House of Commons - Health

Select Committee on Health Third Report

7 Managing reform

234. The events described in Chapter 3 and the evidence we received raised serious questions about the management both of the introduction of the new specialty training schemes in 2007, and of the wider MMC programme. The Tooke Review criticised the poor performance of the Department of Health across several areas of programme management:

The Inquiry has found evidence of DH deficiencies in policy making with ambiguous accountability structures for policy development, and very weak governance and risk management processes.[

269

Sir John Tooke also criticised "deficient project management" by the Department, describing this and other failings as "the structural fault where much of the blame lies".[270]

235. In this chapter we therefore examine the management of the MMC reforms and make recommendations for improving performance in future. We look in particular at:

The policy development process whereby MMC's principles were transformed into specific policies and plans;
Governance arrangements and accountability structures for the introduction of the new programmes;
The project management of the reforms, including the timescales for introducing changes; and
The calibre of leadership demonstrated by both the Department of Health and the medical profession during the implementation of reform.

236. This chapter focuses mainly on the role of the Department of Health in managing the MMC reforms. We consider the role of the other organisations involved with postgraduate medical training in more detail in Chapter 8.

Policy development

237. We saw in Chapter 2 that MMC was developed in a complex policy environment. There were a range of influences on the programme: some, such as Unfinished Business and the increasing number of UK medical graduates, related directly to the needs of junior doctors; while others, such as NHS deficits or the European Working Time Directive, had broader origins and significance. Inevitably, this created a number of different pressures as the aspirations of the reform programme were made into specific plans for implementation. This section focuses on the extent to which the policy development process adhered to the programme's original aspirations, particularly in light of the many other influences on MMC.

CLARITY OF THE OVERALL AIMS OF MMC

238. The guiding principles for the reform of training were clearly expressed at the outset. The so-called "seven pillars" of MMC were set out in 2004: the new training system should be "trainee-centred; competency-assessed; service-based; quality-assured; flexible; coached; and structured and streamlined." Witnesses strongly questioned, however, whether the aim of the MMC programme was actually to implement the seven pillars. Some suggested that other motivations, such as the need to minimise expenditure, were more influential than the seven pillars in shaping the reform programme.

239. The Chief Medical Officer stated that the over-riding aim of MMC was to improve the quality of the training system by realising the aspirations embodied by the seven pillars. He argued that this aim was clear to all those involved:

I do not think there was any confusion about the overall aims of the project. Indeed, I think those were absolutely clear…[

271

240. Sadly, few other witnesses agreed. RemedyUK commented that the aims of the reform programme were "poorly defined, changed over time and were sometimes conflicting".[272] The Association of Surgeons agreed, arguing that the initial aims of MMC, set out in the "seven pillars", became confused with and contradicted the requirements of the European Working Time Directive:

273

241. The Association of Surgeons also argued that the emergence of an overall NHS deficit in 2004/05, which worsened in 2005/06, caused MMC's aims to be further changed and complicated by the need to save money.[274] Alan Crockard, National Director for MMC until 2007, made a strikingly similar point, arguing that one of the programme's leaders was primarily concerned with financial considerations:

275

242. This lack of agreement between the leaders of the reform programme itself regarding the overall aims of the MMC programme was also among the findings of the Tooke Inquiry. Aspiring to Excellence concluded that:

276

REALISING THE PRINCIPLES IN PRACTICE

243. Witnesses were similarly sceptical about the extent to which the specific reforms introduced by MMC, and particularly the changes to specialty training, were consistent with the original seven pillars. The Royal College of Psychiatrists argued that two of the pillars, increasing flexibility and tailoring programmes to individuals "have singularly not been met".[277] RemedyUK agreed that flexibility was "largely lost in implementation".[278] The lack of flexibility in the new training arrangement, largely as a result of the introduction of run-through training in all specialties, was also noted by Fidelio:

279

244. The BMA went further still, arguing that only two of the seven pillars had actually been adhered to during implementation:

280

245. The Department of Health presented a different view, arguing that many of the seven pillars had already been realised through the new programmes:

281

246. The Department went on to acknowledge, however, that the goal of increasing flexibility had not been achieved, particularly as a result of the introduction of run-through training. In a section curiously entitled "Principles still to be implemented", the Department stated that:

282

THE DEVELOPMENT OF RUN-THROUGH TRAINING

247. It is clear from this that the decision to introduce run-through training in all Specialty areas contradicted one of MMC's key principles, namely the need for increased flexibility. This decision provides a compelling example of the weakness and confusion which characterised the MMC policy development process. The specific problems caused by run-through training are described in detail in Chapter 5; what is of particular concern here is how the policy development process allowed for the introduction of a measure which so clearly contradicted the established principles of the reform programme.

