Examination of Witnesses (Questions 841-859)
RT HON
ALAN JOHNSON
MP, MR HUGH
TAYLOR, SIR
LIAM DONALDSON
KB, AND MS
CLARE CHAPMAN
18 FEBRUARY 2008
Q841 Chairman: Could I first of all welcome
you to our sixth meeting of taking evidence on our Modernising
Medical Careers inquiry. I wonder if, for the sake of the record,
I could ask you to introduce yourselves and the position that
you hold.
Ms Chapman: Clare Chapman, Director
General of Workforce.
Sir Liam Donaldson: Liam Donaldson,
Chief Medical Officer.
Alan Johnson Alan Johnson, Secretary
of State.
Mr Taylor: Hugh Taylor, Permanent
Secretary.
Q842 Chairman: Thank you. The first
question is for the Secretary of State. Why was the project management
of MMC and MTAS by the department so inept?
Alan Johnson: Probably because
the accountability was spread so widely. When you look back at
how this was all put together, you had four UK departments of
health, you had all the educational bodies, you had the bodies
that set standards, you had the regulatory organisations, and
all of that put together led to a classic case, I think, of systems
failure. For instance, you had the policy being set by something
called the UK Strategy Group. You had the criteria being set by
the Specialist Training Action Group. Implementation was the responsibility
of the MMC Programme Delivery Board. The Strategic Health Authorities
through the Deaneries were responsible for implementation in England,
local implementation. You had another body dealing with the selection
criteria, so it was very disparate and it was, as it has been
explained to me, a difficulty of knowing who had the lines of
accountability with all of that group trying to work together.
Q843 Chairman: We will move on to
that in some detail in terms of leadership or perhaps a lack of
it, but did ministers know about the situation? Were ministers
kept informed about what was happening? I know it was before your
time.
Alan Johnson: I was not there
at the time, but yes, they were. Indeed, one of the other problems
was that Lord Warner, who was very closely involved in this and
took a very hands-on approach, went, for personal family reasons,
in, I think, December 2006 but at a time when his knowledge and
expertise we could have done with, so there was a problem there
as well, but as far as I am aware, yes, ministers were fully aware
of what was going on.
Q844 Chairman: What have you done
to improve project management in the light of this last 12 months
and the Tooke Review?
Alan Johnson: A far simpler structure
for a start. The Douglas Review very early on made the point about
ensuring that we had a simpler structure, so, for instance, we
had a single senior responsible officer, a single chief reporting
officer that we introduced, a chief operating officer, but I think
the most important innovation was the establishment of a Programme
Board that had the medical profession represented on it as well.
Tooke has made an enormous contribution but from before that when
the Douglas Review came out we sought to streamline what was a
pretty unstreamlined management structure.
Q845 Dr Taylor: Secretary of State,
I am going to continue on the same line because when Alan Crockard
came to us, and I am quoting, he said, "There was a clear
dichotomy between the education and training role overseen by
the MMCB and Workforce needs overseen by the Workforce Directorate
which resulted in two separate senior officers in charge of MMC
and MTAS without close working of their teams. Never should a
project have two SROs overseeing two parts of the same project."
Therefore, Secretary of State, when you listed at the beginning
all the bodies involved it is really no wonder if it fell down
in tremendous chaos?
Alan Johnson: No, and there were
two lines of accountability on the issue as well. There was the
policy accountability through the Chief Medical Office and there
was the implementation accountability through the Workforce Directorate.
I think that was a major problem. Once that was clarified and
rationalised we saw the system work much better, and again that
was something that the Douglas Review helped us with and the Tooke
Review has helped us with even more.
Q846 Dr Taylor: On a rather wider
note, do you think we risk the same thing on an even wider basis,
having the equivalent of three permanent secretaries?
Alan Johnson: No, I do not, but
we have had a capability review of our department and one of the
central features of that was the leadership in the Department
of Health. The capability review said we were a very good department
at delivering. There was an issue about leadership, but personally
I would not want to go back, and I do not think anyone would,
to a joint Permanent Secretary/Chief Executive of the NHS, the
Nigel Crisp position, but how we manage that better is something
we are looking at all the time. As far as I see that was not the
problem in terms of MMC.
Q847 Dr Taylor: No, it was not. I
am just illustrating a potential snag with three leaders.
Alan Johnson: One leader, three—
Q848 Dr Taylor: Okay. That is absolutely
right, and I am delighted to hear it. This is to Mr Taylor. Was
it a serious error to have no permanent Director of Workforce
during the key phase?
