Select Committee on Health Written Evidence

Memorandum by Professor Dame Carol Black (MMC 56)



  I have the advantage of having studied Aspiring to Excellence, Sir John Tooke's interim report of the Independent Inquiry into Modernising Medical Careers, together with records of the proceedings of the Health Committee, and familiarity with developments in MMC following the events last year that led to this inquiry.

  The interim report identifies eight major issues and proposes actions necessary to correct each of them. I am in agreement with the conclusions and the corrective actions and with the broad intention of the recommendations.

  This short memorandum focuses on an understanding of the essential principles on which postgraduate medical education and training are based. It is ordered to match the focal points of the Committee's Inquiry.

To what extent the practical implementation of MMC has been consistent with the programme's underlying principles

  1.  As the Committee has learnt, the principles that we believed underlay MMC were defined by the Chief Medical Officer's Report Unfinished Business. The chief principles to be observed in postgraduate medical education were that it should have broad-based beginnings, offer flexibility and be conducted within a structured programme.

  2.   Unfinished Business described flexibility as the ability to support and accommodate varying needs of trainees and to respond to changing and challenging service demands. It meant allowing for individually tailored or personal programmes, with arrangements to facilitate movement into and out of training and between training programmes. It recognised that for many doctors, though not all, career decisions could change during the early years of specialist training.

  3.  Approaches to training in the past produced doctors with deep and varied experience and was inherently flexible. But often it was incomplete. Numbers of junior doctors were trained through planned rotations of high quality, but for many more, probably most, training was less well structured and often those doctors were less well advised and supported than they should have been. Their training experience was patchy and uncertain, though they often had much clinical experience and indeed were vital to the service.

  4.  With the ever-increasing complexity of medicine and the need to ensure no significant aspects are overlooked in training, a more structured approach is necessary today. So among the profession's purposes in supporting modernisation of medical careers was to ensure the provision of better-structured training for every doctor than had been available hitherto.

  5.  There was a further imperative. It was to ensure there would never again be a group of doctors, "a lost tribe", with few further or, at best, uncertain career opportunities. Indeed if the "lost tribe" were simply replaced by another it would be seen as a new betrayal. To our shame, that is just what is happening today.

  6.  The precise policy aims of MMC, the name given to the Department of Health programme of training arrangements, have become obscure. Founding principles have been lost sight of, and there has been a palpable change in emphasis. The structured approach remains but it has become rigid, the arrangements allowing none of the flexibility, including the individual tailoring, that was promised. There has been a failure to observe fundamental principles that had earlier received such strong support. MMC is not really synonymous with training activities centred on curricula, educational programmes and assessment. It has more to do with central delivery of training programmes that are closely tied to the role of junior doctors in delivering service needs. The weakened focus on needs of trainees themselves became rather clear during the recent debacle.

  7.  The potential benefits of broad-based, themed training are on the one hand a fuller opportunity for making a mature career choice, and on the other a cadre of doctors whose sound core specialist training provides the surest foundations for subsequent specialised differentiation according to service need and technological and therapeutic progress.

  8.  A word about specialisation. I can think of no specialty that works in isolation. The interdependency of people in different specialties has long been a feature of secondary care. Now it is reaching seamlessly across and within both primary and secondary care. It is sensible to recognise this in training programmes.

  9.  Sir John Tooke's interim report addressed the concern to restore flexibility by provision of a period of core training with diverse experiences, with the opportunity for individuals to reflect what their choice of subsequent specialist course should be. That said, for some doctors in particular specialties a run-through training programme might be more appropriate. Even then there is a potential loss; for example, removing the possibility of diversion to explore an unexpected research challenge.

  10.  The 45 recommendations of Sir John Tooke's interim report embrace and reflect the original principles and the means for ensuring they are observed. They captured 87% agreement or strong agreement across the 45 recommendations. I believe that is a powerful affirmation of the soundness of the principles espoused in 2002.

  11.  Flexibility has come have another meaning, which has less to do with the sense of enabling doctors to shape their training pathway in ways that allow them to make adjustments according to their aptitudes, their early experience of different fields of medicine and their developing interests. Instead, MMC described itself as "a key enabler for other DH programmes". It focused on the development of a flexible workforce of doctors; but in reality the approach it favoured denied the very flexibility or adaptability necessary in an evolving service.

  12.  MMC also stated that the skills and the absolute guarantee of standards from new methods of assessment are key to the success of modern workforce programmes like the Hospital at Night, and the Working Time Directive; and that most importantly it will deliver a modern training scheme and career structure that will allow clinical professionals to support real patient choice. Thus there was a shift of emphasis towards current service imperatives.

  13.  It is obvious that training and service are intertwined, that the experience of service is, and must be, part of learning; but we must ensure that service is not at the cost of learning. It is crucial that the long-term investment in training, including those who have training roles, is not put at risk by unbalanced pressures to meet service or financial needs and that secure arrangements are in place to ensure that is so.

  14.  There was a declaration that "streamlined training and explicit standards of assessed competence are also essential if doctors' careers are to accommodate the pressures of a family and modern lifestyles. MMC aims to greatly improve the opportunities for those who wish to take a break in their careers and will promote fairness and equality of opportunity at all stages of a doctor's career". Such statements ring hollow today.