248. As we observed in Chapter 2, 2002's Unfinished Business had envisaged that Foundation training be followed by two separate specialist training programmes, "basic" and "higher" training.[283] The idea of a "single training grade" was tentatively suggested, but it was proposed that this possibility "should be explored specialty by specialty". Two years later, however, MMC: The next steps set out plans for "a seamless training process" delivered through "a single run-through approach" in all Specialty areas.

249. The Tooke Inquiry was unable to establish how and by whom the critical decision to implement run-through training was taken. Sir John Tooke stated that:

284

250. The Department of Health's memorandum shed little light on the issue, stating only that "in implementation, inflexibility has crept in" to the new training system. The Chief Medical Officer provided more information, pointing out that plans for run-through training were discussed with professional groups prior to the publication of MMC: The next steps:

Next Steps.

285

251. BMA representatives acknowledged that they had in principle supported the introduction of a run-through grade. However, Dr Jo Hilborne went on to point out that several details of the run-through system introduced by MMC were not in keeping with the BMA's recommendations. She pointed out that "robust careers advice" and opportunities for doctors to switch from one specialty to another were both absent from the MMC run-through system, creating a particularly inflexible system.[286]

252. Bernard Ribeiro, President of the Royal College of Surgeons argued that the plans set out in MMC: The next steps, including the blanket introduction of the run-through grade, had not been subject to adequate consultation with the profession:

Unfinished Business

253. It is apparent, therefore, that the "fundamental mistake" of establishing a comprehensive run-through training grade resulted from a decision on which significant parts of the medical profession were not adequately consulted. Some parts of the profession, notably the BMA, agreed in principle with run-through training, but were unable to influence the critical details of implementation.

IMPROVING POLICY DEVELOPMENT

254. The Tooke Inquiry made clear suggestions for improving policy development, to strengthen both the MMC programme and future Department of Health initiatives. Aspiring to Excellence emphasised that the principles behind the reform of medical training, and in particular the importance of flexibility, should be re-established:

The principles underpinning postgraduate medical education and training should be redefined and reasserted, building on those originally articulated in Unfinished Business but in particular emphasising flexibility, 'broad based beginnings' and an aspiration to excellence.[

287

255. The Tooke Review also called for the Department to consult more closely with the medical profession and other interested parties during the policy development process, and to listen and take account of specific concerns:

288

Programme governance

OVER-COMPLEX STRUCTURES

256. Problems with the policy development process for MMC stemmed in part from the over-complex governance structures for the programme. The large number of bodies involved and complex lines of accountability between them were cited by the Secretary of State as one of the most important overall causes of the project's failure:

…you had the policy being set by something called the UK Strategy Group. You had the criteria being set by the Specialist Training Action Group. Implementation was the responsibility of the MMC Programme Delivery Board. The Strategic Health Authorities through the Deaneries were responsible for implementation… so it was very disparate and it was… a difficulty of knowing who had the lines of accountability with all of that group trying to work together.[

289

257. The sheer complexity of the management and governance structures for MMC is well demonstrated by this diagram, produced in the Tooke Review:

Figure 6: Overall governance structure for MMC

Source: Aspiring to Excellence

258. Aspiring to Excellence particularly emphasised the problems caused by dividing responsibility between two different directorates of the Department of Health: the Workforce directorate and that of the Chief Medical Officer.[290] Two key elements of the planning for 2007, the development of the national recruitment system and the issue of resolving the status of non-EEA doctors, were the responsibility of the Workforce directorate. Professor Alan Crockard described how the MMC team, reporting to the Chief Medical Officer, was unable to influence these crucial areas of the programme:

291

259. The Chief Medical Officer acknowledged that the split accountability structure had caused problems, but stated subsequently that he had not resigned in the wake of the 2007 crisis precisely because he had not been responsible for key areas where implementation failed.[292] Thus Department of Health witnesses used the complexity of the MMC governance structures both to explain the failings of 2007 and, paradoxically, to absolve individuals from responsibility for them.

