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 sectorsthe IT sector
has huge high volume recruitment processesyou 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 recommendationwe
have only just seen it, the new recommendation, in the last two
weeks, and we are carefully analysing itis 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 gradeit 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
ConsultantsI 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 gradeit 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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