Mr Taylor: In one sense it was
far from ideal but the important point to make about that is that
there was continuity of senior leadership because Nick Greenfield,
who became the acting Director-General for Workforce during the
interregnum while we were advertising and waiting for Clare to
take up her appointment, had been closely involved with the MMC
project, so from the point of view of continuity that was certainly
maintained during that period.
Q849 Dr Naysmith: Mr Taylor, it has
been suggested to us that the shortcomings in the governance and
management of these two projects, MMC and MTAS, suggest that civil
servants in your department are simply not up to the job. Do you
think that is fair?
Mr Taylor: No. I think it is much
too sweeping a generalisation. I think we could point to a number
of examples of excellent collaborative policy making and excellent
delivery, but I think we have to accept responsibility for the
fact that the governance arrangements for this programme in retrospect
were not adequate. We have done, not just connected with this
but more generally, a lot of work in the department over the last
18 months to significantly up our game in terms of risk management,
for example, and overall support for people on policy governance
issues generally and on project and programme management. It would
be idle to pretend there were not lessons to be learned from this
episode and those are lessons which I am determined we will take
to heart.
Q850 Dr Naysmith: So you think there
were problems and you are doing something about them? Are you
doing something about them quickly enough?
Mr Taylor: As the serious problems
with the implementation of the programme began to unfold in 2007
the department did move pretty quickly to establish much clearer
lines of accountability and put real operational management in,
and with the support of the Douglas Review and the Programme Board
which emerged from that began to get a grip on the issue, so in
relation to handling the particular operational issues around
MMC I think we took action very quickly. More generally, we have
been working hard at improving governance processes across the
department through the introduction of stronger and more effective
risk management processes. When you look back on this what you
see in a sense is project management disciplines being followed
in relation to different components of this overall programme
but I think in retrospect what we see is a problem with looking
at the programme as a whole and the impact it was going to have
on junior doctors and consultants out in the field. You can apply
risk management to an individual project or good project management
disciplines, but if you are not looking at the thing as a whole
then you are running into a problem. I cannot ever say that we
will never hit another problem again but I think we have learned
some lessons about how to run these sorts of big projects.
Q851 Dr Naysmith: Can I ask what
your opinion is of the situation that Richard Taylor touched on
rather lightly a few minutes ago, the fact that you have three
individuals of the status of permanent secretary in the department,
Sir Liam, yourself and David Nicholson? All three of you are permanent
secretary status and now you have Alan Johnson telling all three
of you what to do. He cannot do that all the time; you have to
co-ordinate. Is there a problem there?
Mr Taylor: We do not find that
a problem on a day-to-day basis. It is pretty clear that my responsibility
is to make sure that the department runs effectively. David has
responsibility for the operational management of the NHS and for
advising ministers in relation to that. Liam is the Chief Medical
Officer with a defined set of responsibilities. It is our job
to make the best of those three important parts, all having critical
roles for the department, so in relation to MMC, the management
board which David runs, which is the NHS Management Board, that
will be overseeing the operational management and the implementation
of MMC during 2008. In relation to the more strategic issues affecting
the future direction of medical education workforce policy those
sorts of issues would come initially to the departmental board
which I chair, and in practice David, Liam and I have formed together
a sub-committee of that board to oversee the co-ordination of
thinking around medical education, training and workforce issues
and MMC on a regular basis, so we are meeting frequently to make
sure we stay absolutely together on this.
Q852 Dr Naysmith: Is not one of your
roles to warn ministers when their plans for change are over-ambitious?
One of the main functions of Sir Humphrey of television fame was
to stop ministers walking into disasters and falling down elephant
tracks. If that is the case and you agree why on earth did you
or other civil servants not stop the MMC being implemented with
such reckless speed? It must have seemed like that to you, having
overseen a few policies in your time.
Mr Taylor: That was not the view
that was being taken of the programme at the time. We were, I
think, at senior levels in the department monitoring a number
of the key risks associated with it. A lot of effort—and
I think this is all pretty well documented in Tooke and other
places—was going into some of the key risks which were identified
about the number of training places, for example, the plans that
were put in hand to restrict access of people on the Highly Skilled
Migrant Programme to the first cut of offers of training places
and in relation to the computerised project. Assurances on all
those three things were sought specifically. What, I am afraid,
collectively we and others across the system failed to do was
to look at the risk right across the system as a whole and draw
what might in retrospect have been the right conclusions.
Q853 Mr Bone: Just before we move
on, you never said to the minister, "This is a courageous
policy"?
Mr Taylor: No.
Q854 Dr Naysmith: Why were the red
light risks highlighted by Tooke repeatedly ignored? You mentioned
Tooke just now.
