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 Collegesand I should say that I was not
involved in establishing PMETBI 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
statuteso it is not a mystery, hidden anywhereand
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 jobnor,
I think, should it properly be the job of a regulatorto
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 helpfulI mean,
we realised everything was new and we did not want to be unhelpfulso
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 themwe were very
clear and the letter was very carefully wordedthat we were
not approving anything. The word "approve" does not
appear in that letter quite deliberatelyquite 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 testedand what was being tested seemed
to be different in different parts of the UKand 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 aroundand,
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 criticisedand, 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 themalthough we did
not use these wordsthat 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, thoughI
am here as Chairman of PMETBthat, despite a dreadful startI
am sure you know the first chairman left and the first chief executivePMETB
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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