Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 620-639)

PROFESSOR PETER RUBIN, PROFESSOR NEIL DOUGLAS AND PROFESSOR SIR NICK WRIGHT

24 JANUARY 2008

  Q620  Chairman: What are the extent of and limitations to PMETB's responsibilities for postgraduate medical training? It has been put to us that the creation of PMETB was a "direct attack" on the medical Royal Colleges. Do you agree with that?

  Professor Rubin: Perhaps I could tell you what PMETB is intended to do and then I will comment on the Royal Colleges. The role of PMETB is to protect the public by determining the standards necessary for a doctor to go on the specialist or the GP registers. We do that in two ways. For doctors who undertake a regular UK training programme, PMETB determines the content of the outcomes of that training: we ensure that the exams are fit for purpose and we quality assure the standards of training. For doctors who train outside the EU or for doctors who undergo an unconventional training programme in the UK, we establish that those doctors have knowledge and skills equivalent to those who have done a regular training programme, and through the article 11/article 14 rules we establish whether they are fit to go on to the specialist and GP registers. That is what PMETB does. With regard to whether PMETB was established to undermine the medical Royal Colleges—and I should say that I was not involved in establishing PMETB—I think it best to respond in this way. Undergraduate medical education in medical schools in this country has been regulated since 1858. Their reputation is high; the reputation of medical education in the UK is very high. I do not think anyone would say that being regulated has damaged the medical schools in this country. I think it is therefore a rather flawed argument to say that, just because the colleges are being regulated, there is an attempt to undermine them or devalue what they do. I have certainly never taken that view.

  Q621  Chairman: Why do you think PMETB's role seems to be so poorly understood by other stakeholders within medical education?

  Professor Rubin: I really do not know. There has been a lot of genuine misunderstanding and, also, I think, some wilful misunderstanding about the role of PMETB. I think some of that goes back, as you have implied, to the unhappiness around the establishment of PMETB. We are very clear on what we do; Parliament is very clear on what we do. We are established by statute: what we can and cannot do is spelt out in the order. It should be very clear what we do but, I agree with you, there has been a lot of confusion and misunderstanding.

  Q622  Chairman: Could I also welcome Professor Sir Nick Wright.

  Professor Sir Nick Wright: I do apologise. My lateness was due to the vagaries of the District Line.

  Q623  Chairman: Okay. I did ask for the names of our other two witnesses. Perhaps you could just tell us the position that you hold.

  Professor Sir Nick Wright: I am the warden of Barts and the London School of Medicine and Dentistry in Whitechapel and Smithfield.

  Q624  Chairman: Back to PMETB. You say that PMETB is not responsible for recruitment and selection to medical training posts. In evidence to us, the Chief Medical Officer told us that PMETB has "responsibilities for approving, not just the curricula of the new speciality training programmes, but also the applications procedure". Who is right?

  Professor Rubin: The CMO is incorrect. Having looked at the transcript, I think Dr Marshall, who was at the time the DCMO, tried rather diplomatically to correct that rather quickly. That was my interpretation of the transcript. PMETB's role in the selection process is, again, prescribed in statute—so it is not a mystery, hidden anywhere—and our role is to determine the standards that a doctor must have reached in order to go into specialist training; in other words, to determine that the processes used can distinguish the eligible from those who are not eligible. It is not our job—nor, I think, should it properly be the job of a regulator—to get involved in telling those who are running training programmes how to pick the best candidate. That is for them. They know what their programme involves and it is for them to decide who is the most excellent of the applicants. Our job is simply to determine that the processes can distinguish the eligible from the ineligible, so it is a pretty minor role.

  Q625  Chairman: The Department of Health included a letter in its evidence showing that PMETB received a presentation on plans for the MTAS system in September 2006 and was broadly happy with the proposals. Why did you inspect the MTAS system if you are not responsible for recruitment and selection?

  Professor Rubin: The meeting was in August, the letter that we sent was in September. The background to the meeting was that the MTAS team asked to see us. We did not ask to see them. We had not intended to see them. As I have said, our role is pretty small, and we were going to pick up our limited role in the selection as part of our regular QA processes. They asked to see us, and we wished to be helpful—I mean, we realised everything was new and we did not want to be unhelpful—so they came along and gave a very high level presentation. It was not overflowing with any detail. For example, the application form, the electronic form that has been much criticised, was not ready and so we did not see it. They gave a very high level presentation in which they assured us that they would be consulting with interested parties (that is, the Junior Doctors Committee of the BMA and the medical Royal Colleges) on the form when it was ready. So they gave us a very high level presentation and we gave, as you will see, a very high level response, saying, "Broadly speaking, what you are proposing to do, in principle, seems to meet our requirements for the process." So it was all very high level and, I have to say, rather general stuff.

