Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 640-659)

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

24 JANUARY 2008

  Q640  Dr Stoate: But I still want to get to the point: Do you think it is a good idea for this to happen or are you opposed to it?

  Professor Rubin: I really do not think I should answer that because of the conflict of interest position that I am in. The thing with conflicts of interest is, if you declare them, you must stand by them and I am in a conflict of interest position.

  Q641  Dr Stoate: Do either of the other two witnesses have a view on this, because it is rather important?

  Professor Douglas: I am a PMETB board member as of a year ago, so I cannot say anything.

  Professor Sir Nick Wright: Speaking as someone who was head of a medical school when PMETB was set up, many of my colleagues and myself had grave reservations about the fact that you had a statutory body that was reporting to the secretary of state and yet was still responsible for setting the standards of postgraduate education, so the secretary of state was ultimately controlling everything. The one thing about the Royal Colleges, whatever their defects which Professor Rubin has pointed out, was that they were regarded as being independent. They inspected hospitals to see if there were appropriate training facilities and they were independent of the secretary of state; whereas the secretary of state now, theoretically, is in charge of both inspection and the provision of those facilities. We saw this as a retrograde step because the independence of inspection and the setting of standards was not being underpinned. It is rather ironic, when we are abandoning these visits by Royal Colleges, that in Scandinavia they are saying that they think it is a very good idea so they are setting this up to inspect training premises. It is really the question of the divorce of the facilities and the training from the regulation in which I would be very much in favour. Moving this to the General Medical Council would show that there is independence in regulation outwith the secretary of state's purview.

  Q642  Dr Stoate: You are basically in favour, then.

  Professor Sir Nick Wright: Yes.

  Dr Stoate: That is the point I wanted to get to. That is fine. Thank you, Chairman

  Q643  Dr Naysmith: Professor Wright, from a medical school perspective does it make sense to have a single cradle-to-grave regulator for the whole of the medical profession?

  Professor Sir Nick Wright: Yes. The reason for that is, as Peter said, that the reputation of the General Medical Council in regulating and examining standards of undergraduate medical education is nonpareil in the world generally. It has very, very high standards. Anybody who has undergone a GMC visit to either the dental school (GDC) or medical school knows the stringency of the high standards which the General Medical Council sets in education. If that could be translated into their regulation of postgraduate education, as I suspect it would be, because the General Medical Council has a tradition for excellence—notwithstanding the fact that it has been berated in other avenues, education standards are extremely high—I have every confidence the GMC could produce the goods.

  Q644  Dr Naysmith: Do you think it has the skills and capacity to take on postgraduate—

  Professor Sir Nick Wright: Not currently. I think it would need certainly more staffing and more finance. It would be the question of organisation that they would have to approach, so, yes, I think they could do it, given the appropriate facilities.

  Q645  Dr Naysmith: Is it not inevitable that they have been dragged into this current crisis that is going on in postgraduate education at the moment? GMC standards are good.

  Professor Sir Nick Wright: I think it is rather unfortunate that bodies like PMETB, the MMC board and also the Tooke Review were not dragged into sorting out this current process. One of the criticisms I would have of the Tooke report is that they deliberately restricted their remit to not looking at the current problems in postgraduate education that we were facing last year and this year. They say similar things about the MMC board running through with the process and then post hoc the presidents of the colleges writing in the Times and saying it is not working. The fact that the Tooke report did not embrace the problem of MTAS last year and did not look for a solution to the recruitment problem this year is a real defect. I think the more people who get involved in trying to sort out current problems, the better.

  Q646  Dr Naysmith: Who do you think should sort it out?

  Professor Sir Nick Wright: I think the Tooke report should have taken this under its belt, to try to produce suggestions that could change the way in which we link training decisions, consultant decisions. As you probably heard before, it was a Fidelio suggestion that the link between junior staff numbers and consultant specialist numbers should be broken, and there should be a gradation of specialists, specialists and senior specialists, so the number of recruits into these jobs was not linked with the number of consultant vacancies. Add to that the fact that we are, I understand, 21st in the world in terms of doctor:patient per head of population ratio, and it argues for a big expansion of both grades. I would look askance at the Tooke report for not looking at that in some detail.

