Examination of Witnesses (Questions 900-919)
RT HON
ALAN JOHNSON
MP, MR HUGH
TAYLOR, SIR
LIAM DONALDSON
KB, AND MS
CLARE CHAPMAN
18 FEBRUARY 2008
Q900 Mr Bone: I understand the benefits
of it, but if you are trying to say that it is only people outside
the EEA that you can control then it would be easier if you could
control the whole lot because you are running a state health system
employing 1.3 million people. If the state could actually control
it you would do better at it, but you cannot because whatever
you say about estimates you really do not know how many people
are going to come in from the EEA.
Alan Johnson: It is a question
on the free movement of labour in the European Union and I believe
that is a very good thing for the European Union.
Q901 Mr Bone: Does it make your job
more difficult?
Alan Johnson: No, it does not
make the job more difficult at all. The problem we have is international
medical graduates and the fact that well over 50% of international
medical graduates go back after 2-4 years of working in the NHS
so you actually lose them as well.
Q902 Mr Bone: The other side issue
is you have messed around with what I think the Foreign Office
said was an "unwelcome precedent" in what you have done
in changing the rules. For the Foreign Office that is pretty strong
terms saying, "Butt out, you should not be doing this".
Alan Johnson: That was a Government
decision cleared through the whole of Government.
Q903 Mr Bone: The Foreign Office
should not say those things?
Alan Johnson: I have not heard
the Foreign Office saying those things, but this was a Government
decision.
Q904 Chairman: Can I just ask you
about what you are saying. This comes from many years of the NHS
not meeting our own quotas, as it were, from medical graduates
here in the UK. This change has taken place in the last 8-10 years.
Prior to that, and even during the time that these changes were
taking place, we were bringing in quite a large percentage of
National Health Service doctors and other health workers from
areas of the world like the Indian subcontinent. Do you feel that
we have any moral obligation to countries like that which we have
relied on for many, many years to run our National Health Service?
Alan Johnson: I think two things
about this. First of all, the contribution of those international
medical graduates has been immense, and you are quite right, Chairman,
we would not have been able to run the Health Service effectively
without their contribution. That is the first point to make. The
second point is they themselves understand this. I saw a quote
from the organisation representing doctors of Indian origin on
7 February after the Home Office decision which said that they
agreed with that decision and it should have been done years ago.
One aspect of that is we have denuded the world of medical graduates
that their own countries were very keen to ensure they kept. I
do not think the open door policy was the right policy for us
but I also do not think it was the right policy for countries
like India, Pakistan and other areas where we took their medical
talent, if you like, and brought them over here. Now that we have
built four new medical schools, now that we have increased the
number of medical places, including, I am pleased to say, the
fabulous Hull-York Medical School that we were arguing for for
25 years and we have finally established, the policy of self-sufficiency
makes sense for us and certainly on the facts and on the basis
of all the arguments no-one could suggest this is in any way failing
to meet some moral obligation, it is actually the right way for
us to go. Of course, for many of the people who have come through
the system, they have gone back to their own countries and have
really benefited from the UK expertise in medical education.
Q905 Chairman: Do you see a situation
where this country could not be training international medical
graduates to be able to go back into different parts of the developing
work and work there and improve their health services?
Alan Johnson: There could be programmes,
the kind of medical equivalent of Chevening or whatever that we
could use for that, of course. There is no other country in the
world that has this kind of open door policy and does not have
a policy that says we will train up our graduates and if there
are shortages then we will take people who are international medical
graduates to fill up those shortages. That is the way America
runs their system, Australia, Canada and it is the way now, because
of the investment we have put in medical schools, we can run our
system in the same way.
Q906 Chairman: I am going to ask
the CMO, when I said about the situation of people coming here
maybe for specialist training for different aspects and then returning
to the developing world, that has happened and it does happen
now, but will these regulations in any way, no matter what happens
in the next few months, change that at all?
Sir Liam Donaldson: No. I think
it is important that we continue to run fellowship programmes
of the kind that the Royal Colleges have traditionally run to
allow people to come here to gain experience, receive training
and go back again, but as a strand of an overall programme of
training.
Q907 Jim Dowd: You have referred
to the judgment awaited from the Lords and I think they will be
looking at it towards the end of this month and reporting sometime
in late spring, early summer. If the guidance is upheld in the
Lords, do you think any further measures will be required or would
you consider that to be the end of the matter?
Alan Johnson: If it is upheld
I doubt whether we will need any further requirements. We are
looking at other ways to do this, like, for instance, a fees system,
but I think the guidance should resolve the problem providing
it is robust and we could be confident that it would remain in
place.
