Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 740-759)

MS ANNE RAINSBERRY, DR MOIRA LIVINGSTON AND MS SIAN THOMAS

24 JANUARY 2008

  Q740  Dr Naysmith: Even if we managed to restrict the entry of non EU applicants, there is still an increasing number of EU applicants coming in. Do you think that is going to increase in the future?

  Ms Rainsberry: The evidence is that it is. You heard evidence last week from our Dean, Lis Paice, in London, and I would agree with her that some kind of examination would be a way of starting to manage that, thinking very carefully about what the bar should be in that. I think that would be one way of trying to manage that issue.

  Q741  Dr Naysmith: We are going to have the first graduates from the new the British Medical Schools coming out in the next two or three years. They are going to be adding to the competition, so we really have to do something about that as well, do not we, fairly soon?

  Ms Rainsberry: Yes.

  Q742  Dr Naysmith: Even if we did restrict non EU applicants, we are still going to have a problem in a few years time.

  Ms Rainsberry: Yes, and I think, as Sir John Tooke identifies, key in that will be the debate about what is the role of a doctor and are we having a consultant-delivered or a consultant-led service, because if you are sitting in an SHA the answer to that question makes an awful lot of difference to what you then commission.

  Dr Livingston: I think the other aspect of Tooke, it is a question that remains unanswered but it is highlighted as an area, is this issue of excellence and understanding what excellence might be. If excellence is that a doctor who is in the country will train to become a specialist, then, of course, that means we continue to have a very broad programme, but it will be highly competitive and will be of interest to Europe because the salary is good and the training is paid for. If we then think that excellence is a different model and excellence is about ensuring those who have the ability to move swiftly through a training programme achieve the competences, then you need a different type of structure to support that to ensure you have your workforce output at the end. I do not think we have a clear view on what excellence is, but if we knew what that was, then we would get the eligibility right. We would then be able to understand just how high is this bar and then actually consider, through proper modelling, what the competition ratios may well be in truth, not in terms of number of applications but in terms of eligibility to the post.

  Q743  Dr Naysmith: Anne, you talked about managing expectations amongst those who wanted to get into the really competitive areas finding that they did not get a job. Actually, medical training is a very general training which trains you for all sorts of different specialties, so it is not unreasonable to say that we should be helping people who do not get their first jobs to do other things. Is that something that is happening fairly widely? Is it coming from recommendations from the department, or is it just some areas where there was a lot of expectations that were unmanaged coming up with ideas how to do it?

  Ms Rainsberry: Yes. There is certainly evidence from the royal colleges in terms of the curricular and looking at core medical training and themed training in surgery. It is starting to look at that and, obviously, one of the issues that have been raised with run-through training was this issue that you were just nailing your colours to the mast. If you did not get in, it was seen that all was lost.

  Q744  Dr Naysmith: Do you know of any good schemes that we might recommend?

  Ms Rainsberry: Certainly in the London Deanery there are a number of programmes that are looking at generalising, if we can use that phrase, before you actually give people a broad base. There are challenges in that in terms of the design. The issue for us (and Sian mentioned transition) is just managing through people who have been training in a specialty for a large number of years who suddenly find that they cannot get into the higher levels. That is a particular challenge we are having to deal with.

  Q745  Dr Naysmith: The other thing was something which Sian said, about controlling entry to the hospitals from the overseas doctors. Should not hospitals have the right to choose whether they want overseas doctors or not?

  Ms Thomas: Some hospitals are saying that to us, and I think that just signifies the dilemma. Going back to the point about competition, it is where you want to put the pinch point of competition. Where do you want to have, as Moira said, the analysis of high skill? If we have got hard to recruit posts, it is absolutely entirely appropriate that we recruit from overseas but we must try and drive over supply into previously unpopular specialties by giving better advice to doctors and channelling good doctors into parts of the country that previously they may not have gone to.

  Q746  Chairman: What level of competition is desirable? If we have got three people eyeing one post, what percentage of competition should there be?

