Examination of Witnesses (Questions 660-679)
PROFESSOR PETER
RUBIN, PROFESSOR
NEIL DOUGLAS
AND PROFESSOR
SIR NICK
WRIGHT
24 JANUARY 2008
Q660 Dr Naysmith: Before I come on
to the role of the medical schools, could I pick up on the F1
and F2 issue we have been discussing. Why do you think it is really
successful in some places and not others? In my own area, in the
Avon and Somerset Deanery, they have written to me saying, "Please
do what you can to protect the foundation two-year course because
it operates so well and is the best bit of the whole procedure.
Why is it that it operates so well around Bristol and operates
badly elsewhere?
Professor Rubin: PMETB and GMC
are jointly responsible for quality assuring the foundation programme.
Perhaps I might give you some evidence, but I should emphasise
that this evidence is as a result of interim analysis. One of
the things that PMETB has introducedand we did it for the
first time last year and we are now doing a second one this yearis
a trainee survey. Last year we had a 64% response to our training
survey, for examplewhich by survey standards is pretty
mega. This year we are halfway through it and we have had just
over 2,500 responses from those who did the foundation programme
2 last year. Of the 2,500 who did foundation programme 2 last
year, 75% of them thought it was very good and that F2 added significantly
in terms of value to what they had learned in F1. There is a significant
majority of people out there saying F2 is rather good. Where it
is not that good will be down to local issues, it will be down
to local implementationas is often the case here. I would
agree with what Neil has just said. We are getting deep into structural
issues here, but whatever happens to foundation there is clearly
something of considerable value in F2 and we must be careful not
to lose that value, whatever happens in any rearrangements that
subsequently happen.
Q661 Dr Naysmith: The other thing
Professor Douglas also said is that the evidence is not really
in yet.
Professor Rubin: Exactly.
Professor Sir Nick Wright: From
a medical school view, where foundation schools and medical schools
have worked in close collaboration I think the foundation has
been a success, but sometimes they have not. For example, under
Tomorrow's Doctors medical schools are constrained to teach
communication with patients to a high level. You do not want to
see that replicated in the foundation programme. If you concentrate
on the care of the acutely ill patient, a major thing in the undergraduate
curriculum, you do not want to see that replicated in the foundation
years. If there is collaboration between the medical school and
the foundation school, I think everybody is satisfied. But where
there is a disjointed approach, I think there will be problems.
Q662 Dr Naysmith: I am going to go
on to ask some questions on the role of medical schools. Some
of matters may have been touched on, so excuse me if you sense
we are going over old ground. The Tooke report commented on the
growing divergence between the health and the education sectors
and between medical schools and the deaneries. In your experience
as the head of a London medical school, do you agree with this?
What problems has it caused?
Professor Sir Nick Wright: I think
we are very privileged in London because the London deanery is
certainly not dysfunctional, it is very good. Apart from the way
in which the London deanery is engaged in sort of nationally promoted
activity like MTAS and MDAP, I have had no complaints at all.
We have an associate dean, Professor Joe Herzberg, who attends
my senior management team twice a term. We have very close relations
with him. He reports to us on the inspections he is doing on the
FY1, any problems he has, if it goes well with the foundation
schoolwe often get him together with our foundation school
headand through Lis Paice and through the heads of the
London medical schools committee, with which he works regularly,
we have a very cordial and good relationship with the London Deanery.
Speaking as a London medical school dean, I have had very little
cause for complaint over our relationship with the deanery. I
know this is not so in other parts of the country. I hear my colleagues
complain continuously about the poor relations between themselves
and the deanery in relation to many, many items: particularly
for trying to arrange out of service time for people to do PhDs
and things like that, and lack of flexibility and lack of co-operation
with joint funding initiatives. I know that certain deaneries
outside London are very dysfunctional and certainly need a great
deal more work, but I would emphasise that in London it has worked
extremely wellbecause I think we were determined to make
it work well.
Q663 Dr Naysmith: You are saying
there is nothing wrong with the system.
Professor Sir Nick Wright: Not
at all.
Q664 Dr Naysmith: It is just that
in certain places they do not operate the system well.
Professor Sir Nick Wright: We
work very effectively with the system, because we have frequent
contact with both our associate deans in the London medical schools
and frequent contact with Lis Paice for the London Deanery. I
probably see Lis Paice once every three weeks and if there is
any problem we can sort it out because we have multiple venues
at which we meet.
Professor Rubin: This is another
example of what NHS Medical Education England would improve on.
Q665 Dr Naysmith: It is interesting
that you mentioned Lis Paice because when she was here last week
she was very much in favour of introducing a medical licensing
examination, such as the one that goes on in the States, at the
end of medical school training. Do you think it is a good idea?