ESCALATION OF CONCERNS

260. Witnesses also argued that the MMC programme was not well understood by Ministers and other leaders at the Department of Health, and that concerns about the progress of the project were not escalated appropriately. Professor Alan Crockard stated that "the Department of Health management board had no concept of the implications of MMC".[293] He went on to suggest that the problems experienced in late 2006 were not made known to the leaders of the Department:

294

261. As we saw in Chapter 2, Professor Crockard told us he approached a number of other agencies, including the National Audit Office, when his concerns about the project were ignored by the Department of Health in late 2006. Representatives of the BMA described a similar experience when their concerns about the project, set out in the 2006 "Call for Delay", were "ignored".[295] RemedyUK suggested that the Department continued to disregard concerns expressed by the profession:

296

IMPROVING GOVERNANCE

262. Recommendations for improving the governance of the MMC programme were set out in the Tooke Review which called for "clearer roles and responsibilities for a single Senior Responsible Officer" and "clear roles and accountability for senior DH members…"[297] Professor Alan Crockard recommended that there should never be more than one Senior Responsible Owner for future programmes.[298] Dr Ian Wilson of the BMA echoed this suggestion, calling for a single leadership role within the Department of Health:

…

299

263. The Department of Health pointed out that changes of this kind had already been made, stating that a single leadership role for MMC had been established in March 2007:

300

264. The Department set out its "new, simplified, governance structure" in its response to the Tooke Review in February 2008:

Figure 7: New governance and reporting structure at the Department of Health for MMC

Source: Response to the independent Tooke inquiry into MMC

265. The Tooke Review had recommended that the four UK Chief Medical Officers be the Senior Responsible Owners for the MMC programme in their respective administration. As shown in the diagram above, the Department of Health rejected this recommendation in England, creating a separate SRO position, accountable to the Director General of Workforce. Thus the responsibility of the Chief Medical Officer for England for MMC appears to have been reduced in the wake of the 2007 crisis.

266. The Department also emphasised other improvements to its governance systems. It stated that additional staff and better performance management arrangements had been introduced to improve the running of the project itself. In addition, the Department emphasised that more than half of the members of the new Programme Board were from the medical profession, citing this as evidence of a "deeper level of clinical engagement" within the new governance structure.[301]

267. Despite this assurance, Dr Ian Wilson of the BMA, a current member of the Programme Board, expressed concerns about the level of engagement. He warned that there was a risk that officials would once again begin to overlook the concerns of the medical profession, one of the reasons for the crisis of 2007. Dr Wilson stated that:

302

Project management

268. The implementation of MMC was further hampered by basic failures of project management. The Chief Medical Officer acknowledged that such failures were at the heart of the problems experienced in 2007:

Dr Naysmith: So it was project management really that was at fault?

Sir Liam Donaldson: Yes, I think that is a fair summary.[

303

In this section we examine the main problems with project management and how they should be addressed.

TIMESCALES FOR CHANGE

General timescale

269. A consistent criticism of project management was the sheer lack of time to plan and implement the 2007 changes, and particularly to put the new recruitment system in place. Professor Sarah Thomas, Postgraduate Dean for South Yorkshire and South Humber, commented that:

The design of the IT system did not start until half-way through September 2006… It left very little time to get it all finished…[

304

270. Work Psychology Partnership, the company contracted to design the application forms, pointed out that there was a similarly short timescale for completing their work, which was fundamental to the 2007 recruitment system. This meant that the short-listing system could not be piloted and the application form had to be adapted from previous work rather than being produced from scratch:

305

271. The Tooke Review compared the timescale for implementing the new Foundation programme in 2005 with that for the new Specialty training arrangements in 2007. It found that the timescale for the 2007 changes was significantly more contracted, despite the increased complexity of the changes being delivered. The compression of planning and decision-making for 2007 into an inappropriately short space of time is well demonstrated in the diagram below:

Figure 8: Decision-making process for the 2007 reforms

Source: Aspiring to Excellence

272. The Department of Health acknowledged that the "very ambitious timescale" for introducing the 2007 reforms had left "insufficient time for piloting and full testing" of the new arrangements.[306] The Department even accepted that it should have delayed the implementation of the new recruitment system for a year, in line with the "Call for Delay" issued by the BMA:

307

The "big bang"