  Ms Thomas: When we were giving advice at the department last summer around the recruitment process, one of the first questions I asked as an HR professional, which is characterised in all high volume recruitment situations which are apparent in lots of different sectors—the IT sector has huge high volume recruitment processes—you need better hard measures to shortlist, but I asked a question about the ratio of interviews to posts. Because in the profession for high skill that is generally between a two-to-one or a three-to-one ratio, you generally expect to have a face-to-face assessment process with three people for every one post. You certainly would not put all your backing on a two-to-one ratio, it may not give you the best applicant, so, actually, three-to-one may sound a huge over supply, but in terms of recruitment process a three-to-one interview process is good. In terms of the comment before about over supply, I ask employers this question, and have asked it for a year now, in terms of their own thinking of good applicants, eligible applicants, to the posts available, and anything between 5% and 10% in any sector is considered reasonable. The question I think for health is, when you are funding people's training at huge cost, what is a reasonable level of over supply? Maybe I would say 10% is probably too much, but we do need some for the people to go and work in those parts of the country that could not get good doctors.

  Q747  Mr Bone: I am trying to get this pinch point argument. I have been thinking about it. I am not entirely sure I understand it. Are we saying that it is okay or desirable to bring overseas people in at the beginning and give them training posts, and then, when it comes to the end and they become qualified, that is where the pinch comes and you do not want them then and you have paid for their training costs?

  Ms Thomas: I think an employer perspective would be that if we have grown the UK graduate workforce to enable UK graduates to have the best opportunity they possibly can to be competitive and you have a system where you have to give them practical training for their first year of training to get them on the register, we have to have a situation which somehow gives them maximised opportunity, and that means, for the first few years of their training, we should give as much priority as possible to the EU and UK graduates. The EU graduates have that right through law. Then there is a situation around at what point actually employers would want competition. I talk to foundation trusts that want competition internationally for their consultant vacancies. So, actually, the reality of the situation is we are in a global healthcare market that is very competitive and employers will always want, potentially, the widest pool as possible.

  Q748  Mr Bone: I think I have got it right now. You are saying the pinch point should be when they are qualified.

  Ms Thomas: Further up the training programme. At what point it is debatable, but further up the training programme.

  Mr Bone: That makes sense.

  Q749  Chairman: The European Working Time Directive. It clearly shows a significant reduction in training doctors' hours in relation to that. The logic then tells me that we should have an increase in training posts on that basis. Why has this not happened?

  Dr Livingston: I think the reduction in training hours across Modernising Medical Careers was driven to address that to ensure there was a competence structure and an assessment process in place and that we could then demonstrate that the curriculum had been delivered and that the doctor was fit for purpose as a specialist. I think all of that is an issue. I think that MMC is part of the solution to the original Working Time Directive issue. If we then think about how service reconfigures, certainly if we go back a couple of years, the service reconfigured by increasing the number of very junior doctors in order to cope with the Working Time Directive and they have subsequently been amalgamated into some of the new training posts and also the FTSTA, because there is concern that doctors at that level providing a service to patients are not as experienced as patients deserve their doctors to be. If we look forward, the discussions that we are having with the service are actually about new and different ways of delivering the service, I think that when we compare the UK NHS to other models of healthcare, we need to bear in mind that employers have a very different view on how they wish their service to be delivered and that they may choose multi-professional approaches, that they may have different team structures, and so I think the priority for services, certainly in the North East, is to actually look at the workforce in a different way, and they are not necessarily looking to increase the number of doctors. I think there are some striking examples where that will need to be the case, such as looking at obs and gynae, paediatrics and, I think, anaesthetics may well be another critical area, but I think in general the plans seem to relate to a change in the make up of the workforce rather than necessarily having more junior doctors in the system or more senior doctors delivering.

  Q750  Chairman: Do you agree with that?

  Ms Thomas: Yes, I think I agree broadly with that. One of the big risks, of course, of increasing numbers of people to cope with shift patterns where there were gaps for the European Working Time Directive results is the situation we have got around the SHAs bulge, which is that we have got lots of people who have done training programmes who now cannot find posts in their specialty. We have to be responsible when we do that and not lead people to believing that there may be posts for them in the future; so we are back to we need to be clear about what it is that the service wants in terms of the doctor for the future.

  Q751  Chairman: If consultants and trainees are working fewer hours, when do they train or when do they have the opportunity to train people? The logic is that there are less opportunities in that sense.

  Ms Thomas: One of the really welcome points in John Tooke's report is bringing in the aspect of the Working Time Directive. I am not sure his recommendation—we have only just seen it, the new recommendation, in the last two weeks, and we are carefully analysing it—is necessarily the solution, but he has raised again this issue of the tension between reducing hours, because it is certainly true that many doctors do not have exposure to procedures in the hours available, and if that is the case, then you either increase the number of years that people are doing their training or you change the role that they do when they finish their training, because they will not have had that experience. I think the fact that he has written it in his report means that we now need to go back to that, because certainly that was something that had become lost in the MMC debate.