  Q647  Dr Naysmith: Do you think you are talking on behalf of most medical schools is that just your personal view?

  Professor Sir Nick Wright: I think quite a number of my colleagues would share my view.

  Dr Naysmith: Thank you.

  Chairman: We are going to move on to the question of the Tooke Review now.

  Q648  Mr Bone: The first question is just a yes/no answer because of the way it is phrased but we will be moving on afterwards. In general terms, do you agree with the analysis and recommendations set out in the Tooke Review?

  Professor Rubin: Strongly.

  Professor Douglas: I agree.

  Professor Sir Nick Wright: I would agree with that.

  Q649  Mr Bone: In the consultation programme you have approval for the review in something like the terms you might get for a presidential election in one of the African democratic republics: 87% approval. Are you surprised at the medical profession, in that everybody thinks it is the best thing since sliced bread?

  Professor Douglas: I was surprised that that particular analysis was used. The point has been made to you before that a group of people who are deeply involved in it, who have been designing or running part of the programme, were counted as one vote whereas an individual might be counted one vote, so I thought the analysis was a bit simplistic. But the overall messages put out, that the vast majority of the profession supported the vast majority of the recommendations, is absolutely correct and also not terribly surprising.

  Professor Rubin: Would it be appropriate to mention what I consider to be the most important recommendation, about NHS Medical Education England, or do you want to keep it more general?

  Q650  Mr Bone: We have sort of moved on and Professor Wright did that at the start. I was going to ask if you were surprised at the fact that it was not more critically scrutinised. Are there bits that need more debate and would that be helpful?

  Professor Rubin: I think the MMC and MTAS events were a defining moment in the relationship between the medical profession and the Government. It was the moment when a lot of members of the profession said, "Enough"—rightly or wrong. It was the moment when a lot of members of the profession felt that the voice of reason, which they thought was their voice, had not been heard. Rightly or wrongly—I am not saying—that was the moment. In his report Professor Tooke has enunciated many of the feelings of the medical profession in this country and that is why I think those who respond to him were so positive in their response. When you get into the detail, of course, then a lot of things need a lot of careful consideration.

  Professor Sir Nick Wright: The Tooke report took evidence from a large number of people. Most people in my position, for example, helped the Medical Schools Council in their report. I was part of the Academy of Medical Sciences consultations, through my own Royal College, through my own Medical School, and I also appeared before the Tooke Committee for Fidelio. Most people had multiple channels into the committee, and if you look at the response to the consultation they were uniform in their views on the consultation document. No, I am not surprised and, together with the things Peter has said, I would not be at all surprised if there is uniformity.

  Q651  Mr Bone: Mr Chairman, this is the sort of evidence we are gathering. It surprises me that because this report seems to have done a very good job and seems to have represented people's opinion, the Government is doing very little, distancing itself, in effect, from it, and not implementing it. What are your views on that?

  Professor Rubin: If the major recommendations in Professor's Tooke's report are adopted, they will have far reaching consequences. With the best will in the world, it would be unrealistic for any government to say by return post, "That's great. Let's do it." I just do not think that would be realistic. Some of the implications of the report are very far reaching—and quite rightly so. To put it into context, speaking now both for GMC and PMETB, we are UK-wide bodies and in that UK-wideness we have worked with NHS Education Scotland and have been very impressed by NHS Education Scotland. By its very existence it sends a message that education is important in the health arena. Just by existing it sends that message. It has the budget. The golden rule applies, does it not? He who has the gold rules and it really does have a big impact on health education in Scotland. Our view as regulators, speaking both for GMC and PMETB, is that the establishment of NHS Medical Education England, with a ring-fenced budget for medical education, with a sophisticated workforce machinery and workforce planning machinery, would by itself go a long way to ensure that we do not have a repeat in the future of the MTAS/MMC problems. That is a view that is shared not just by the regulators but by the Academy of Medical Sciences, by the Medical Schools Council, by the Academy of the Royal Colleges. It is a widely held view by all those who represent different aspects of the medical profession.