273. Witnesses also criticised the decision to introduce all of the new Specialty training programmes and the new recruitment system simultaneously in 2007. This so-called "big bang" approach to change was described as "neither necessary nor appropriate" by the Royal College of Surgeons.[308] The British Association of Orthopaedic Trainees argued that "a staged, gradual introduction, rather than the 'big bang'" should have taken place.[309] The Royal College of Psychiatrists pointed out that the "big bang" approach had been adopted "against the advice of many people".[310]

274. The Department accepted that the "big bang" approach to introducing the changes had made matters worse in 2007. It stated that:

311

RISK MANAGEMENT

275. The Tooke Inquiry was also highly critical of the quality of risk management during the implementation of the MMC reforms. Aspiring to Excellence commented on "woefully inadequate risk escalation" procedures within the Department of Health. It also pointed out that two key elements of the project, the national recruitment system and the need to resolve the status of non-EEA doctors, were given "red" risk ratings in May 2006 and July 2006 respectively. Despite this, the Tooke Inquiry found "little evidence of contingency planning or escalation" to mitigate these serious risks, which went on to have such disastrous consequences in 2007.[312]

276. The Royal College of Physicians of Edinburgh also criticised risk management processes, and particularly the absence of a "plan B" in the event of problems with the new systems:

313

277. Methods Consulting, the company responsible for the national IT system, argued that individual risks to the project were anticipated and monitored. However, Methods stated that the negative consequences of problems with the new systems were not well understood. Mark Johnston, CEO of Methods, acknowledged that the scale of the adverse reaction to the introduction of the new recruitment system in 2007 was not anticipated by suppliers:

314

278. Hugh Taylor, Permanent Secretary at the Department of Health, made a similar point. He stated that the Department's senior leaders were made aware of individual risks to the project, but did not have an overall picture of the risks associated with implementation in 2007. He argued that this made it more difficult to make decisions about the future of the programme and to decide, for example, whether to delay implementation:

315

EXTERNAL COMMUNICATION

279. Another element of project management which went badly wrong was communication with applicants themselves, both prior to the introduction of the new systems and during the crisis of 2007. Officials acknowledged, for example, that the intention that only 50% of posts were to be filled in Round 1 of recruitment in 2007 was not made sufficiently clear to candidates:

Professor Marshall: It was not adequately communicated to the applicants, and I think if it had been---

Sandra Gidley

Professor Marshall: I do not know the answer to that. I do not think it was.[

316

280. It is clear from the documentation provided in the final report of the Douglas Review that messages to candidates came from a number of different sources during the 2007 crisis. The Review Group published several statements to candidates in March and April 2007, announcing significant changes to the recruitment system on a weekly basis. Statements later in April and during May concerning the future of the IT system, however, were made by the Secretary of State; from June onwards, most communication with candidates was undertaken by the MMC team.

281. Dr Jo Hilborne of the BMA emphasised the poor quality of communication with candidates and argued that this stemmed in part from the confused governance structures for MMC. She made clear, however, that responsibility for communication fell ultimately to the Department of Health:

317

IMPROVING PROJECT MANAGEMENT

282. A number of suggestion for improving project management were set out in the Tooke Review, including:

Improved risk management, specifically through "faster escalation and resolution of 'red risks'";

Better documentation of decision-making and more clarity about key policy choices; and

Simpler governance structures and a single line of accountability.[318]

283. The Department of Health acknowledged the need to substantially improve project management. Officials pointed out that improving communication with applicants had been one of the immediate aims in response to the 2007 crisis.[319] The Department also agreed to make changes to improve risk management and other project assurance systems:

320

284. As we have seen, officials acknowledged that the decision to press ahead with the implementation of reforms in 2007 represented a serious error. The Department stated that it would avoid similar mistakes in future by establishing clear systems for determining whether projects should go ahead:

321

285. The Department of Health also pledged to pilot future changes more thoroughly and to avoid a "big bang" approach to reform:

322

Box 3: A contrasting picture—the introduction of the Foundation Programme

The programme management difficulties cited in this chapter relate mainly to the introduction of the specialty training reforms in 2007. Witnesses frequently commented that the arrangements for the implementation of the Foundation programme from 2005 were considerably more robust. The Tooke Review and others emphasised that:

The timescale for planning the Foundation programme reforms was much more realistic than that for specialty training, with key decisions taken at an early stage.[323]
The Foundation programme was extensively piloted, while the specialty training reforms were introduced without any assessment of their likely impact.[324]
Funding was available to support the new Foundation programme but not the new specialty training schemes, in particular because of the spread of deficits across the NHS in 2005/06.[325]
There was a close match between the number of posts and the number of applicants when the Foundation programme was introduced in 2005; as we saw in Chapter 3, this was not the case when specialty training was reformed in 2007.[326]

We discuss the future of the Foundation programme in more detail in Chapter 5.