Mr Taylor: Specifically those
things were not ignored, is my recollection. The two things that
were highlighted were the risks around the computerisation programme
and specific assurances were given in relation to those in relation
to the—
Q855 Dr Naysmith: I am not sure it
is a good idea to mention the computers.
Mr Taylor: I am just honestly
answering your question, which was that those risks were highlighted
and assurances were taken in relation to that. Whether it was
then right in retrospect to proceed straight into the national
implementation of an unpiloted, untested system, particularly
one which I think to some extent people were not fully prepared
for, is a separate question, but in terms of pure project management
assurances were obtained about the operability of the system.
The other red lighted issue was that of the whole question about
the policy in relation to people on the Highly Skilled Migrant
Programme and their active risk mitigation being in place and
I think it has been pretty well rehearsed what the circumstances
there were, having taken a decision to issue guidance which would
have had the effect of excluding people on the HSMP from the first
round of applications. There was a judicial review challenge and
so on and we got into a difficult sequence of timing around that.
It was not that those risks, in the jargon, were not being actively
managed; they were. I think the bigger question was whether the
totality of risks associated with the project were overseen and
that is where I think in practice we probably fell down.
Q856 Dr Taylor: Going on to policy
development, Unfinished Business seemed to have fairly
general support but in the move from that towards Modernising
Medical Careers a lot of the principles seemed to get lost. The
BMA puts it that of the seven principles only two were realised
during implementation. How did this happen? Obviously, we cannot
blame ministers because ministers change fairly frequently, but
this is exactly where one needs extremely strong civil servant
backing to make sure that these things do not happen and that
these agreed principles do get translated into action. Does this
mean the Department of Health really is not very good at policy
development?
Alan Johnson: No, it does not
mean that. In terms of the involvement of all the different bodies
in the principles here, the phrase is that success has many parents
and failure is an orphan, but from the start of these principles,
from the time when Liam published Unfinished Business,
there was a fair consensus around about the need for change. Indeed,
most of the people I have spoken to are highly critical of how
MMC was implemented but the actual principles behind it they support
and I have not met anyone who would want to go back to the old
system. It was unfair, it was opaque, it was blue-eyed boys and
girls, so the principles behind the change were absolutely right.
In terms of the department's capability to implement policy, I
think you only have to look at the cancer strategy, what we have
done with cardiovascular disease, heart disease and the stroke
strategy just before Christmas. Developing policies is one of
the strengths of the department and delivery of policies is one
of the strengths as well. What happened here, I think, as Hugh
has just alluded to, was that there were lots of things happening
at the same time, lots of things that were the right thing to
do but all being done at the same time and an assumption that
we would not have the problem with international medical graduates
that proved to be a false assumption. There were also the points
I have made about the lack of accountability in all these different
organisations together and no-one quite sure who was in the lead
on it, and a computer system that was not piloted, MTAS, in advance.
Put all that lot together and you get the disaster that was MMC.
You have made the point very fairly about ministers changing,
but Patricia Hewitt on several occasions apologised for the way
this caused disquiet and huge problems for people in the medical
profession, junior doctors in particular.
Dr Taylor: I do like your quote. Is it
a proverb, "Failure is an orphan"?
Jim Dowd: It is. It is Chinese.
Q857 Dr Taylor: Is that a proverb
that I have not heard about?
Alan Johnson: I would like to
say I made it up but I think it is a proverb of some description.
It is a Hull proverb from my constituency.
Jim Dowd: Hull in China then, is it not?
Q858 Dr Taylor: I rather get the
impression that you feel in retrospect that the big bang approach
was misguided and wrong.
Alan Johnson: Liam might like
to say a word about this but, as I understand it, the argument
that we should have phased this in had a number of problems as
well in terms of what that would mean. "Phasing" is
an easy word to use but if you look at the practicalities of phasing
in different aspects of this, there was a strong argument to say,
"Look: if we are going to do this let us do it all at once
because if you try and phase it you just lead to a long period
of confusion, et cetera", so that argument probably went
on. If you are looking at the cause of the problems here, certainly
it has been said to me by many clinicians that we tried to do
too much at once, but no-one was really looking in any depth at
what the alternative was because I am sure there were problems
there as well.
Q859 Dr Taylor: But if there had
been better in-depth planning perhaps a staged introduction could
have been brought in.
Sir Liam Donaldson: I think it
would depend how you staged it because let us say that you were
to stage it geographically or by speciality, then doctors hoping
to apply as their first choice for a speciality that was not phased
in may have worried about their future and have been forced to
go for a second choice option, so I think the option of phasing
it in was not free of problems and risk either.
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