Examination of Witnesses (Questions 860-879)
RT HON
ALAN JOHNSON
MP, MR HUGH
TAYLOR, SIR
LIAM DONALDSON
KB, AND MS
CLARE CHAPMAN
18 FEBRUARY 2008
Q860 Dr Taylor: I always accept your
comments about cancer and cardiac care, which obviously have improved,
but in items like this what lessons have you learned for policy
development?
Alan Johnson: The need to have
a very clear accountability structure on this in particular. Because
we did it with four countries in devolved administrations and
a whole set of other people involved there were no clear lines
of accountability, is my answer to that first question, and however
complex the issue is we have to make sure that we do not repeat
those mistakes, and indeed the lessons we have learned and the
lessons that we are still learning from the final report from
Sir John Tooke, who has done an excellent job at finding a way
through this and making very clear where the errors were, as did
the Douglas Review very early on.
Sir Liam Donaldson: Could I just
add something on that? The other lesson to learn is that it is
not always clear that implementation is free of the need for policy
making. Before this crisis developed, if somebody had said, "The
detailed design of an application form—is that policy or
implementation?", I guess most people would have said it
was implementation, but in fact it probably ended up being one
of the biggest policy considerations in the whole thing. Realising
that apparently minor aspects of implementation need a much wider
participation of policy makers, particularly clinical policy makers,
is one important lesson that maybe could not have been foreseen
but is obvious whenever you look at the causation of the crisis.
Q861 Mr Bone: My questions are all
to do with leadership. It seems to be accepted now that leadership
was very weak during the implementation of MMC, both in the Department
of Health and within the medical profession. Does everyone agree
with that or am I being unfair?
Alan Johnson: I do not think you
are being unfair because it is an obvious question. I think the
governance structure was too complicated. I do not think the answer
lay in the leadership of the department. I think it lay in that
complication. Okay, you can say that we should have recognised
the perils of that very early on. The fact is we did not, and
certainly the issue about having a clear level of accountability,
which we changed very early on when Douglas first raised it, but
there was a problem in terms of the accountability for the policy
being with Liam and the accountability for the implementation
being with Clare's predecessor, and I think at one stage there
was absolute ambiguity about who was responsible for what.
Mr Taylor: I would certainly say
in retrospect that leadership was diffused and that is an issue.
That was on both sides and that is not meant to be a critical
comment of my colleagues in the medical profession, but I think
one of the catalytic effects in positive terms was bringing the
key elements of leadership and the medical profession together
under Professor Douglas initially and then in the Programme Board,
which provided a much better and stronger forum for issues to
be thrashed out in a coalition than had been the case previously.
I think it was the absence of that very strong policy-making forum
for collective leadership, if you like, that was missing.
Q862 Mr Bone: Just following up on
that point, most of the leaders who were involved in this are
still leading whatever part of it they were before. At any one
stage one of those leaders could have said, "This is going
horribly wrong. Stop", and none of them did, so what confidence
do you have that leadership has improved now and that we could
not have the same thing happen again when there was a group from
the medical profession and the Department of Health embarking
on a major project?
Alan Johnson: This was a complex
issue. I do not believe it can be laid at the door of an individual.
Indeed, I think Tooke said something very similar in terms of
the whole history of MMC, that there was not one person that should
be carrying the can for this. It was a collective failure right
through the system. If there were lots of occasions of this happening
in complex areas then there could be a criticism of the leaders
involved, but I hope this is definitely going to be a one-off.
There has been nothing like this before. No-one ever attempted
to make all these changes to the curriculum, to the way that the
system worked, to the whole structure of the medical education
and training all at one time, and I really do not believe that
there is any individual at whose door all of the blame can be
laid.
Q863 Mr Bone: I would like to follow
on from that and get some specific comments on it, but your answer
sounded a bit to me like when Social Services report that some
young child has been killed. They say it is a systematic failure
of 30 people but no-one individually is to be blamed and it will
not happen again. Unfortunately, in Social Services it happens
time and time again, but you think this is a one-off?
Alan Johnson: Yes. I think the
analogy with Social Services is wrong, actually.
Sir Liam Donaldson: I do not think
the analogy is fair. In some of those child protection cases that
you referred to the evidence is revealed over and over again to
different people. It is just that they choose not to act on it.
