Select Committee on Health Minutes of Evidence


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 introduced—and we did it for the first time last year and we are now doing a second one this year—is a trainee survey. Last year we had a 64% response to our training survey, for example—which 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 implementation—as 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 school—we often get him together with our foundation school head—and 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 well—because 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 moment—and the medical colleges I think probably do a good job—if 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 exam—that 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 component—not the critical component because clinical skills and communication skills are also vital—but 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 colleges—this was, as you say, early in the process, a week into the interviews—and 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 consultants—that should not be underestimated: the amount of time that consultants and GPs put into the appointments process—provided 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 deans—those being the members of the medical profession on the team—was always, at the end of the meeting—not always at the beginning—that 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 graduates—with the moral issues that gives rise to—with 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 ST3—exactly 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 levels—particularly 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.


 
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