  Professor Sir Nick Wright: I think the heads of the medical schools feel very strongly that the Department of Health has ridden roughshod over the ten key principles that link the Department of Health and the Department of Education and medical schools working together. There is a whole list within the Tooke report of reasons why the Department of Health is disengaging from the academic education agenda: the lack of effectiveness of SELAR (Strategic Learning and Research Advisory Group), for example; the loss of workforce confederations with academic representation; the absolute refusal of Derek Nicholson to accept the representations from the Medical Schools Council that there should be a statutory academic representative on Special Health Authorities. I understand that only three of them have that. We lobbied very strongly to get that but got a very dark brown answer from him. It has always been the tradition in this country. The Special Health Authorities, the previous Strategic Health Authorities, the teaching hospital Trusts always had a non-executive director who is an academic. That has been lost.

  Q652  Mr Bone: I think we are going to ask about that later.

  Professor Sir Nick Wright: As Peter says, having a national body for medical education in England perhaps controlling the budget—the main budget and all the other budgets which the Department of Health or certainly SHAs have clawed back to prop up their own financial problems—would send a very strong signal that education within the National Health Service is a pivotal part of it—as, of course, it should be.

  Professor Douglas: Speaking with a different hat on, that as Chair of the Academy of Medical Royal Colleges Education and Training Committee, I would entirely agree with Peter that recommendation 47 is the key one in the new version of Tooke. I work very closely with NHS Education Scotland in Edinburgh. They are an extremely effective organisation, controlling the funds is critical to properly planning the training for the juniors. If anything gets enacted, it has to be recommendation 47. I am very concerned that I am not seeing evidence that this is necessarily going to go through very readily.

  Q653  Mr Scott: Obviously you are all in favour of the NHS Medical Education England, but do you really think it is necessary for the new body to be set up? Could it not be devolved to postgraduate deaneries and Strategic Health Authorities?

  Professor Douglas: My own view is that it is necessary to have a new body set up. The controlling of the funds by other bodies whose prime interest is not in training is a key issue and, also, because of the fact that there are numerous deaneries which work slightly disconnectedly sometimes, it would be very helpful. That is what has happened in Scotland: the deaneries are connected through NES. I think it would really make a very positive difference to training of the juniors in England.

  Professor Sir Nick Wright: I would be very strongly against what you suggest. If you go around and talk to my colleagues in London, we have had reduction in the educational levies which have affected us somewhat but, for example, in Leicester they faced the removal, because of a problem with their SHA, of a minimum of £20 million of support for their academics. They were going to lose a significant number of staff in their school and it was only by intervention centrally that this was stopped. If the SHAs control the educational levy in the budget and they run into financial problems again—it is not ring-fenced; we thought it was—they could claw it back and use it for other purposes, and I have no confidence they would not do that.

  Professor Rubin: I feel very strongly that there needs to be a national body. There are a number of reasons for that but perhaps I could give an example of one of the problems that led to the mismatch between applicants and places. As I am sure you have heard in other evidence, on the one hand we had the Home Office and the Treasury having an open door policy and trying to encourage doctors to come to this country, and then we had the Department of Health saying that we must be self-sufficient in doctors and produce all the doctors we need internally. Those were two mutually incompatible policies. It needs a national oversight to ensure that policies in different parts of government are genuinely joined up. Just staying on the subject of workforce planning: we can be sure that we will get workforce planning wrong because we always have, so that is something about which we can absolutely confident. But I think we will get it less wrong if we have some serous brains working on it at the national level, looking at all the issues involved. To try to duplicate really high quality workforce planning around each of the SHAs will be an unnecessary duplication of activity. As Neil and Nick have both said, there is the important issue that, with the best will in the world, I am sure if you sat down any SHA chief executive or Trust chief executive and said, "Is education and training important to the NHS?" of course they would say yes, but they are under pressure to deliver on short-term, here-and-now targets. I think it needs a body outside the heat and burden of the day to look ten or 15 years down the road and say: "This is what we think we need in the future."

  Q654  Mr Scott: Do you not think that a new body could give the department a scapegoat when something goes wrong of saying, "It's not our fault. It's all down to them"?

  Professor Rubin: Of course it could but that is not why we would want to see it established. We would want to see the body established as a very effective organisation.

