Examination of Witnesses (Questions 720-739)
MS ANNE
RAINSBERRY, DR
MOIRA LIVINGSTON
AND MS
SIAN THOMAS
24 JANUARY 2008
Q720 Dr Taylor: Your views, Moira?
Dr Livingston: I fully support
everything that Anne has said. I do want to note a point about
the 87% response rate to the Tooke Inquiry, because it is my understanding
that where an organisation responded, such as an SHA, it was given
the same weighting as a single trainee, and it would be very interesting
to see that in some way managed, through perhaps a further request
for some data on the actual pattern of responses, once we look
at organisations with an appropriate weighting. Moving on to NHS
Medical Education England, if you think about the policy direction,
we have Our NHS Our Future, which is all about developing
local services for local people: how do we develop local services
for local people. That is running through the commissioners at
the moment in PCTs. In developing local services, we then train
people in order to be able to deliver those services. In training
people we need to therefore understand what those local services
are going to be and, if we genuinely want to deliver care closer
to home, deliver care which is exactly what the local public have
asked for, we need to be able to flex and develop training according
to local needs. Thinking about separating the medical profession
off, I think there are certain elements which we need to consider.
In the Terms of Reference for the Tooke Inquiry, it was very important
that engagement of the medical profession was achieved, and I
think there is evidence that engagement was sought and has been
achieved, but the devil is in the detail and I think the challenge
now is how do you maintain that. I think that much of MMC has
been a challenge because of the difficulty in getting a consensus
view from the medical profession and a consistent view from different
bodies within the medical profession. I think that understanding
how we can achieve that is an essential part of us moving forward
and having a fully integrated and effective workforce development
plan locally and nationally. If we then think about the Warwick
Report, which was an evidence-based consultation which the Workforce
Review Team carried out, the evidence is that workforce planning
actually is not done very well anywhere inside health and outside
of health, it is an extremely challenging area, but the thing
that is much more likely to lead to success is when you integrate
service planning with funding and with education and training,
and that is very difficult to do from a distance. The other element
is around quality assurance. I think that it is essential that
we have a system of continuous improvement and drive forward the
quality of education. At present within SHAs we are all required,
through a service-level agreement with the Department of Health,
to have a learning development agreement and that has provided
us with a tremendous lever. In the North East we have all bar
one trust as a foundation trust in terms of acute secondary care
providers, and having a lever such as that allows to us to go
in and discuss funding, directing the funding and driving up the
quality of training. I have concerns that if we no longer have
that lever that we cannot work through a dialogue with organisations
delivering training to ensure across the board that the quality
of training is continuously improving to benefit patient care.
Q721 Dr Taylor: One of the things
you said was that it was difficult to take a consensus view from
the medical profession, which we all realise. Was not the point
of NHS:MEE, or one of them, to have a medical director in charge
of that who would speak for the whole of the profession on training
issues?
Dr Livingston: My question back,
I think, is: is that the solution? If we go back a few years,
deans were accountable to universities. Did we see an improvement
in medical training at that point? We have royal colleges, we
have an academy, we have specialist societies, we have the GMC,
we now have the PMETB, and I think that, despite august bodies
doing an extremely good job and working hard and delivering what
is required of them individually, we cannot seem to get a consistent
consensus view. If we then think about the proposal of NHS Medical
Education England, there is not enough detail in the Tooke Report
that would enable us to analyse: "What exactly is
this? Who is around the table? Why would it be different?",
and when we think about the engagement that we have had, which
has been extensive throughout the consultation period of "unfinished
business" and through Modernising Medical Careers,
of all those bodies that I have described, despite that engagement,
we have what we have, why would it be different? I think I would
like to understand that more, and I have not seen anything in
Tooke that helps me understand that more at the moment.
Q722 Dr Taylor: Sian, do you want
to add anything?