  Ms Rainsberry: I think that was one of the reasons why MMC was competency based, in the sense of trying to get away from this idea of time served, and is basically saying, "You will move on to the next stage when you are deemed to be competent." So, I think that is an important principle that needs to be taken into account. I would also like to agree two points really. One is that there is a challenge about allowing employers to create additional training posts just to support rotas, and certainly in surgical specialties that is a big contribution to the bulge that we talk about. Equally, there is an awful lot of work going on which is looking at alternative solutions to meeting the European Working Time Directive which does not rely on doctors and training to do that, because they are a very expensive resource, and a lot of the evidence is that the way the old House Officer grade used to get used in hospitals really did not add a lot to patients and a lot to the training and, actually, by providing different models, certainly at night, you can get more training done during the day, more concentrated training, and provide different service models at night; so I do not think it necessarily follows you need more training posts because we have got to reduce hours.

  Q752  Dr Taylor: We are nearly at the last lap. Moira, starting off with you, because as a committee we probably have not looked into the position of doctors in staff grade jobs and things like this and as you were responsible, we believe, for implementing the policies of Choice and Opportunity, we would like to know how you have got on. We know that the department estimated, because they did not know how many there were, that there were 12,500, no career structure, variation in the type of work and the stigma and the fact that it is a professional cul de sac. How do you think you see the career of these people going and how can you implement the suggestions?

  Dr Livingston: I think that if we go back to unfinished business, where it was highlighted that there was an urgent need to review the staff doctor grade, which is the non-consultant career grade and the associate specialist. The choice and opportunity was consulted upon, and in January 2004 Choice and Opportunity was launched and was seen as a key part of Modernising Medical Careers. It is fair to say that a lot of the energy and focus of the work went into modernising medical training, and I think that that emphasis on training was very necessary and within the limited resources available at the time. I was asked to look at the implementation of Choice and Opportunity and the recommendations within that and worked very closely with NHS employers who were tasked with implementing the recommendations around the new contract, so the work that we did, which involved a very wide consultation with the service as a key focus because of the importance of the employer role in supporting this grade of doctor, did progress and the work was completed by December 2006. What then happened is that the work, which is a best practice guide for employers, is sitting with NHS employers and NHS employers will be responsible for publishing that guide and it is to be published at the time that the new contract goes out to vote and has been accepted. So there has been a delay in that we felt that the new contact was an essential component of Choice and Opportunity, and whilst waiting for that to be agreed there has been a hold on the publication of the work that we did within the MMC team. As we move forward, there was some work to be completed on a best practice guide for the doctors themselves who are currently in the posts but, more importantly, for doctors who then enter the new career post, as it was called under MMC, and that has been on hold because we were unable to find an organisation that would actually take responsibility for that. I think that that is a piece of the jigsaw that was missed. In terms of what we achieved, I think there are some things that we did manage to achieve. One was to bring together a body of evidence for the employer to understand how to ensure that doctors in these roles could fully reach their potential, how they could be supported in achieving their aspirations and how employers could view them differently in terms of their contribution as clinical leaders within organisations, so their role as managers, teachers, their role in research. Where we were unable to gain any momentum was around the issue of credentialing. The original aspiration had been that doctors in the new career post would be able to get the credentialing as they progressed within their job, learning as they go for new competences that they have gained, and there just is not a regulatory structure in place to support that. Because the doctors in the career posts are not part of the training structure and there was a lot of tension about using the term "training" with respect to these doctors who were in employment, they fell out with the remit of PMETB and, although we did work with skills for health to look at a structured framework for their development, again it was something that could not sit with the GMC in its remit and could not sit with PMETB. Whereas all the organisations were interested in this, and I know that PMETB were concerned that their framework did not allow them to do work on this grade—it is something that they would have in their sites for the future should the situation arise that they were able to address it, and their priority was going to address a kind of credentialing system post CCT initially for Consultants—I think that remains one of the recommendations that we were unable to successfully move forward. When we talk about MMC, I think there are three elements that are confused. I think Modernising Medical Careers was about modernising medical training, it was about choice and opportunity, and then there was MTAS, and I think sometimes that is confused and lost. I do feel concerned because I think you need to champion this area of development and, looking at the new MMC website, I think the non-consultant career grade work does not feature and I think the reaffirmation of the principles of the MMC Programme Board, which were deemed MMC principles, actually are MMT principles, actually modernising medical training principles because they do not take account of Choice and Opportunity, which was a key part of the whole programme.

