Examination of Witnesses (Questions 880-899)
RT HON
ALAN JOHNSON
MP, MR HUGH
TAYLOR, SIR
LIAM DONALDSON
KB, AND MS
CLARE CHAPMAN
18 FEBRUARY 2008
Q880 Jim Dowd: Having said that you
will respond in general by the end of February I am now going
to pursue a line of questioning where I will try and get out of
you what it is you are going to say by the end of February. You
mentioned MEE and I was going to start there actually. I quite
understand you say we have got to wait a couple of weeks for this,
but do you broadly accept the need for a centralised overseeing
of medical education in England?
Alan Johnson: I am afraid you
are going to get a straight bat on all of these because we are
not going to respond until we respond with a full and detailed
response. It is fair to say MEE is one of those recommendations
which will take an awful lot of thought and consideration. I doubt
very much whether we will be able to give a full response to that
at the end of February and, indeed. I do not think John Tooke
is expecting it. The fact that it appeared in the final report
suggests that he too went through a long thought process to decide
whether that was a sensible recommendation or not.
Q881 Jim Dowd: Putting MEE to one
side for a moment, would I be overstating the case if I suggested
that there is a recognition, whether it is a reorganisation of
SHAs, and I know you spoke to this Committee immediately after
you took up this appointment and said you were reluctant to look
at structural change within the NHS, if there is no central body
surely there is a case for reorganising the responsibilities of
the SHAs, for instance in the way they commission education and
training.
Alan Johnson: I am not going to
be drawn on this. The other thing about MEE is this is a specific
strand of work that 1,500 clinicians are working on at the moment
with Lord Darzi, so for me to give an off-the-cuff response would
not do you a proper service in terms of your inquiry and would
not be fair to the amount of work that is going on out there at
the moment looking into this subject in more depth.
Q882 Jim Dowd: Clearly I would not
ask you for an off-the-cuff remark in response to this but it
is not as if we just dragged you off the corridor and asked you
to come and give evidence. This is our sixth session and you have
had the Tooke Report for three months or more, so it is not quite
off-the-cuff.
Alan Johnson: Not this particular
recommendation we have not.
Q883 Jim Dowd: It is an informed
response. What about the issues that he raises around compromise?
Will you be seeking a compromise between Tooke's suggestion and
the current situation, for example by creating a small new national
organisation to oversee the work of SHAs?
Alan Johnson: That is another
straight bat.
Q884 Jim Dowd: So you are taking
the Fifth?
Alan Johnson: What we are determined
to do is to publish our response to the Tooke Report in one document
at one time in one place and not to dribble out bits and pieces
of it.
Jim Dowd: I stand rebuffed and rebuked,
Chairman.
Q885 Mr Bone: I know we have rearranged
this meeting once, Secretary of State, but it is pretty useless
having a Secretary of State for Health coming here and taking
the Fifth Amendment on something that he says he is going to announce
in a few days' time. If that is the case, why on earth did you
not wait until after Tooke to come here? This is hopeless in terms
of a select committee when a Secretary of State cannot answer
the questions, it is horrendous.
Alan Johnson: I came when I was
asked to come. The question was when will you be responding to
the Tooke Review and the answer was the end of February and that
is very, very quick. Expecting me to give a response to the Tooke
Review just in response to questions here is not the right way
for government to proceed and it actually does a disservice to
Tooke's work. I do not accept that criticism and I do not accept
that we have come along not to answer questions. On this specific
issue the response will be at the end of February.
Q886 Chairman: MEE is about medical
education, it is not about workforce planning, something this
Committee has looked at in recent years and found wanting as far
as the National Health Service is concerned. It is not necessarily
about budgets, and we looked at the issue of overspend in the
National Health Service in our deficits inquiry last year and
there were issues about the raiding of education budgets up and
down the land, and some of it was anecdotal but we did find some
evidence of it. Are all of these things going to be looked at
when you look at the future outcome of the recommendations of
Tooke?
Alan Johnson: Yes. Indeed, as
I have mentioned, the work is going on at the moment in the next
stage review and training and education is a specific strand of
that. This thought of putting one organisation in charge of that
has got its advocates and its detractors. Since Tooke's Report
was published I have had many people saying to me that they do
not agree with that recommendation. The deaneries have put on
record their concerns about that recommendation. Given that is
the case, we need to consider it and we need to consult, which
is why, as I say, even if you invite me back in early March it
is not a case of not wanting to give a response on MEE, it is
a case of wanting to consult properly before we give a response.