  15.  The experience of MTAS has made the primary claim open to question. Many believe that MMC appears to have been designed with the primary purpose of meeting NHS workforce needs linked to training opportunities. But it has become clear that for many doctors those opportunities have become seriously limited. Moreover the arrangements have shown little if any regard to the career and personal aspirations of trainee doctors.

The strengths and weaknesses of the MTAS process

  16.  Any process of selection must assess what is valid, must not ignore what is significant, measure what it claims to measure, and be capable of discerning between candidates fairly. It should be accepted by participants—candidates and assessors, and the public—that the process meets such criteria. There were demands that the MTAS process be so validated and evaluated before general introduction, but this was not done.

  17.  In the selection methodology we find a shift in the meaning of terms: in the terms competent and competency, for example. There was an untested belief that the methods of assessment were capable of recognising and discerning between the different qualities and attributes that doctors, at each level of responsibility, must bring to their practice.

  18.  The approach to competency adopted by the Department of Health has become reductionist in nature. In trying to reduce specialist knowledge and skills to a "list of parts", it loses the sense of how a doctor—like other professionals who must take important decisions in the face of incomplete information and uncertainty—is shaped through education and experience to make the kinds of judgements that are the essence of maturing practice. It goes without saying that that they must be competent in the range of functions that are necessary for safe practice as they undertake training in service. But the demonstration of a range of competences alone is far from sufficient assurance of the knowledge, skills and attributes demanded by the service element that is an indivisible part of training. Indeed much emphasis was given to requirement that doctors should be "judgement safe" early in training, particularly given their part in acute work.

  19.  May I recall the statement made by Sir John Tooke in his evidence to the Committee:

    "To be proficient and capable in one's role requires considerable experience, depth of knowledge about one's discipline, experience in exhibiting fine judgment—a lot of medicine requires that—and not just a capacity to undertake certain tasks under defined conditions. I think the idea of proficiency is a more embracing one that wraps up competence but accepts the need to embrace these other qualities that we and society would wish to see in a doctor". It is view with which I wholly concur.

  20.  Whatever kind of medicine—I use the term generically—doctors come to practice, they build upon common educational foundations. Indeed the soundness of these foundations is critical to each specialty, from general practice to the most specialised and arcane sub-specialty. This commonality permeates the professional ethos; it is recognised and highly valued by patients; it is very important.

  21.  The subject of selection and assessment procedures is treated authoritatively at Appendix 4 of the interim report.

What lessons about project management should the Department of Health learn from the failings in the implementation of MMC

  22.  The interim report contains a great deal about the management of MMC, including a detailed forensic analysis of its proceedings, and I am not in position to add more.

  23.  Out this analysis emerges a clear need for a greatly strengthened mechanism for bringing together the diverse interdependent perspectives that bear on health policy, workforce requirements and postgraduate medical education and training, with high accountability.

The extent to which MMC has taken account of the supply and demand of junior doctors and the number of international medical graduates eligible for training in the UK

  24.  The policy decided in 1997 to achieve medical self-sufficiency in the UK was made a reality by the expansion of medical schools. From the outset this investment had clear quantifiable implications for training and the provision of training posts for all doctors who achieve the required standard. And it had implications for the future immigration of medical graduates from outside the EEA, in relation both to postgraduate training and to employment in the NHS.

  25.  It is regrettable that failure to address the issues adequately and in good time has led to the calamitous position of many doctors in the UK today, not only of UK medical graduates but also international medical graduates who trained outside the EEA, including those who have already served the NHS. The resulting uncertainties facing many able young doctors today and in the near future call for the swiftest and fairest possible resolution.

  26.  The rigid training structure of MMC has brought other restrictions. The UK has a high international reputation for postgraduate medical education, fostered particularly through the links established by the Royal Colleges. It uses that standing to benefit countries with less developed training programmes. These links have long supported and enabled education and training, research, and quality improvement and they facilitate international exchanges. Appropriate overseas experience for young doctors during and at the end of training provides important mutual benefits.

  27.  We should also have proper regard to the reasonable expectations and claims of doctors from abroad, the contributions they make to medicine and the service in the UK, and the skills many are able to take back to their own countries.

The roles of the Department of Health, Strategic Health Authorities, the Deaneries, the Royal Colleges and the Postgraduate Medical Education and Training Board in designing and implementing MMC

  28.  The roles and responsibilities of these bodies are intimately related, in respect of service needs, evolving service opportunities to exploit medical advances, trained workforce requirements and finance. Yet the linkages between them are often tenuous and fragile, and sadly, distrustful. I believe we could and should take steps to expand our alliances and relationships, to address these matters in new more open collaborative fora.

  29.  Experience of the development and implementation of Modernising Medical Careers has brought important lessons for us all—for the Department of Health, its internal structures, its relationships and its accountabilities internally and externally; for the professional institutions, collectively. The interim report has spelt them out clearly.

  30.  The experience has also reinforced the importance of strong medical leadership, its role in developing and presenting a coherent view of the principles and values that identify the profession, and the ways in which these must be grasped and handled in policy development and implementation. Leadership is a hallmark of professionalism. To warrant that hallmark it is quite clear that the institutions of medicine, in partnership with other stakeholders, must construct more effective mechanisms for safeguarding and advancing the principles they share.

January 2008

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