  Q753  Dr Taylor: Because these doctors provide the backbone of a tremendous amount of service.

  Dr Livingston: Absolutely.

  Q754  Dr Taylor: Am I right to take encouragement from Tooke's diagram, because his diagram of the inquiry recommendations puts the staff grade in the same sort of block as the specialist registrars and there is an arrow, if you follow it very carefully, that allows them to go towards CCT?

  Dr Livingston: This is part of Choice and Opportunity. It allows them to enter the specialist register through PMETB, through something called the CESR route, through article 14 or article 11 in primary care. I think that certainly the ambition is there to support these doctors to progress, and I think that as a new doctor entering that career structure, if we get sign-up from employers, then gathering evidence of their performance will result in them having an effective portfolio, which will give them a better chance. For doctors who are currently in the system, actually going back five years and looking for evidence of achievement of competences that demonstrate their equivalent to a specialist is quite a challenge. I think that Tooke does ask for an urgent review, an urgent need to implement the new contract. I think that this debate sits within the overall debate of what is an excellence model. We have talked a lot about the difficulty in workforce planning and how do you look at a 10-year programme with all the changes in technology, the change in service. How do you know that what comes out at the end from the start is what we are going to need? I do think we should take another look at a potential model which is slightly different to the model that we might be running with, whereby we can see doctors working in the service learning and developing all the right skills but actually they provide a drip-feed into the senior end and, because they are more senior and more experienced, actually provide us with a shorter run-through to delivering a fully trained workforce, if we mean by "fully trained" a specialist. I think at the moment everybody goes on the very long path. We do not have a fast-track path and, looking at other professional groups, the model we have in medicine is quite unusual in terms of other professions outside of medicine. The expectation that everybody is automatically on the excellence path is very high, and I think, as part of the debate, I am not sure that we are questioning that and I am not sure that we are looking at other models that would provide us with a workforce planning model that offers us a drip-feed from the service with doctors who have been fully supported, allowed to develop appropriately, with competence akin to what will be required in terms of service, but, therefore, better prepared to enter specialty training at a higher level.

  Q755  Dr Taylor: You have mentioned the best practice guide and the new contract. Can Sian tell us when the contract is coming and why it has been delayed?

  Ms Thomas: NHS Employers have been negotiating the new contract for SAS doctors, as you know, for some time and we concluded those negotiations in November 2006 and agreed with the Department of Health and the BMA the overall framework of that contract, and we are ready, through the BMA, to ballot SAS doctors. Before we could do that, or the BMA could do that, this needed to be sent to the Government for ratification, and that has taken a year, and in December 2007 we received the decision from the Government that we could implement the contract and the BMA are now balloting their members. So, we will know by the end of March if their members have supported the contract recommendations and then it will be implemented by employers from 1 April.

  Q756  Dr Taylor: So the delay was not your fault.

  Ms Thomas: It is not for me to say.

  Q757  Dr Taylor: You have said it very clearly. Finally, do you have any suggestions about what they should be called, because staff grades, trust grades, associate specialist, non-consultant career grade—it is absolutely ridiculous, is it not? What is a complementary title for them that implies it is not a cul de sac?

  Ms Thomas: There are two pieces of work in NHS Employers we are doing with employers. The first is to determine what we want doctors to do in the future: what is their role in the healthcare team and what will the career structure look like? Employers will determine that, and they may actually not all determine the same thing and may want to do different things, which is obviously, in an autonomous employer situation, what they are entirely able to do. What we will try to do is determine what the overall structure will look like. The second piece of work is on looking at what the individual career pathways for doctors look like to make them attractive in a world where 70% of students at the moment are women and their potential medical pathway might look very different for a workforce that might look very different in the future from what it does now.

  Q758  Dr Taylor: It has got up to 70% now, has it?

  Ms Thomas: 70% of undergraduates are female.

  Q759  Dr Taylor: Very good.

  Dr Livingston: If I can just add to that. Creating an alternative to specialty training is essential to improve the morale of the medical workforce, a real alternative which is valued. It has been one of the issues for doctors in the system, the importance of them getting on specialty training, because the choice was not there for an alternative route. Even where there is a work/life balance issue it is a very difficult decision for the doctor to make because we have not made it attractive enough. This work is essential to reduce some of the heat within the system around that.


 
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