Q887 Chairman: In view of what I
said and in view of why we are here looking at MMC as an inquiry,
it is pretty crucial in terms of the outcome of the Tooke Review
to know where medical education is going pretty quickly in view
of the circumstances of last year, this year and future years
as far as we can see at this stage. When do you think you could
respond on a wider view on that particular recommendation? Not
the end of February and not the end of March?
Alan Johnson: If it is in with
the Darzi Review it will be July.
Q888 Chairman: It could be as late
as that?
Alan Johnson: It could be, but
it was not in the October report. It is in this report and there
has been no consultation on that.
Q889 Chairman: I accept that.
Alan Johnson: Perhaps the outcome
of this inquiry might, as it often does, decide the course of
events. You would have an influence over this as well.
Chairman: We will move on.
Q890 Dr Naysmith: I count the Secretary
of State as a friend of mine so I may be about to lose that friendship
by pursuing the Tooke Report just a little bit further. I will
have to rephrase the question I was going to ask. One of the things
that are recommended by Tooke is the uncoupling of run-through
training and particularly splitting the 2-year Foundation Programme.
We have had a lot of evidence, and I know from my own area, that
there are people who think that the 2-year initial F1 training
Foundation is a good thing and has contributed a lot. Tooke recommends
that disappears. Are you prepared to say anything about that?
The reason I am asking that is before you give your initial response
at the end of this month I hope you will take into account the
fact that there has been a lot of evidence to this Committee that
not everyone in the profession is united in getting rid of the
2-year Foundation.
Alan Johnson: You did rephrase
it very skilfully, and our friendship will not be affected by
this, but it is the same answer. Indeed, I do not know yet what
our response is going to be on that, we are still thinking that
through.
Q891 Dr Naysmith: That is all I wanted
to hear, that you have not made up your mind yet.
Alan Johnson: Mr Bone said that
we would be giving the response in a couple of days, but actually
it is not a couple of days until the end of February. In terms
of the way our thought process is going, we have not got an answer
to give you at the moment. It deserves proper consideration. It
was in the original report in October and we do expect to be able
to give a definitive response in February rather than a watch
this space response.
Q892 Dr Naysmith: Could I ask you,
does the requirement of the Medical Act for medical schools to
guarantee their graduates employment until they register fully
with the GMC fall foul of EU employment laws? Is that why splitting
the Foundation Programme is desirable, that you become qualified
as a doctor after one year of post-graduate training rather than
two years? Perhaps we could ask Sir Liam Donaldson.
Alan Johnson: It is back to us
having to consider that as part of the work that we are doing
on the Tooke recommendations. I cannot give you a response on
that.
Q893 Jim Dowd: Just on that point,
this is the final evidence session of this inquiry so do you think
our final report would be better informed and save a lot of tedious
repetition if we were to wait until the Department's full response
to the Tooke Review was available before we concluded this report?
Alan Johnson: That is a matter
for you. All I can say is that it would be quite normal for governments
of all political persuasions to spend more time considering a
report like that before giving a response. The reason I said we
will respond by the end of February, and the reason why John Tooke
is absolutely delighted with that and people in the medical profession
are delighted with that is they recognise that is the quickest
that Government can go on a report of that nature. You would have
to decide yourself when to bring your investigation to a close.
All I can say is we are working as quickly as we possibly can
on that Tooke Report.
Q894 Mr Bone: We are going to move
on to self-sufficiency and competition and the EU and non-EU,
so this is something you can get your teeth into, you will not
need to take the Fifth Amendment on this one. The Home Office
has introduced new immigration rules preventing non-EEA doctors
from applying for UK training posts from 2009, and we heard some
evidence about that in the previous session. What impact will
this have and why was it not done earlier because did the Government
not talk about self-sufficiency in 2000?
Alan Johnson: Well, in 2005 really
the monitoring suggested we were going to have a problem in 2007
and as soon as we found that was the case we acted immediately
on something called permit-free training and it stopped that year
in 2006. Then the question was how to tackle this issue of international
medical graduates because we cannot have, on the one hand, a policy
of self-sufficiency and, on the other hand, an open door policy.