If you look at what happened in the MMC, the biggest risk that
was flagged up to ministers was the risk that there would not
be sufficient training posts to fulfil the demands of the programme
and Lord Warner acted immediately to counter that risk and announced
the creation of more posts and guaranteed a level of posts. Secondly,
as the permanent secretary said, there was a full discussion at
the NHS Management Board, which is the most senior governance
structure in the NHS, of the programme just before it went into
the final stages of implementation and reassurances were given
about the risks and therefore the board corporately decided to
proceed. If you look at the point at which the crisis was in its
early or mid stages Patricia Hewitt appointed Professor Douglas
to chair a group to take further decisions and that group had
the opportunity at that point to cancel the programme but they
did not, and I think they were right not to because at that stage
a large number of interviews had taken place and a lot of consultants
had given their time to undertake the interviews. There was not
a point at which the whole risks of this programme were revealed
in an unambiguous way and no action was taken, and I do not think
the analogy is fair.
Mr Taylor: One further point on
this is that I do think it is very important to build into your
corporate governance systems proper challenge as well as assurance.
One of the things that we have sought to do as a department is
use our strategic risk register, which we take now to our audit
committee which is run by non-executives and expose that to them
in a much more systematic way than, I have to say, we were doing
at the time when some of this was under way. The risk with all
that is that you are still not seeing the things coming round
the corner to hit you. I do think we have better systems in place
now to give not just the leadership authority that you are talking
about but some of the challenges to that which you get in effectively
by having corporate governance systems.
Q864 Mr Bone: This is just for the
Secretary of State. I know, Secretary of State, you have more
or less answered this, but because this is an evidential session
I would like to get it on the record. Some people have said that
the Chief Medical Officer is the architect of these failed reforms,
and if that is the case do you think that the CMO is the best
person to resolve the crisis? I know you have indicated what you
think but perhaps you could give a formal response to that.
Alan Johnson: Yes, I do. I think
the CMO has done a terrific job over ten years. On this particular
aspect let me remind you of what John Tooke said. He said that
MMC was an honest attempt to accelerate training and assure the
fundamental abilities of the next generation of doctors. In fact,
I think this began in 1988 under the previous Government. I am
paying a tribute to the previous Government.
Q865 Mr Bone: Oh, sorry! Do carry
on!
Alan Johnson: It happens very
rarely. The previous Government recognised the need for change
and reform to medical education and training. It was Liam's report,
Unfinished Business, that galvanised action and on those
very important principles. See what comes out of your report but
I do not think there is anybody hankering for the old system in
the sense of all that unfairness and the opaque nature of that
system. I think it was an honest attempt. It went wrong in the
implementation. That is now being put right and, as I say, I do
not think there are any scapegoats in this and as far as Liam
is concerned I think he is absolutely the person to take through
the implementation.
Q866 Mr Bone: Thank you. Can I just
move to Sir Liam? One of the problems with reports, and the Tooke
report is no exception, is that you can read them in several different
ways. Sir Liam, I think you said that you would not resign because
the Tooke report supported the principles of MMC which the Secretary
of State just referred to, but Sir John told us that he could
not even work out what these principles were. He and others have
argued that MMC swapped one "lost tribe" for another.
If that is the case thousands of careers have been lost, confidence
in the profession has gone and some people would say you are more
of a hindrance than a help now. Would that be totally unfair?
Sir Liam Donaldson: I do not think
I ever said that. If I said anything along those lines it would
be that Sir John had commended the principles of Unfinished
Business, but essentially in the Modernising Medical Careers
programme the part of that which has become controversial was
the reform of specialist training. There were many other aspects
of it that have not been part of the criticism and controversy
of Modernising Medical Careers, so the Unfinished Business
proposals led partly to a foundation programme, they did not recommend
wholesale introduction of a specialist training run-through grade.
They said yes, it should be looked at along with other factors,
and the programme broadened out over time. If you look at the
factors that precipitated the crisis, in my view there were three.
One was the planning assumption of international medical graduates
being excluded could not be adhered to. Secondly, the design of
the application form proved to be faulty and led to difficulties
with discriminating the right candidates for the right jobs, and,
thirdly, wholesale run-through training was introduced, but that
itself is a factor on which there are mixed views, some Royal
Colleges strongly favouring it, others now having reservations,
some having favoured it initially and now withdrawing their support.
I was not responsible for the decision on international medical
graduates and I was not responsible for the detailed design of
the application form.