Leadership

286. Inevitably, the crisis of 2007 and the ineptitude of the management of the MMC reforms caused many to question the leadership shown by both the Department of Health and the medical profession. Although the heads of the BMA and of the MMC project both resigned during the 2007 crisis, other senior leaders at the Department of Health and the Royal Colleges remained in post. In this section we look at the quality of leadership and how to improve it.

THE DEPARTMENT OF HEALTH

287. Leadership at the Department was widely criticised during the inquiry. The Tooke Review commented that the split accountability structure for the MMC programme meant there was "an overall lack of leadership" of the programme.[327] BMA representatives agreed, arguing that the absence of an overall leader for the project was the responsibility of the Chief Medical Officer:

328

288. Mr Matthew Jameson Evans of RemedyUK agreed, arguing that ultimate responsibility for the failings lay with the Chief Medical Officer:

329

289. Dame Carol Black, Chair of the Academy of Medical Royal Colleges, was asked whether she and other leaders of the profession continued to support the current Chief Medical Officer. She did not answer directly, stating only that the Royal Colleges "continued to support the principles of MMC". She did not identify what these principles where, or whether they continued to correspond to MMC's original "seven pillars".[330]

290. The Chief Medical Officer defended his position, setting out a number of reasons for not resigning in the wake of the 2007 crisis:

331

291. Sir Liam Donaldson also argued that having a single person in overall charge of the MMC programme would have brought its own disadvantages:

332

292. The Secretary of State, meanwhile, expressed full confidence in the Chief Medical Officer, arguing that he had "done a terrific job over ten years".[333] As mentioned above, the Chief Medical Officer appears nevertheless to have less direct involvement with MMC following recent changes to the programme's governance structure.

THE MEDICAL PROFESSION

293. The leadership of the medical profession, and particularly the failure of the profession to speak with a coherent voice during the planning and implementation of MMC, was also widely criticised. The Tooke Review stated 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.[

334

294. Dr Moira Livingston from NHS Northeast agreed that the medical profession had struggled to offer a coherent view during the implementation of MMC, in spite of the large number of bodies with leadership responsibilities:

335

295. Dame Carol Black, chair of the Academy of Medical Royal Colleges, accepted that the individual Royal Colleges had failed to act in a co-ordinated fashion:

336

296. She also acknowledged that the AMRC itself had been unsuccessful in helping the different interest groups to work together:

337

IMPROVING LEADERSHIP

297. The Tooke Inquiry made a number of suggestions for improving leadership at the Department of Health, including:

The Chief Medical Officer to be given overall responsibility within the Department for all issues relating to medical education;[338]
The creation of a new organisation, NHS Medical Education England, to lead future reforms, something which we consider in more detail in Chapter 8;[339] and
The Chief Medical Officer to act as the main point of liaison between the Department of Health and the new national body.[340]

298. In addition, a number of witnesses suggested reforming or replacing the AMRC to improve medical leadership and to allow the profession to act more coherently. Fidelio called for "an over-arching but representative College of Medicine" to be set up to co-ordinate the work and communicate the views of the Royal Colleges. Sir John Tooke also emphasised the need for the profession to "find a way of speaking coherently" in order to influence future policy development.[341] Aspiring to Excellence recommended that:

342

299. Dame Carol Black, Chair of the AMRC, stated that improvements to the Academy had been made. She did not make clear what these were, however, stating only that:

343

Conclusions and recommendations

300. The management of the introduction of the MMC reforms by the Department of Health was inept. Key policy decisions and the processes for making and documenting them were ineffective and the medical profession, while frequently consulted, rarely influenced critical decisions. The governance systems for the programme were far too complicated, roles and responsibilities were ill-defined and lines of accountability were irrational and blurred. The arbitrary division of responsibilities between the Chief Medical Officer and the Workforce directorate was a fatal fault line within the management of the programme.