The original way to tackle this and the preferred way to tackle
this was not through the Highly Skilled Migrant Programme, it
was through employment law guidance that we can issue ourselves
in the Department of Health that will ensure not just those people
who have not yet come to this country as IMGs but those who are
already here would only take post-graduate places if UK trained
students could not fill those places. So our preferred route was
down the guidance route. As Liam referred to earlier, we were
stopped from doing that because there was a legal challenge. We
actually won the legal challenge but we won it too late in the
day to actually allow us to implement it. That is our preferred
route. The decision made by the Home Office on 6 February was
very helpful. It will stop around 3,000 additional people applying
for posts in 2009.
Q895 Mr Bone: I think the Secretary
of State has been most helpful in his answers on this subject.
I think what you are saying really, and I think most people will
commend you for saying, is UK jobs for UK citizens as far as possible
but you were not allowed to go down that route because of a legal
challenge. We understand that 3,000 less people will come in because
of that, but two things have come up. There are around 10,000
IMGs already here, so that is not really going to reduce it too
much. The extraordinary thing we heard in the last session was
nobody knew how many people would be coming from the EEA, the
European Union. Is it right that nobody in the Health Department,
nobody in Government, knows how many people because if you do
not know how many people are coming how on earth can you plan
for self-sufficiency?
Ms Chapman: Approximately, if
you take last year's information, it was about 5% of applicants
came from the EEA, so if that is repeated again this year that
would be the dimension.
Q896 Mr Bone: That is fine if that
is the case but nobody has made a forecast of the actual numbers
that are going to come. The Foreign Office has not, the Home Office
has not and apparently the Health Department have not. Is that
right, you do not actually make an estimate of how many are coming
in from Europe?
Alan Johnson: Our estimate is
5%.
Ms Chapman: The estimate would
be 5%. One of the things that we did get as a result of last year
was much better data because of the centralised system in terms
of information to interrogate. I think the 5% is a pretty solid
number to forecast against.
Q897 Mr Bone: So the Health Department
is putting its head on the block saying it is 5%.
Ms Chapman: I am saying that last
year it was 5% and if the last year is a good predictor then that
is a good basis for planning.
Q898 Mr Bone: What some people cannot
seem to handle on this is, yes, you are taking historic data and
saying if that is repeated again that is what will happen, but
what some people say you should be doing is actually forecasting
the numbers that are likely to come in, not saying that last year
might be repeated again. Has the Health Department actually done
a forecast?
Ms Chapman: There are two things
on that. One is that as a result of the forecasts that were done
in spring/summer of last year we actually forecast very accurately
the number of applicants and also the likely success rates of
all of the applicants, and it was our forecasting that really
helped us to put together a very targeted support package for
any doctor that was identified as having the potential to succeed
in further specialist training, so there is plenty of evidence
that our forecasting really helped to inform decision-making.
Alan Johnson: Two things on this.
First of all, it is the international medical graduates that are
the problem; it is not people coming here from other European
Union countries. Secondly, for us to set up a system to accurately
predict how many students will come from 27 Member States I would
suggest is the way we sometimes respond to written questions and
the cost of providing that information would be far in excess
of the results that it would produce. Working on the basis of
what the normal number is, which is around 5%, is pretty good.
The second point is we did not know anything about these ratios,
we did not know very much about these ratios at all until we introduced
MMC which gives us a much better picture. All the problems that
are going on in MMC were going on before, they just were not centralised
in one place, they were happening all over the country, so one
did not get the same volume of difficulties because, as I say,
it was an opaque system. It has enabled us to predict much more
clearly what the ratios are going to be, which is why we predict
for this coming year we are going to have three applicants for
every place and last year it was 2:1. You are right, as a responsible
Government we have to try to tackle this in any way we can. We
are not just stopping at the basis of the Home Office ruling,
we are also pursuing an appeal on the guidance that will actually
prevent IMGs who are already here to the House of Lords. The hearing
begins on 28 February and it is possible we may have the result
by the end of March.
Mr Bone: I am sure most people think
self-sufficiency is a very good idea and would welcome what the
Government is trying to do but it has got tangled up in the legal
system. Just put it the other way round, if we were not in the
European Union you would not have to take people from the European
Union and you would be self-sufficient.
Jim Dowd: It is not the EU, it is the
EEA.
Q899 Mr Bone: I know, but I am just
using that as an example.
Alan Johnson: It is the EEA. That
is not the problem. It allows medical undergraduates in this country
to go and train for post-graduate education in any other part
of the European Union, that is not our problem.
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