Q867 Mr Bone: I suppose one of the
things that some people would find strange is that nobody is taking
the rap for this disaster. Some people could unkindly say, Sir
Liam, that you are more concerned about saving face than the future
of medical teaching. That I think would be one way people could
look at it but can I put it to you another way? If you really
thought this was your fault would you have resigned? You mentioned
that there were other areas, but if you thought that you were
the driving force—and it has gone wrong; nobody argues with
that—would you have gone?
Sir Liam Donaldson: As the Secretary
of State said, it was a widely participative process with a lot
of different stakeholders involved. Had I been the single person
sitting in my office having these risks played to me repeatedly
by different people and ignored that, then yes, obviously, that
would not have been a competent performance, but that was not
the way it was.
Q868 Mr Bone: the other thing that
I have not got my head round is that Government is normally very
cautious when it is bringing in major changes and lots of different
things at the same time, you know, you have pilot schemes and
so on, and in fact yesterday the Government announced a pilot
scheme on a new Sarah's Law, so why were so many decisions and
changes taken at the same time? Who was responsible for the fact
that it all happened at the same time?
Sir Liam Donaldson: In the end
57 or so specialities redesigned or reaffirmed their training
programmes and those were all signed off by the main regulator,
the Postgraduate Medical Education and Training Board, so there
was a groundswell of view that because the SHO programme was being
changed it therefore threw out the interface with the next level
of training and the training needed to be redesigned, so each
of those specialities looked afresh at their training programme
above the level of what was the SHO and put in reforms to their
training programmes, so 57 different groupings looked at it.
Q869 Mr Bone: Yes, so it is like
if a committee decides something it finishes up with a camel;
it is that sort of thing. In hindsight, and hindsight is a wonderful
thing, would it have been better to have one person driving it
through rather than almost having committee-like decisions on
the MTAS?
Sir Liam Donaldson: I think it
probably would but in the past we have been accused by stakeholders
of being undemocratic for taking that approach.
Q870 Dr Naysmith: Secretary of State,
the Tooke Review has been mentioned quite a lot this afternoon
and it has usually been in a congratulatory way. One of the things
it very clearly recommended was that the Department of Health
needed a dedicated lead for medical education. Do you agree with
that?
Alan Johnson: Yes, we have accepted
that recommendation that was made. Indeed, we implemented that
before the Tooke recommendation when we put Dr Martin Marshall
in, who in effect became the dedicated lead. Now Martin has moved
on and when he left we put David Sowden into the job, so yes,
we do accept that recommendation.
Q871 Dr Naysmith: David Sowden, when
he was here, told us that you cannot appoint a permanent head
of medical education over the next six to nine months because
of "some particular issues within the Department", and
he would not expand on that. What was he referring to?
Alan Johnson: I do not know. If
he did not expand on it --- you should have pushed him a bit further
because I cannot speak for him.
Q872 Dr Naysmith: Maybe I will just
quote a little bit. What he said was, "For my sins, I said
I would be prepared to do it"—that is, lead the MMC—"as
a secondment for a short period ... There are some particular
issues within the department which would have made it difficult
for them to make a permanent appointment over the next six to
nine months. It seemed important that there was somebody in place
who could take forward the 2008 process and lead on the development
for 2009". You have no idea why he would say that?
Alan Johnson: I have not, no.
I do not know whether Hugh has.
Mr Taylor: I am not sure. One
point that it is just worth mentioning is that one of the things
we wanted to do was to get somebody into the post and, to be blunt,
to do that quickly we needed to make a temporary appointment.
If we want to make a permanent appointment and it is a Civil Service
appointment we have to go through a proper selection process involving
the Civil Service Commissioners and so on. Because in effect we
can put him in on a short-term basis it meant that we could make
the appointment straightaway. He was on a temporary basis because
that was the quickest way of getting somebody with his expertise
and relevant qualifications into that role.
Q873 Dr Naysmith: Do you have any
idea, Sir Liam, what he might have been referring to?
Sir Liam Donaldson: No, I do not,
I am afraid.
Q874 Dr Naysmith: Can we move on
then to the other actors in this drama? It has been suggested
here as well that there have been tremendous weaknesses exposed
in the Academy of Medical Royal Colleges in providing a coherent
voice for the profession. Do you agree with that, that the academy
could have been much better in giving a lead?