Professor Sir Nick Wright: I think
you find heads of medical schools would be very strongly against
a national examination taken at the end of the undergraduate curriculum.
We pride ourselves in this country on the diversity of the medical
education we give. For example, in Imperial College, Cambridge,
you would expect there to be a very, very academic education.
We would look for those people, most of them, many of them, to
go into academic medicine, to be high-flyers, to be very good.
Then you look at a medical school like mine, where we like to
think we do produce very, very good people. We are quintessentially
a community-based medical school.
Q666 Dr Naysmith: Surely there must
be a certain basic standard.
Professor Sir Nick Wright: Yes.
Q667 Dr Naysmith: Also, there are
many academic excellence centres in the United States as well.
Professor Sir Nick Wright: The
whole thing is competence based. We all have a competence-based
curriculum. If we had that at the end of the undergraduate curriculum,
it would not show us a great deal. Professor Rubin will back me
up on this, when the General Medical Council, I think it was,
did a survey of all FY1 positions a couple of years ago, only
19 FY1 doctors were found not to be fit for purpose and only three
of those were UK graduates.
Q668 Dr Naysmith: If that is the
case, what would be wrong with it?
Professor Sir Nick Wright: It
would change behaviours. It would change the way we approach things.
We have a very diverse medical education system.
Q669 Dr Naysmith: Is there any evidence
that the American medical professional produces doctors who are
significantly worse?
Professor Sir Nick Wright: No.
The timing at the end of the undergraduate curriculum would not
receive support from the Medical Schools Council and neither probably
would a national examination at the end of the FY1 year. Certainly,
in their evidence to the Tooke Committee, their view was that
local selection into core training programmes, with a portfolio
and a CV et cetera, was the way to do it, and then into specialist
training would be part of a national examination, possibly replacing
the Colleges part 1 examination. Medical schools are not against
national examinations: it is the timing of them. In their evidence
to the Tooke Committee they suggested it might well be at the
end of core specialist training, so we are certainly not against
that. And if it did come into operation, then medical schools,
I hope, would be invited to set part of that agenda. We are certainly
not against a national examination.
Professor Douglas: I am strongly
in favour of national examinations. We desperately need one to
be fair to the trainees. There are very good trainees in bad medical
schools and vice versa. The MRCP has published, this year, evidence
showing differences in performance between medical schools. We
need to have this as part of the selection process. I advocated
it to MMC England in June 2005 and it was howled down by the postgraduate
deans and the tutors at that stage as being undoable but I think
it is an essential part of the selection process.
Q670 Mr Bone: Would that not lead
to a dumbing down? If everybody is passing at the momentand
the medical colleges I think probably do a good jobif you
have a national standard, and you are saying that some are not
very good at the moment, to get the same numbers through you would
have to dumb down a bit, would you not?
Professor Douglas: No. I am saying
that the standard is good overall but some are absolutely excellent
and some are just good. The people who are excellent deserve to
be credited with being excellent.
Q671 Mr Bone: Is that not exactly
the point I am making. Would a national exam not allow that to
be clear?
Professor Douglas: It would allow
that to be clear, provided it is a ranking examthat is,
not a pass/fail exam. It is one of the many signals we should
be feeding into selection. Indeed, there is an argument for placing
it in F2, if F2 existed, because you could then make everybody,
whether they are from the UK or from outside, sit this test as
one componentnot the critical component because clinical
skills and communication skills are also vitalbut one component
for selection into specialty.
Q672 Dr Taylor: Perhaps we could
turn now to the Douglas Review and, first of all, to MTAS. It
is clear now that MTAS was a spectacular disaster. A lot of us
think it was clear in March that it was going to be a spectacular
disaster, certainly from the letters that we as MPs received.
Why did the Douglas Review not call a halt right at the beginning
of March, when really people were writing to us and saying, "There
is time to go back to the old system just for this year"?
Professor Douglas: The Academy
met on 5 March. At that stage we took information from all the
collegesthis was, as you say, early in the process, a week
into the interviewsand the messages we got from each of
the colleges and faculties was that there were many excellent
candidates who were coming forward and who had got themselves
into a position to be appointed. The view of the colleges was
that we should continue to go forward and not disadvantage those
people who had got themselves into a position to be appointed
and put in a huge amount of time to their applications, and also
a huge amount of time had been put in by the HR staff of the deaneries
and by consultantsthat should not be underestimated: the
amount of time that consultants and GPs put into the appointments
processprovided that some of the most obvious faults were
fixed immediately. We asked for a meeting with Patricia Hewitt
that night and got it, and she agreed to fix some of the obvious
faults: CVs had to be available from then on; full, probing questioning
would be allowed and not just formulaic interviews; and only very
appointable candidates were appointed to try to leave some jobs
for later on. And the review was set up. Once the review was in
place, we had several heated debates as to whether we should keep
going forward. The consensus from the colleges and from the BMA
and from the postgraduate deansthose being the members
of the medical profession on the teamwas always, at the
end of the meetingnot always at the beginningthat
we should continue to go forward but it was a very close call
on several occasions.