Ms Thomas: Yes, one of the things
I would say is that you are quite right, this was a new recommendation
and we have only seen it for two weeks and we have not had a chance
to discuss this recommendation with employers, but we are doing
so on 6 February and I should think we will spend the majority
of the meeting talking about this point, and so we are very happy
to give you a note after the sixth on the views of the employers
we talk to. I would say three things about it. First of all, there
is definitely a need for strategic oversightwe cannot have
a situation where there is not a strategic view about medical
education, so we do need thatand, as has been alluded to
today, there are wider government issues to consider, not just
Department of Health issues, wider policy issues. You can only
do that at a strategic level. The second is that that needs to
be balanced against a demand-led, employer-led service focus,
and so the challenge is how do you bring those things together?
Finally, just about clarity of roles, we have already had major
structural change in the NHS and we would always say further structural
change needs to be very carefully considered before we go ahead
and implement.
Ms Rainsberry: Can I make one
further comment. I am not sure that just getting consensus is
a good objective, because it is a very important area we are talking
about. Actually, my experience over the last few months sitting
on the MMC England Programme Board is that, whilst we have come
up with what, I think, is working for the service, it has not
always been through a process of consensus, and we have had some
very frank, robust and important discussions through the different
perspectives, and so I think if that board can continue it is
a very valuable contribution. The other thing I think the Tooke
Report is saying is that there is a need for greater co-ordination
and, you touched on it with the previous witnesses, I think the
model that the SHAs have around the Foundation Programme Office,
which is commissioned by the SHAs and works on behalf of it but
is a co-ordinating body, could be something that you could look
at for specialty training which could provide that co-ordination
across England. The last point, I would say, is one of size. It
does work well in Scotland, I would agree with that, but the number
of their trainees is similar to one of our medium-size deaneries
and so I think it is a massive job.
Dr Livingston: I think the last
point is very important. We have embarked on a consultation in
the North East and, again, we would be very happy to submit the
outcome of that consultation to this Committee, if you would like
to receive it, on NHS Education North East. We are looking how
we can integrate the whole work force, be employee-driven, and
look at the whole quality issue and process as well as an understanding
of the learning environment in which education needs to take place
within NHS delivery organisations. I think the interim report
is due at the end of this month and we are quite interested in
some of the models that the consultancy organisation is coming
up with for the future.
Q723 Dr Taylor: I am sure we would
be very grateful for any further thoughts. Can I go briefly back
to education budgets. I think it is right to say that Tooke recommends
that the funding for NHS:MEE would be ring fenced, but what you
have implied is that really there have not been cuts in actual
medical education training budgets, the cuts have been borne largely
by continuous professional development for nurses and people like
that. Is that right across the country or is that just you? I
think you said you had not had to make any cuts at all.
Dr Livingston: I think we reduced
the numbers of some of the nursing and physios as a result of
Effective Workforce Planning. If we look at the overall number
of trainees within the system, across England there was a massive
increase in training opportunities this year, and that was supported
by the SHAs and managed through the budgets that are allocated.
Q724 Dr Taylor: What about last year
when there were the reductions?
Dr Livingston: Last year we had
a 15% increase, and it was a much higher increase this year.
Q725 Dr Taylor: Not coming from the
north-east and being very envious of the north-east, is it not
fairly true that you are reasonably well-off up there compared
with some of us elsewhere in the country? I think Doug implied
that there were drastic cuts, particularly in budgets for continuous
professional development for nurses particularly.
Ms Rainsberry: I think the reality
of the situation is I am sure that SHAs would have made reductions
in budget where it could be retrieved relatively quickly through
the subsequent years. For example, in London we had a lot of discussion.
You have contracts with HEIs, so you cannot just slash and burn,
and you only have a 10% variation in that in any event. You do
not want to destabilise an HEI to the extent that they have to
make a faculty redundant, and then you want to increase commissions,
and, therefore, the things that tend to be reduced would be things
like NVQ training, continuous professional development, things
that have a much shorter lead time which you can then put money
into the system the following year. It is damaged limitation.
