and the medical profession. Regarding the latter, the report commented that "…individual medical constituencies all too often responded as such rather than exhibiting the professional leadership required to resolve issues of importance to the service as a whole."[113]
• Lines of accountability, funding and incentives for some of the key organisations in medical education were flawed or inadequate. The report particularly highlighted problems affecting Postgraduate Deaneries and PMETB.[114]
• Ineffective workforce planning during the development of MMC created further problems. The "rigidity" of the run-through training system, the uncertainty surrounding FTSTA posts and the failure to resolve the status of non-EEA doctors were all the product of poor workforce planning.[115]

THE TREATMENT: STRUCTURAL CHANGE

94. In response to these numerous and serious problems, the Tooke Review made a total of forty-seven recommendations for change, many of which we discuss in more detail in subsequent chapters.[116] Amongst the most significant of these were proposals for a further restructuring of the medical training system. Aspiring for Excellence called for the two-year Foundation programme to be split and for run-through programmes to be un-coupled into "Core" and "Higher" specialist training schemes, changes which would reverse the two key structural reforms brought in by MMC. The Review also proposed integrating academic medicine programmes with mainstream training, substantially changing recruitment and selection techniques and increasing the length of GP training from three to five years. The new training structure proposed by the Tooke Review is shown below:

Figure 5: Future structure of medical training recommended by the Tooke Review
Postgraduate training - Inquiry recommendations

Source: Aspiring to Excellence

95. Aspiring to Excellence suggested that the implementation of these changes should begin in 2009.[117] We examine the structure of the medical training system and the Tooke Review's proposals in more detail in Chapter 5.

THE TREATMENT: ORGANISATIONAL CHANGE

96. Aspiring to Excellence also made a number of recommendations for reform of the organisations responsible for postgraduate medical training. In particular, it proposed:

• That a new body, NHS Medical Education England (NHS:MEE), be created to co-ordinate post-graduate medical education, define the principles to underpin training, and oversee the implementation of future reforms. NHS:MEE would hold the budget for postgraduate medical education, which would be ring-fenced, and would scrutinise the commissioning of training by Strategic Health Authorities.[118]
• That a review of the role of Postgraduate Deaneries be carried out, particularly as the inquiry found that Deaneries were often poorly integrated with local providers and Universities.[119]
• That the postgraduate regulator, PMETB, be absorbed by the GMC, the regulator for undergraduate training, to improve and integrate the regulation of medical training.[120]
• That the Department of Health improve policy development, governance and project management for medical education while devolving detailed operational responsibilities to NHS:MEE.[121] The Review also recommended that the Chief Medical Officer should be the Department's Senior Responsible Officer for medical education with responsibility for liaising with NHS:MEE.[122]

97. The Tooke Review also recommended improvements to medical workforce planning and called for a wide-ranging debate on the role that doctors should play at different stages of their career. Finally, Aspiring to Excellence was critical of the undue focus on measuring "competence" which characterised the MMC reforms, arguing that this was an inappropriate foundation for the medical education system:

…the Independent Inquiry Panel was clear: mechanisms that smacked of an aspiration to mediocrity were inadmissible. Put simple, "good enough" is not good enough. Rather, in the interests of the health and wealth of the nation, we should aspire to excellence.[123]

RESPONSES TO THE TOOKE REVIEW

The general response

98. The response of the main stakeholders in postgraduate medicine to the Tooke Review was extremely positive. The Royal Colleges, the BMA, NHS Employers and Fidelio all expressed strong general support for the inquiry's findings. RemedyUK, the most active opponent of the 2007 reforms, urged that all of the recommendations in Aspiring to Excellence be implemented.[124]

99. In addition, a formal consultation on Aspiring to Excellence was conducted between October and November 2007. A total of 1,440 respondents stated whether they agreed with each of the interim report's 45 recommendations: an overwhelming level of support was expressed. Sir John Tooke told the Committee in November that:

…there is 87% agreement or strong agreement across the 45 recommendations and only 4% disagreement… For each of the recommendations there is a majority opinion in favour. In my experience of consultation exercises I do not believe I have ever seen that degree of overall support for a set of recommendations…[125]

100. Witnesses did raise concerns, however, about some of the Review's specific recommendations. The BMA and Postgraduate Deans, for example, disagreed with the recommendation that the two-year Foundation programme be split.[126] Meanwhile, Representatives from NHS Employers, SHAs and Postgraduate Deaneries all expressed concerns about the creation of NHS:MEE.[127]

The Department of Health's response

101. The Chief Medical Officer accepted many of the criticisms made by the Tooke Review and described Aspiring to Excellence as "an excellent report". He warned, however, that "there are some differences of view on the proposals".[128] The Secretary of State commented in February 2008 that the independent inquiry had made "an enormous contribution" to the task of resolving the 2007 crisis.[129]

