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 excellencenotwithstanding
the fact that it has been berated in other avenues, education
standards are extremely highI 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 wronglyI am not sayingthat
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 reachingand 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 budgetthe main budget and all the
other budgets which the Department of Health or certainly SHAs
have clawed back to prop up their own financial problemswould
send a very strong signal that education within the National Health
Service is a pivotal part of itas, 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 againit
is not ring-fenced; we thought it wasthey 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 applicationsand this would have been all rightbut
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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