301. Project management for the introduction of changes to specialty training was equally poor. Much of the key planning for the 2007 changes took place in a mad scramble at the end of 2006. The "big bang" approach to the reforms and the failure to pilot any of the new arrangements proved particularly serious errors. Individual risks to the project were assessed, but problems were not made known to senior officials and there was no risk management of the project as a whole. As a result, the Department did not recognise the deficiencies within the programme and could not prevent implementation from going ahead prematurely. Project management decisions took little account of the needs and concerns of applicants themselves and communication with junior doctors was appalling.

302. The leadership shown by the Department of Health during this period 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 overall responsibility for the 2007 crisis. The confidence of the medical profession in the current CMO has been seriously damaged by MMC. Serious criticisms of the CMO have arisen in part because of the ambiguity of the role. We recommend that the job description be reviewed to define the role more accurately and then publicised to facilitate wider understanding of the CMO's duties and responsibilities.

303. The Department has already made a number of changes to programme management in light of the 2007 crisis and in response to the Tooke Inquiry. The governance systems for MMC have been simplified and improved and a single line of accountability established. The new MMC Programme Board appears to give the medical profession a more meaningful role in decision-making. And the Department has adopted a more conservative approach to implementing future reforms.

304. We welcome these changes. However, the constitution, independence and leadership of the MMC Programme Board remain too vague to provide assurance that it can develop and implement effective solutions to the challenges identified in this report. Members of the current Board themselves warned that the views of the profession are still not receiving adequate attention. We therefore recommend the following additional improvements to programme management for MMC by the Department of Health:

Members of the Programme Board should be selected in equal numbers by the Department of Health and bodies representing the medical profession; a similar process should be used to select Chairs for the Programme Board;

All future policy development decisions should be approved by the MMC Programme Board;

A document reviewing the principles behind the MMC reforms should be agreed by the Programme Board and published by August 2008;

Meetings and decisions of the Programme Board must be properly minuted and attendance at the Programme Board should be consistent;

All future changes should be piloted and evaluated;

A "big bang" approach to reform should be avoided wherever possible in future;

Communication with junior doctors should be improved and a single source of authoritative information established; and

Complete clarity is required regarding the roles of the CMO and the NHS Medical Director in the delivery of MMC. The Department should make clear how the CMO's role as professional lead for doctors in England can be carried out effectively given his distant relationship with MMC.

305. In particular, these changes should help to ensure that the new Programme Board represents a genuine partnership between the Department of Health, the NHS and the medical profession. Such an approach is vital if the new Board is to avoid the weaknesses and pitfalls which affected the previous UK Strategy Group and the Douglas Review group.

306. We also recommend the following improvements, which the Department should apply to all future change programmes:

The Department should produce, and publish where appropriate, formal business cases to support major change projects. The expected costs and benefits of reforms should be clearly stated and, if possible, quantified.
Formal mechanisms for reviewing progress and risks across the whole of projects should be introduced. Regular reviews should inform decisions about whether timetables for the implementation of change are realistic.
The Permanent Secretary should monitor all substantial change programmes being conducted by the Department and should ensure that other senior officials are informed about the progress of key projects.
The Department must ensure that project management is adequately resourced and proper training provided. Managing major change projects should not be regarded as a task that can be tacked on to existing job roles.
Ministers and officials should set more realistic timescales for introducing major changes, and should be prepared to delay implementation if necessary.

307. The leaders of the medical profession itself were also ineffective, divided by factional interests and unable to speak with a coherent voice. The weak and tokenistic nature of the Academy of Medical Royal Colleges was exposed by the MMC crisis. We therefore recommend that the Royal Colleges review the role of the Academy of Medical Royal Colleges and consider replacing it with an executive body which has the authority to make decisions on behalf of all the Colleges.

269 Aspiring to Excellence, p.20 Back

270 Q 161 Back

271 Q 6 Back

272 Ev 140 Back

273 Ev 95 Back

274 Ev 94 Back

275 Ev 129 Back

276 Aspiring to Excellence, p.40 Back

277 See Ev 164. Some witnesses also pointed out that some of the seven pillars could be interpreted as mutually exclusive, for example the ambition for training to be both "structured and streamlined" and "flexible". Back

278 Ev 141 Back

279 Ev 189 Back

280 Ev 134 Back