Select Committee on Health Minutes of Evidence


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 oversight—we cannot have a situation where there is not a strategic view about medical education, so we do need that—and, 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 Ipswich—this is another little case study for your geography, and I do not get many emails from chief execs—directly 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 it—you 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 bigger—you 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 say—it goes back to the first point I made—certainly 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 expectations—it is the point you were talking about earlier—in 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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