Q726 Dr Taylor: So there could not
have been reductions in junior doctors' salaries and the numbers
of those?
Ms Rainsberry: No.
Q727 Mr Bone: Can I direct my question,
first of all, to Ms Thomas. Supply and demand. Am I right in thinking
you said it is good that there is plenty of competition for training
posts. We are told that, on average, there are three people applying
for every training post and that is good for patients. Is that
your view?
Ms Thomas: Yes, we said to this
Committee, I think 18 months ago, on the question of supply generally,
that one might expect most employers in any sector to say that
a modest over supply is a good thing because it improves quality.
One expects that competition leads to improved choice for employers
around candidates, so, as a general point, that is what we would
say. I think it is a good thing that we have grown the supply
of UK graduates, because it certainly is not a sustainable labour
market strategy to rely on overseas recruits, and it is certainly
true that in some parts of the country people have recruited doctors
they would never previously have been able to recruit. In fact,
as a result of some of the media attention on 1 August, I had
an email from a chief executive at Ipswichthis is another
little case study for your geography, and I do not get many emails
from chief execsdirectly to say for the first time Ipswich
General Hospital has filled all of its junior doctor training
posts with good doctors, and that is exactly, as a patient, what
you want to hear if you are in Ipswich. Similarly, in Barnstaple,
they recruited all of their orthopaedic training posts, a very
high competitive specialty but they had not traditionally been
able to fill all their surgical posts. Even in the high competition
specialties, not every location in the country was able to find
doctors, so, yes, on the one hand employers would always say in
any sector (and it is particularly true in health care where safety
is an issue) one wants more in the pool for better quality. However,
we are different in health.
Q728 Mr Bone: Can I stop you there.
That is very refreshing, Chairman, and that really is encouraging,
because you are putting, effectively, the patients first, but
we are not in a normal organisation, we are into this state planning,
state-controlled unique organisation, and it is difficult for
me to get into that organisation and I am not in favour of it,
but having got there, you would think the one advantage you would
have in state planning is that because you ration the amount of
health care you are not subject to market forces for demand, you
actually set ityou say, "This is how many doctors
and nurses we are going to have"and the one advantage
of that system is that, if you know that, surely you can work
out what number of people you need to put in at the beginning
to supply those places, you can build in for competition a service,
say 10%, but we seem to be hopeless at it. It is really unfair
for the student, is it not, who wants to go into the medical profession,
who goes into university, does years of work and then does not
get a job at the end of it. Are we just hopeless at it?
Ms Thomas: I completely agree
with everything you have said. We have not been very good at it.
I think I agree with some of the comments earlier on at the Committee's
first session, that we are never going to get this right and the
world changes so quickly in medicine and it takes so long to train
health care professionals that, actually, we do need a broad,
flexible lens when we look at this issue. It is never going to
be possible to work it all out exactly right. Two things have
changed, and one is the EU market that is affecting the pool of
people, and the second issue is, as I say, the huge expansion,
60% expansion, in medical under-graduate trainees. So, we have
this balance: on the one hand we want this pool to be biggeryou
quoted 10%, some employers might quote 5%we do need to
analyse exactly what the over supply picture would be, but we
cannot have the situation we now have, which is not a modest over
supply, it is, in fact, a huge over supply of very expensive trainees,
and I think that is why this question, which is really a question
for wider government policy-makers, needs to be resolved. Employers
have not been in agreement all year on one side of that question
or another. We have found it very difficult, actually, to get
a consensus with employers, and only since these figures have
become more known and the really grievous situation for these
trainees has become known have employers finally given a view.
The employer view at the moment, but we think it should be under
review, is that UK and EU graduates need to be prioritised. It
does need to be kept under review, and I should say, there is
still not an insignificant number of employers that would not
agree with the statement I have just made.