Q673 Dr Taylor: We have certainly
had the feelings from the colleges that they were pressurised,
and certainly Liam Donaldson, when he came to see us, said it
was absolutely clear that the colleges agreed to go ahead. We
got the impression that colleges had rather been steamrollered
by the department. Is that fair or not?
Professor Douglas: It is entirely
unfair. There is no doubt that the department would have liked
it to go forward but we were independent and we debated it independently.
Indeed, I took the medical members of the committee out of the
room to debate it without the department around and the consensus,
always at the end of the day, was to go forward.
Q674 Dr Taylor: Thank you. That has
cleared that up. To clear up one other point, last week Professor
Black said, "When the Douglas review was doing its work the
chairman of that body asked the academy and BMA together to produce
a letter which would be supportive of that review and would also
correct some of the inaccuracies already in the press about it.
It was a genuine attempt to see whether two bodies which perhaps
are quite separate could come together to support the CMO."
Is that your recollection?
Professor Douglas: I absolutely
suggested that the two individuals concerned wrote a letter to
the media because I did not feel I could do that in my independent
role as Chair. They had offered to support if they could. I was
keen that they established the difference between MTAS, which,
as you say, was in very deep problems, and MMC, the principles
of which many of us supported then and still do now. That is what
I asked them to do. She is right that I requested them to write
a letter.
Q675 Dr Taylor: Right. It did not
actually help, did it?
Professor Douglas: I did not write
the letter.
Dr Taylor: Okay. Thank you.
Q676 Dr Stoate: Let us stick with
the Douglas Review and the competition ratios. You wrote to the
Times last week to complain at competition ratios of up
to 20:1, and yet the MMC board has currently endorsed the 2008
arrangements and NHS Employers have gone so far as to welcome
high competition ratios. Is it not true, therefore, that the profession's
leaders are in fact being taken for granted around this issue
and, in fact, it is trainees who are receiving the lowest priority
if it is acceptable to have ratios of that level?
Professor Douglas: I joined in
writing to the media, having made considerable thought as to whether
I should do that. I had not contacted the media at all over the
last year about MTAS or MMC. Peter was at the meeting of the English
Programme Board in December when we were first shown the figures
for next year for England. You will recall that one of the big
problems, as Peter said earlier on, for the 2007 process, was
that the numbers of posts were too low and were not known until
post hoc basically. When we were shown the numbers in December
it became immediately apparent to me that there were too many
jobs at the lower levels. There were 1,200 excess jobs at ST1
compared to the feed-in from foundation. 1,300 too many jobs in
ST2 compared to the feed-in from ST1 and FT/STA1. That was going
to result in sucking in international graduateswith the
moral issues that gives rise towith the expectation that
they will have that they might train further, and problems for
the 2009 process as they compete again. Even more concerning to
me was the fact that there were going to be many hundred too few
jobs at ST3exactly the same issues we had last year. I
took this to ministers that day. We wrote to all the appropriate
channels and made full recommendations as to what I suggested
they could do to try to rebalance the situation just a little
bit to try to help the situation, and, despite others taking the
papers that I had written to ministers, I was getting the impression
that there was just no movement on this. It was out of a feeling
of intense frustration for these senior trainees, many of whom
had been in medicine training towards their career for the last
ten years and the only thing they had done wrong was to graduate
at the wrong time, that I wrote a letter to the Times.
Q677 Dr Stoate: That is fair enough,
I can see exactly what you mean by that, but postgraduate deans
last week told us "so far, so good" with the 2008 process,
and yet obviously the colleges took a rather different view that
they were very worried indeed about these very high competition
levelsparticularly in surgery, where it did go up as high
as 20. Why do you think the deans are so much at odds with the
colleges over this issue?
Professor Douglas: I think I have
made the colleges' view quite plain. You would have to ask the
deans why they have their position.
Q678 Dr Stoate: Fair enough. If three
applicants for every training post appears to be too many but
competition is desirable, what level of competition do you think
there ought to be? What do you think would be a reasonable level?
What should we be aiming for in terms of numbers of applicants
for each post?
Professor Douglas: I do not think
you can say anything from this year's competition ratios because
people are allowed an infinite number of applications. We just
do not know.
Q679 Dr Stoate: I am asking you what
would be desirable.
Professor Douglas: There is no
way of knowing what desirable is.
|