102. On 28 February , the Department published its formal response to the Tooke Review. The Secretary of State welcomed the report, calling it a "careful and balanced analysis and diagnosis" and "a significant step in moving forward" in response to the 2007 crisis.[130] The Department accepted a number of the Review's recommendations:

• 24 of the Tooke Review's 47 recommendations were accepted. Many of the recommendations accepted, however, were qualitative changes with no timetable or way of measuring progress indicated.[131]
• The recommendation to merge PMETB with the GMC was accepted, although the Department stated this would not take place until at least 2010.[132]

103. However, the Department deferred decisions on whether to accept the Review's other 23 recommendations, which included the most significant changes proposed:

• The Department deferred decisions on changes to the structure of medical training, including whether to split the Foundation programme and un-couple run-through training. It cited the need for more time to evaluate the new schemes and to consider the Tooke Review's proposals, calling for a "period of stability" before introducing further changes.[133]
• The decision about whether to set up NHS Medical Education England was also deferred. The Department stated that this question would be considered as part of the NHS Next Stage Review, due for publication in June 2008.[134]

Conclusions

104. The independent Tooke Inquiry produced a perceptive and comprehensive analysis of the problems which affected the MMC programme and the causes of the 2007 crisis. The Secretary of State was right to quickly accept many of the Inquiry's recommendations for change and improvement. Decisions on the Inquiry's most significant and far-reaching proposals, however, were deferred. We recommend that the Department publish an updated response to the Tooke Inquiry, setting out its final decisions on all 47 recommendations, immediately after the Darzi review has been published.

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89   The Review Group's report acknowledged the "major crisis" caused by the new Specialty training recruitment system (p.3), labelled the planning for MTAS "overambitious" and criticised the lack of consultation with the profession regarding the details of the recruitment process (p.12). Back

90   Q 844 Back

91   MMC's Chief Operating Officer, Terry Hanafin, was also replaced in late 2007 Back

92   MMC Team letter, 11 October 2007 Back

93   Department of Health, Recruitment to foundation and specialty training - Proposals for managing applications from medical graduates from outside the European Economic Area, 8 October 2007, pp.10-11 Back

94   Ibid, p.8 Back

95   Department of Health, Recruitment to foundation and specialty training-Proposals for managing applications from medical graduates from outside the European Economic Area, 6 February 2008, p.9 Back

96   Department of Health, Recruitment to foundation and specialty training-Proposals for managing applications from medical graduates from outside the European Economic Area, 8 October 2007, p.8 Back

97   High Court Ruling, 9 November 2007, paragraph 55. Back

98   Department of Health, Recruitment to foundation and specialty training-Proposals for managing applications from medical graduates from outside the European Economic Area, 8 October 2007, p.8 Back

99   Department of Health, Recruitment to foundation and specialty training-Proposals for managing applications from medical graduates from outside the European Economic Area, 6 February 2008, pp.14-16 Back

100   Q 913 Back

101   Q 911 Back

102   See Q 907 and Qq 912-913 Back

103   MMC 60 Home Office Back

104   Department of Health press release, New immigration rules for international medical graduates, 6 February 2008 Back

105   MMC 60 Home Office Back

106   Department of Health, Recruitment to specialty training-proposals for improvements in 2008, 12 September 2007 Back

107   See http://www.mmc.nhs.uk/default.aspx?page=321 for further details Back

108   Q 581 Back

109   Tooke Inquiry, Aspiring to Excellence: Findings and recommendations of the independent inquiry into Modernising Medical Careers, October 2007 Back

110   Aspiring to Excellence, p.11 Back

111   Ibid Back

112   Ibid, pp.43-50 Back

113   Ibid, p.12 Back

114   Ibid Back

115   Ibid, pp.11-12 Back

116   45 recommendation appeared in the interim report in October 2007, with a further 2 recommendations (along with revisions to the original 45) appearing in the final report in January 2008. Back

117   Ibid, p.46 Back

118   Aspiring to Excellence, pp.64-65 Back

119   Ibid, p.41 Back

120   Ibid, p.44 Back

121   Ibid, pp.22-23 Back

122   Ibid, p.22 and p.40 Back

123   Ibid, p.5 Back

124   Ev 140 Back

125   Q 155 Back

126   See Q 413 and Q 602 respectively Back

127   See Q 722, Q 718 and Q 607 respectively. Witnesses pointed out that as it only appeared in the inquiry's final report, published in January 2008, the proposal to create NHS:MEE had not been subjected to consultation Back

128   Q 120 Back

129   Q 844 Back

130   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.1 Back

131   For example the Department agreed to redefine the principles underpinning medical training (Recommendation 1), to consult with the medical profession on future policy changes (Recommendation 3), and to strengthen its links with education and research (Recommendation 8) Back

132   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, pp.42-43 Back

133   Ibid, pp.47-49 Back

134   Ibid, pp.54-55 Back

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Prepared 8 May 2008