Q729 Mr Bone: On that point, Chairman,
if the employer is sitting there and has all these different applicants
to choose from, some home-grown, some from the EU and some from
outside the EU, and we are sort of saying the problem arises because
people are flooding in from the EU and outside, why are employers
choosing people from outside the UK? You do not need to prioritise;
the employer can make the selection. So, if I am interviewing
people I can choose who I want. Is it a bit of a red herring?
Ms Thomas: There are two points.
The first is that there is a general point to be reflected on,
which is at what point do you want over supply and competition?
Do you want it very early on in the training programme or do you
want it much later? If you talk to foundation trusts who are employing
CCT holders, they want the international market, they want to
be able to say they have international expertise in their hospitals
at consultant and CCT level. So there is a first decision, which
is at what point do you want the pinch point of over supply? Do
you want it at the beginning or more towards the end? The second
point is just an issue about the dilemma around the cost; so I
completely agree that a large pool of people is adequate. The
final point is about legislation and recruitment. It would be
something I would bring to the Committee's attention, because
a lot has been said about entry to foundation. We have a legal
framework in the Medical Act which requires medical schools to
guarantee employment. That could be inconsistent with employment
law, where guaranteeing employment to anybody might actually be
unlawful. At the moment we have a situation in the foundation
programme that needs urgent review around the recruitment processes
for those individuals, because at the end of the day it may be
called a foundation programme of training, but it is employment
those people have, and, therefore, the route to those posts needs
to be through fairly robust employment law processes.
Q730 Mr Bone: Finally, I think you
touched on it in your answer there, very briefly, cost. There
is a suggestion that if you flood the market with supply you keep
costs down. It is a sort of cheap and cheerful model, if you like.
Do you think there is any credence in that?
Ms Thomas: I think what I would
sayit goes back to the first point I madecertainly
one would expect in any sector, if you do flood the market and
leave it to the market, then you do potentially apply some pressure
around cost, but it is at what point in the career pathway you
do that, and, arguably, you can achieve far more doing that at
the end of the process when people have completed their training.
Certainly the cost to the UK taxpayer of displaced trainees is
significant, so that has to be a factor in making the decision
about where the competition should be early on.
Q731 Dr Stoate: Can I clarify one
point? I think you just said that you would like to see priority
given to UK and EEA graduates in the selection process. Is that
right?
Ms Thomas: We support the general
recommendations in the Tooke Inquiry. We generally do support
the first four-year broad-based concept of core training. As Neil
Douglas pointed out, we can debate the finer points of where the
cut-off point between F1 and core are and this issue of basing
the decision of entry to core on evidence, which, after only five
months training in F1 as employers, we are not quite sure how
we are going to do that, but on the point about exactly how people
are selected, I think we need more discussion, certainly.
Q732 Dr Stoate: How would you suggest
doing it?
Ms Thomas: If legally there is
a way in which entry to foundation programme and core should initially
close off recruitment for EU and UK graduates and you set the
bar at the appropriate level, then that might be a way, if you
could then say this is the first four-year programme, that you,
if you like, give as much chance. What we want to do is give opportunity
to those graduates to show excellence at the right point and to
be competitive at the right point, which might be at the end of
core.
Q733 Dr Stoate: We heard earlier
on, though, that there did not seem to be a problem with the junior
levels. If anything there was an over supply of posts. It was
when you got up to the higher specialist training grades that
there was massive over application with competition ratios of
20 to one. So your idea of sorting it out after core training,
I do not think, would address it.
Ms Thomas: One way that could
address it is better career advice during core. There is a world
of difference between choosing four themed specialties and being
asked to choose from 57 specialties, so taking that decision a
bit later on for the trainee might actually give people better
information about where the competition ratios were and potentially
ease that problem.
Q734 Dr Stoate: But it would not
stop a huge number of graduates coming in from outside the EEA,
which the Court of Appeal ruled we could not do anything about.