  Q626  Chairman: You stated in September 2006 that the MTAS system "broadly meets the relevant section of PMETB Generic Standards for Training". What was this judgment based on? With hindsight, do you think you were correct in saying that?

  Professor Rubin: We thought that, broadly, it would meet the requirement to distinguish the eligible from the ineligible. Despite all that has happened since, I believe that Professor Tooke's inquiry did not find that there was any evidence that it failed to distinguish the eligible from the ineligible. There were a lot of arguments over whether the best candidates were selected and so on, but that was not the regulator's role, to get into that particular aspect of the selection process.

  Q627  Dr Naysmith: I do not think you answered the Chairman's previous question. He asked you why you took part in this procedure when it is not your responsibility and you said you were invited by them to see them. What was the purpose of this? You could have said, "It is really nothing to do with us. What are you telling us this for?" Presumably a number of highly paid individuals sat around a table and gave this great presentation which was, in your view, unnecessary. Why did you go through with it?

  Professor Rubin: Because we wanted to be helpful. We were very conscious that a lot of new things were happening. A lot of new things were happening. MTAS was new, MMC was new, we were new, and we felt that to say, "No, we don't want to meet you" would be unhelpful, basically. It was as simple as that. We were clear to them—we were very clear and the letter was very carefully worded—that we were not approving anything. The word "approve" does not appear in that letter quite deliberately—quite deliberately. Equally, we thought it would have been gratuitously unhelpful to say, "We don't want to know."

  Q628  Dr Taylor: I am rather struggling with the feeling that selecting the eligible from the ineligible is only a minor role. It would seem to me to be absolutely crucial.

  Professor Rubin: The eligible, for example, going into the first year of specialist training, will be somebody who has completed the foundation programme or has experience overseas of the equivalent to the foundation programme. The arguments around MTAS and the selection process, the arguments that have raged since last spring, have been about whether the very best candidates were being short-listed and the very best were being appointed to the posts. When I use the term "minor" that is minor in comparison to our major responsibilities for delivering the content of 57 curricula, examinations in 57 specialities, and quality assuring postgraduate medical education throughout the UK. That is big stuff. In contrast to that, our responsibilities for selection are really quite small.

  Q629  Dr Taylor: I understand that. Do you feel that the Department of Health and the Royal Colleges have tried to make PMETB a scapegoat for what happened?

  Professor Rubin: The first thing to say is that people use the term "colleges" as if there is a homogeneous organisation called colleges. They are not homogeneous.

  Q630  Dr Taylor: Although the Academy surely tries to speak for all of them.

  Professor Rubin: The Academy tries very hard to speak for them but there have been some examples of wilful misunderstanding surrounding the MTAS process. Since you ask the question, Dr Taylor, let me give you one very striking example concerning the Royal College of Surgeons of England in their evidence to Professor Tooke. In their evidence, which was in the public domain on the website, they made the most extraordinary claim, which was that PMETB did not approve of having a clinical component to their flagship MRCS exam, their postgraduate exam. That was an extraordinary misrepresentation. The truth was that, as part of our regulatory functions, we had established that their flagship exam, the MRCS, had serious problems. We had established that the clinical and oral components of the exam were subject to deep uncertainty as to the level of the exam, uncertainty even as to what was being tested—and what was being tested seemed to be different in different parts of the UK—and uncertainty in the minds of examiners as to how to allocate grades for different levels of achievement. We, as regulator, said what you would expect us to say: "You've got to clean up your act. You must produce an exam that is fit for purpose and do it in a very short timeframe." That was misrepresented in their written evidence to the Tooke inquiry as saying: "PMETB does not agree with us having a clinical assessment," sending a completely different message. Clearly I wrote to Professor Tooke to put the record straight and so on, but that is an example of what I would regard as wilful misrepresentation to try to make PMETB look something that it is not.

  Q631  Dr Taylor: You were obviously aware of the problems and the crisis emerging. Should you not have been the first to point this out?

  Professor Rubin: From the very beginning, it was clear to me that, at the heart, the problem was one of a huge mismatch between the number of applicants and the number of places. That was clear very, very early on. Workforce is not something that PMETB does. We do not do workforce. That, at the heart, was the problem. Certainly there were issues around the application form and so on, but, had there been less of a mismatch between applicants and places, the problems that were there with the form would have been much more easily manageable at a local level. It was clear to us that the heart of the problem was a numbers problem. It is hard now, perhaps, to remember that there was a cacophony of conflicting anecdotes circling around—and, as a regulator, you need evidence, not anecdote. For everyone claiming that the brightest in the generation were not being short-listed there were counterclaims that the brightest in the generation had been so careless in completing the form that they had managed to conceal their brightness very effectively. There really was a maelstrom of conflicting anecdote. It was my judgment call. The board at PMETB was not united on this: there were many members of the board who wanted me to be up there campaigning. It was my call on this, and my call was that, as a regulator, it was not our job to get into the maelstrom of conflicting anecdotes.

