Select Committee on Health Written Evidence

Memorandum by Professor Sir John Tooke (MMC 61)


  I appreciate that the Committee has now completed its collection of oral evidence but hope that you will admit some summary written observations in the light of the published transcripts.


  Everyone accepts that contemporary healthcare depends upon a multi professional team approach, with different professionals bringing particular attributes to the team. Each professional "cluster" needs particular educational foundations (in the case of medicine a deep and challenging education with a strong science base to support the development of clinical reasoning skills, upon which diagnosis and the capacity to deal effectively with ambiguity and uncertainty rely).

  Notwithstanding the need to develop shared understanding about roles with the other members of the healthcare team, for a variety of reasons, listed below, medicine does have to be treated differently:

    —  Medical education is much more expensive than that of other healthcare professionals, reflecting the key requirements of the role.

    —  The length of training cannot be determined locally—it is set in stone by EU directives.

    —  There cannot be wholesale revision of curricula to meet perceived local imperatives. The curricula apply across the UK and have to be approved by external regulators.

    —  Medical trainees subserve other key national interests being crucial, for example to the biomedical research that supports UK plc, and are not just NHS service personnel. The training content and structure needs to be sensitive to such issues. This aspect does not impinge on the other professions to anywhere near the same extent.

  Whereas the Final Report proposed the creation of NHS:MEE (reflecting the fact that our remit was medicine) the Panel supports the concept of NHS Education England, embracing the needs of the various professional clusters. However the current crisis in PGMET needs to be urgently resolved, so important is such training for the future health needs of the population. The national significance of the medical professional contribution in a variety of domains makes it imperative that there is national oversight and scrutiny of PGMET.


  The Inquiry proposed splitting years one and two of Foundation, principally to ensure UK medical graduates achieve full registration with the GMC. Failure to guarantee such status would lead to legal challenge to Universities, would be a profound injustice to new graduates with tens of thousands of pounds of debt, and would deter the socio-economically disadvantaged from applying to study medicine just at the time when medical schools' widening participation programmes are beginning to achieve traction.

  The Inquiry Panel is yet to see convincing legal opinion that such protection can be afforded in ways other than splitting F1 and F2 in an employment sense. Persisting with a two year Foundation programme will shorten and impact negatively on core training. Three years of core training is key to flexibility and future workforce redesign—and is necessary to help provide trainees with adequate time to develop the relevant specialty experience and skills in the face of EWTD.

  Thus from an education and flexible workforce perspective we strongly urge that a themed "F2" is incorporated into "core", and split, in an employment sense, from F1. It is a fragile argument to say the current Foundation programme has not run long enough to change. All good curricula are responsive to the required outcomes (ie the health needs to be addressed) and should be subject to continued review and evolution.

  We have already written to you with additional evidence of strong professional and organisational support for this move. The only voice of discord was heard from those directly involved in the current provision, keen to maintain the status quo.


  Our Interim Report pointed out the steady erosion of the Health:Education sector partnership in recent years. Such partnership was a founding principle of the NHS. Harnessing academia for the benefit of health is a mechanism adopted by most developed nations to drive up health care quality and innovation, and is crucial if the UK is to achieve its stated goal of being a strong knowledge-based economy.

  We suggested a variety of ways in which better links can be fostered including:

    —  Incentivisation of Trusts to engage in education and research.

    —  Scrutiny of SHAs regarding the local academic relationships they have fostered, and the use of PGMET funds.

    —  Review of the relationship between Postgraduate Deaneries, Medical Schools and service including the trialling of graduate schools.

    —  Clear accountability at Trust Board level for PGMET.


  The consultation response showed that a mere 12 people—1.3% of respondees—had any measure of disagreement with the suggestion that there should be a "National Institute for Health Education" (Recommendation 12).

  Our belief that such a body is necessary stems from a fundamental lack of confidence by the medical profession in the Department of Health's ability to manage the implementation of changes in PGMET, and the clear need to separate policy from implementation. Devolution of complete responsibility to SHA level engenders even less confidence, given the current lack of workforce planning and commissioning capacity, the lack of labour market intelligence and the very recent history of education and training budgets being raided to meet service pressures. The Panel believes that local ownership and demand led solutions, informed by service are key to success; nonetheless the national dimension must not be ignored and without a body such as NHS:MEE to provide scrutiny, the national interest is at severe risk. Such risk takes a number of forms:

    —  Lack of integration of the local with the overall requirement for medical workforce.

    —  Poor provision of subspecialty expertise, not required in every SHA.

    —  An erosion of an integrated approach to development of the clinical academic workforce, crucial to UK plc.

    —  Inequity of specialist service provision, striking at a fundamental principle of the NHS.

  In addition NHS MEE would address the following deficiencies identified by the Inquiry:

    —  Provide coherent professional advice on PGMET to policy makers.

    —  Develop and act as the guardian of the principles underpinning PGMET and the evolving role of the doctor.

    —  Integrate curricula requirements (service and professional viewpoints) and interface with the Regulator.

    —  Scrutinise the allocation of PGMET resources both centrally and at SHA level.

    —  Act as the commissioning agent for certain small volume, highly specialised areas of medicine.

    —  Act as the point of reference in England to facilitate UK-wide collaboration on matters relating to PGMET.

  In any complex system transition imposes risk. The Health Select Committee revealed deficient central workforce planning. We believe the transition to demand led, local input should be managed over a number of years during which time, adequate local labour market intelligence is developed, central agreement on professional roles is secured and new PGMET structures become embedded.


  We have recently sent evidence to the Committee regarding the degree of support for the Inquiry's final recommendations. We should emphasise the overwhelming support for all our Recommendations from the medical profession. Even where some Postgraduate Deans and Foundation School Directors naturally feel unable to support us, the vast majority of the profession, including the trainees, wish to see full implementation. We owe it to tomorrow's doctors—and to the nation—to harness their aspirations. It is the profound expectation of the medical profession that the Inquiry's recommendations will be adopted in full. Such a response would maximise engagement in resolving the difficult challenges ahead, which is in the best interest of patients.

Professor Sir John Tooke


MMC Inquiry

21 February 2008

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