Ms Thomas: It certainly would
not unless the immigration rules change.
Q735 Dr Stoate: Our understanding
is that the guidance given to the NHS, which was ruled unlawful,
was in fact drafted by NHS Employers. Is that right?
Ms Thomas: It was certainly not
drafted by us, no.
Q736 Dr Stoate: Certainly our information
is that it was, but you are saying otherwise.
Ms Thomas: Our role is to implement
the policy decisions of the Department of Health, and that is
what we do.
Q737 Dr Stoate: What would you do
then to restrict immigration rules? How would you see that happening?
Ms Thomas: It is not for me to
comment. I am not an expert on the immigration arrangements. I
think I have just said, the position employers are telling us
at the moment, and it is not a consensus, is that we probably
ought to try and priorities EU and UK graduates, and we should
do that legally, through, if possible, a change to the immigration
rules.
Q738 Dr Stoate: What do you think?
Dr Livingston: I think it is a
really important issue that needs resolution. Sitting in SHAs
with responsibility for delivering an effective recruitment process
this year, we would like to know what success is going to look
like for us. I think that if we have similar competition ratios,
there will be a lot of noise, but that will not necessarily mean
that the process has not been well implemented. I think it is
essential at a national level that a decision is made. I think
there are two other issues in terms of competition. I think the
first is: do we have the eligibility criteria right for specialty
training? Do we believe in an excellence model? In which case,
is the barrier high enough in terms of eligibility. The second
question is: are we confident that if we are producing a home-grown
cohort, our future medical workforce, that that will be a highly
competitive workforce in an open market if we cannot influence
that? So what do we need to do to ensure that future medical graduates
from the UK are highly competitive, and we should be in a very
good position to influence that through working closely with higher
education to ensure the curricula is mapped into the service changes.
We should not forget that, as we move forward and look forward,
Lord Darzi's NHS next stage review is going to really help us
understand the future picture of services, and that in turn should
then greatly influence the content of curricula and the commissioning
of education, and that may play some part, but working with higher
education to ensure that we are confident that the money that
we have invested in training medical students puts them in a very
good position to be competitive.
Ms Rainsberry: I just wanted to
say, I do not think it was hopeless. If you look at the high level
numbers, and this is with no disrespect to IMGs because they have
actually produced and given a lot of service to the NHS, but the
ongoing hypothesis at the beginning of this whole process was
that they would not be included, and that was the basis on which
the additional medical school commissions came through. If you
take that as a hypothesis and you look at that running through,
broadly, the numbers were right. I think that is an important
point. The other point is that there is a real challenge for us
around the managing doctors' training expectationsit is
the point you were talking about earlierin terms of which
specialties they wish to train in, because a lot of the mismatch
we are talking about that occurs and a lot of the noise, quite
frankly, is about people who cannot get into surgical specialties
or cannot continue to pursue their career in surgical specialties.
There is a lot of evidence this year that SHAs funded transition
packages, creating new training posts in specialties where we
needed more doctors, provided career supports, counselling to
doctors who did not get posts in round two to help them think
about moving from, say, a general surgical specialty to maybe
obstetrics and gynaecology.
Q739 Dr Stoate: That is all true,
but that is not going to solve the problem of a very large number
of non EEA graduates applying for posts. That is the issue I am
trying to get to. What would you do to address that specific issue?
Ms Rainsberry: I am not an expert
on this, but going back to when I was an HR director in a trust,
I think the work permit rules we had there, both in terms of the
work and the study, seemed to work very well. Where you had specialties
that you found it hard to recruit and you had evidence that you
could not get trainees, and that worked for Europe as well as
it did for the UK, then you would make an application and someone
would either come through on a training permit or a work permit.
I wonder whether we have got the system to manage it, because
in the short-term (and this was the link I was trying to make)
we do have a mismatch between what people want to train in and
what we need for the service, and, therefore, we are reliant on
doctors from overseas for some specialties.
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