  Q632  Dr Taylor: You have really answered my next question. You do not feel as Chair of PMETB responsible for what happened in any way.

  Professor Rubin: The answer is no. I do not feel responsible. I will draw your attention to Professor Tooke's report, in that PMETB is about the only organisation that is not criticised—and, of course, he took very extensive evidence. I should say, Dr Taylor, however, that, as with all regulators, what I did behind the scenes was often very different from what I was doing in the public arena. I gave various bits of advice to various officials at that time, to the Department of Health at various times, but there is a difference between what you will say privately to somebody and what you will say in public when you are a regulator.

  Dr Taylor: Thank you.

  Q633  Mr Bone: Basically you are saying that what you say in public is not what you are doing in private, then.

  Professor Rubin: In the advice that you give to, say, a senior official in the Department of Health, when the timeframe is absolutely electric and when you realise that there are a lot of people who are having to make snap judgments, I think it is perfectly appropriate for the regulator, in my case as the Chairman of a regulatory board, to give advice to say, "I hear that you are planning to do A; I think you should do B". That is personal advice given by the Chairman of the regulatory body. I was not claiming then to be acting for the board. I think, therefore, because I was not acting for the board, I did not have board approval for the advice I gave, it would have been quite wrong for me to go in the public domain with that kind of advice.

  Q634  Dr Naysmith: You did say the system was broadly okay in 2006. At that time you broadly appeared to distinguish eligible from ineligible, but you had not seen the application form. How could you say that if you had not seen the application form?

  Professor Rubin: The wording of the letter, as I said, was carefully chosen to say: "You have presented us with very high level principles and these high level principles seem to meet our requirements." But it was very high level stuff.

  Q635  Dr Naysmith: You are admitting, basically, that, without seeing the application form, you just believed what they said, that they were going—

  Professor Rubin: We said that we were pleased to note that they were going to check the application form with the Junior Doctors Committee of the BMA, with the medical Royal Colleges, and we pointed out to them—although we did not use these words—that they had a mountain to climb because they were talking to us in August and they still did not have the application form ready. The background to the meeting, as I said, was for us trying to be helpful, to say, "Okay, you have told us how far you have got and, in principle, where you have got to seems to be okay but that is a long way from implementation, of course."

  Q636  Dr Stoate: If everything is going so well at PMETB, then why do Professor Tooke and the CMO both call for it to be absorbed by the GMC?

  Professor Rubin: I think the reason is an administrative reason that it makes sense. I should preface that by saying, as Kevin has already mentioned, that I Chair the Education Committee at the GMC and I am in a clear conflict of interest position. For that reason, I have stood back from the responses of both PMETB and GMC to the structural issue. But, if I can answer your question as to why they are saying that, I think it is the administrative and strategic argument that there is sense in having all medical education, undergraduate and postgraduate, CPD, regulated by one organisation. I would make the point, though—I am here as Chairman of PMETB—that, despite a dreadful start—I am sure you know the first chairman left and the first chief executive—PMETB is now a functional organisation that has major achievements.

  Q637  Dr Stoate: What effect would it have on the arrangements, if it were, absorbed into the GMC?

  Professor Rubin: If some or all of Professor Tooke's recommendations or recommendations that you make are implemented to postgraduate medical education, then an effective regulator will be very important, and so that would be the worst time to shut down the regulator that deals with postgraduate medical education because we are now functioning very well. Yesterday afternoon I had one of our regular meetings with college presidents and, notwithstanding all the history, there is now a very constructive relationship with the medical Royal Colleges and PMETB. We are very much functioning strongly with strong achievements under our belt.

  Q638  Dr Stoate: In a nutshell, then, you are not happy about it being absorbed. At one stage you said it was an administrative process and therefore it did not seem to make much difference. Now you are saying it would have a disastrous effect.

  Professor Rubin: I did not use the word "disastrous".

  Q639  Dr Stoate: No, but it was what you were implying.

  Professor Rubin: I repeat that I have stood back from the views of both organisations about the structural issue of a merger but I would like to make the point that PMETB has made significant improvements to the quality of postgraduate medical education in the UK.


 
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