Alan Johnson: Yes. In a sense
it is less important whether we agree with that. That was a specific
recommendation in the Tooke report and I think it is a matter
for the profession to respond to that. That is one of those recommendations
that is not for us to act upon. Given the amount of analysis that
Tooke's people did, I think it would be very difficult to argue
that that is not a sensible recommendation and a valid point to
make about this lack of coherence.
Q875 Dr Naysmith: It is a good point
to make, and it is probably right, but actually getting all of
the Royal Colleges herded together and going in the same direction
is quite a difficult thing to do, I suspect, but you think it
is the right way to go, do you?
Alan Johnson: I do not think it
is impossible to get better coherence from the different specialties.
As far as I am aware, they have not acted with any hostility towards
Tooke's Report and I presume that they are looking, even as we
speak, at how they can actually give that some substance.
Ms Chapman: Secretary of State,
can I add one thing on to that, and that is when the difficulties
first started to emerge it was Carol Black and the Academy that
actually raised the point that the Academy wanted to be part of
the solution, not the problem, and then that led to the recommendation
for a review and obviously the Douglas Review ensued. The work
that was done on that group and subsequently on the Programme
Board has shown that when you bring the people together across
the profession to a place where actually consensus can be reached
so recommendations can go to ministers then a very productive
role can be played. I would just point that out.
Q876 Dr Naysmith: It is interesting
you say that because we put both to Carol Black and Bernie Ribeiro,
the President of the Royal College of Surgeons, that they had
been present at crucial meetings when they could have stopped
things going ahead and they both admitted that they had been but
had not done so without explaining why. I suspect it was to do
with the fact that they were not quite sure what some of the people
who were recommending that they be there would say if they did.
That is why it is important to have some kind of coherent voice
for the medical profession at this higher level of training.
Ms Chapman: On the Douglas Review
and then subsequently on the Programme Board, that has actually
been happening because they have been sitting around the table
and are able to see the whole programme as opposed to individual
component parts.
Sir Liam Donaldson: Could I just
add, Chairman, that does beg the question again that when they
were sitting there at the time in those meetings, what was it
that was worrying them that they wanted to put their foot down
on and say it should not go ahead? At that point, as I said before,
the principal risk identified was that there would not be sufficient
training posts. That was what we were lobbied about repeatedly
and that was where Lord Warner stepped in and increased the number
of posts. On the detailed aspect with the application form at
that stage, I do not think people at that level would have appreciated
that there could have been a problem with that. The international
medical graduate situation, at that point it looked as if the
planning assumption would be adhered to so there would not be
an excess of numbers over applications.
Q877 Chairman: Can I ask, when will
the Department respond to the final Tooke Report?
Alan Johnson: At the end of February.
I have given an assurance that we will publish our response by
the end of February. There will be some bits of our response that
will be an immediate response because of the nature of the recommendations.
Some, like MEE for instance, that only appeared in the final report
upon which there has been no consultation might take a bit longer.
We will issue a response to the Tooke Review by the end of February.
I have to say, John Tooke was very pleased about that. His fear
and worry was that it would gather dust on a shelf somewhere for
months or even years.
Q878 Chairman: Obviously you are
not going to respond to it in total by the end of February from
what you just said, Secretary of State. Would you like to give
us a percentage of what you are likely to respond to in terms
of recommendations? Will it be 50% or more?
Alan Johnson: Most, I think, because
we have had since last October from the interim report to look
at 47 of the recommendations. There were two that came up in the
final report that were not in the interim report. There is also
the issue about the next stage review that Lord Ara Darzi is leading
for us where some of these aspects relate to specific work streams
that he is doing, so it would make more sense for him to look
at that in the round and then report in the summer. The vast majority
of the recommendations we will be able to give an early and a
full response to.
Q879 Chairman: So it would be wrong
of us to read into the situation that those which you did not
respond to would be those you did not agree with?
Alan Johnson: No. The things we
do not agree with we will say. I have already put it on record,
and I have certainly said to John Tooke, that I think this is
a really, really helpful report. He has done an excellent piece
of work. The thrust of what he is putting forward I agree with,
but some of the recommendations are for the professions, as we
have just mentioned, not for us. Some have very clear structural
problems that, having been through MMC and seen the results of
perhaps acting too hastily, we want to take a bit more time about
and so might the organisations that he is referring to. He suggests
the GMC should merge with PMETB. We cannot give a full response
on some of these without more consultation and a bit more time
to think it through. You should read into the fact that we are
going to publish a response by the end of February that we think
this is a very good piece of work, the momentum for which needs
to be maintained.
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