  Professor Sir Nick Wright: There has been this lack of engagement of both Trust chief executives in foundation and non-foundation Trusts and SHAs in the education agenda. All our attempts through the Medical Schools Council to get the Healthcare Commission to set some sort of targets for both Trusts and SHAs, both teaching and research, in the same way as they have targets in other things, have failed, so they will not have a target for education. I would far prefer to have a national body for medical education which will have those standards and targets, than the SHAs, and perhaps even Trust chief executives, who have lots of other things to think about and will not engage with the academic agenda.

  Q655  Charlotte Atkins: Professor Wright, did MTAS cause any particular problems for academic trainees? Have these been addressed in the Tooke report?

  Professor Sir Nick Wright: Yes, I think they have. It was our understanding before this all came out, that the academic applications would be processed before the general applications—and this would have been all right—but they were not. They were caught up within the maelstrom of general applications, so you had people who were high-flying academics not being interviewed and not being short-listed through the scandalous way in which this process was done. There would not necessarily be a repeat of the evidence that very good academics were not short-listed or even dropped because, as you probably know, Fidelio have kept quite a large database of the people who had these major problems. Bringing academic applications into the general thing was an absolute disaster, so they did suffer through that, yes. I think this has been addressed in the current round because they are being done before, which is a good thing. Also, if you look at Tooke report and go through it, a great deal of thought has been given to academic trainees, to the concept of the academic team: the fellows, for example, being managed by the deaneries of the medical schools jointly, which I would certainly approve of, and also, if in fact you do get the abolition of run-through training, to making sure that the academic FY2 positions are maintained because they have been a success. I think the Tooke report has given considerable thought to that and I would have no worries, as long as those were adhered to, about the academic recruitment in the future.

  Q656  Charlotte Atkins: Should the foundation schemes be split to allow the Medical Schools to meet their legal obligations to guarantee students work until they achieve GMC registration?

  Professor Sir Nick Wright: It is the view of the Medical Schools Council, which is why we agreed that it should be split. We have not referred to the MDAP problems of the year before, the Multi-Deanery Application Process, which was also an unmitigated disaster. We now have the situation where, when we admit students for medical school, there is a sort of contract that we get them medically qualified and we get them medically registered and, because of that, they have to get an FY1 position. In the old days, we used to have a matching scheme that made sure we could control to some extent where our students went, particularly locally, so that we matched our students to the jobs we had and that worked very well. With the advent of EC legislation and equality of opportunity, we cannot do that any more. My responsibility under the Medical Act is to make sure that my graduates are fit for purpose and, also, that their FY1 positions are suitable for them. If they are going up to Blackpool or Inverness, I have limited ability to make sure those jobs are appropriate. Also, we are responsible for the FY1 year within the medical school. Similarly, we know that there are individuals within medical school who do qualify but they may need special attention during their FY1 year. Again, we used to make sure these people got very good positions so that they could be looked after properly. Now, we cannot do that any more. I have to say that the foundation applications have worked better this year but, because of equality of applications, for example, from overseas and elsewhere, we would like to control the FY1 positions to make sure that our students who have got FY1 jobs are registered. That is the main reason behind that.

  Q657  Charlotte Atkins: You agree with the splitting of the two-year foundation scheme.

  Professor Sir Nick Wright: I do.

  Q658  Charlotte Atkins: And the creating of a three-year core speciality training programme.

  Professor Sir Nick Wright: As long as there is sufficient flexibility within that core specialty training, yes.

  Q659  Mr Bone: Does anyone else want to come in on that?

  Professor Douglas: I think foundation is a slightly difficult issue. In the original interim version of Tooke some of us were surprised that the recommendation to split F1 and F2 was not really compatible with recommendation 2, which is that everything should be evidence based, because the evidence is not in. We know that foundation has worked very, very well in some areas of the country and done very badly in others. I would agree entirely with the principles behind what John Tooke has recommended in his final report: namely, that people should be guaranteed F1 jobs; that we should select into foundation and to subsequent speciality training on merit, absolutely; and that we should not hinder the progress of people who are clearly committed to a specialty and have the ability to practise that speciality. How exactly you do that? It does not matter to my mind whether you split F1 and F2 or you have the same content on either side of a different divide. That is open to debate.


 
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