Q908 Jim Dowd: Would you then honour
any commitments given to non-EEA individuals in the meantime,
any contracts?
Alan Johnson: We would need to
look at how the ruling goes but we said last year, for instance,
before the challenge that we would allow those who were already
in the system to complete their training.
Q909 Jim Dowd: Already in the system
up to what point?
Alan Johnson: Already applied,
I think.
Ms Chapman: This year we are actually
going to have more than one pulse of recruitment, so there will
be the opportunity for ministers to make a decision on whether
or not any guidance would apply to further recruitment rounds
that would happen this year.
Q910 Jim Dowd: I think I understand
that.
Mr Taylor: It does not take away
people who are on the system. It does not take people out of positions.
Q911 Jim Dowd: I understand that,
but what we are trying to get at with this particular line of
questioning is if it is upheld ultimately by the Lords it is perfectly
legitimate for them to say it was always legal and, therefore,
anything that happened between the time it was first challenged
and now you can go back and revisit, or are you going to take
the position which the law understands that until it proves to
be unlawful it remains lawful, or vice versa?
Alan Johnson: We would not apply
it retrospectively.
Q912 Jim Dowd: The Home Office describe
the new rules as a short-term solution to the current problems,
but if your guidance is not upheld in the Lords, and I put this
to anybody who may have an answer, will the changes not have to
be made permanent?
Alan Johnson: If the guidance
is not upheld then we will continue to look at other options rather
than through the Highly Skilled Migrant Programme. We do not like
using the Highly Skilled Migrant Programme, these people are highly
skilled, and the Home Office were reluctant to take that route,
as were we, but they accepted, as we did across Government, that
we had to get in a position to ensure that as far as we can in
2009 we do not repeat the problems that we had last year. There
are other things that we are looking at and other ways of doing
this. There are not too many other options but we are exploring
them all.
Q913 Chairman: Could you tell us
what those other options are, Secretary of State?
Alan Johnson: I mentioned one,
which is a fees regime. The other is to see whether we could pass
into legislation from my Department something that would cover
this rather than dealing with it through the Highly Skilled Migrant
Programme. This is predicated on the fact that we lose the appeal.
If we lose the appeal, how we can get that guidance into a much
firmer setting. We would have to look at the reasons for losing
the appeal, and I hope we will win it and we are quite confident
that we have got a good case to put to the appeal, but we need
to ensure we have got a mechanism in place to ensure that we have
a self-sufficiency policy, not a self-sufficiency and an open
door policy.
Q914 Dr Naysmith: Following that
up, Secretary of State, do you think that the current capacity
of our medical schools in the United Kingdom is about right at
the moment or are there any plans to increase or even decrease
the numbers in the future?
Alan Johnson: I think it is about
right. The number of medical school places has gone up from something
like 3,500 to just over 6,000. We monitor this all the time and
we did create more places, as Liam referred to, at the time of
Lord Warner. I think we have got it about right.
Q915 Dr Naysmith: Given that we are
looking at training places in six years' time it is pretty difficult
to predict exactly what the situation is going to be. Maybe Ms
Chapman might have an idea about that. Do you think it is possible
to do that?
Ms Chapman: I think that the Select
Committee's report on workforce planning and also the work that
we have done as part of the Lord Darzi next stage review has shown
that we are very good at planning supply, but we are far less
articulate at planning demand. One of the things that are being
looked at as a result of the clinical vision being looked at for
the service is making sure that we build two things into that.
One is the workforce implications of the service redesign and,
secondly, the financial implications of the service redesign so
that you are bringing service design, finance and workforce planning
in line. Do I think that is possible? Usually when there are changes,
about 80% stays fairly static and about 20% has got the discontinuities,
so the challenge is spotting where the discontinuities are so
you can plan for them.
Q916 Dr Naysmith: You will accept
that in this situation that we are talking about this afternoon
we have got major changes taking place, like cutting off largely
the supply from outside the European Economic Area, plus admitting
you do not know what is going to happen. If there is some sort
of vacuum in this country of medical graduates then what will
happen in the EEA is that more graduates will apply.
Ms Chapman: I think two things
have happened as, again, was made clear in the Select Committee's
report. Since 1997 there have been over 250,000 more people brought
into the service as capacity was built and over 35,000 more doctors.
I think what we have seen during that period of time is a big
increase in the capacity of doctors and also some adjustments
in terms of the service that is being delivered, so looking forward
I do not expect there to be such a massive increase in capacity
and, therefore, the predictions we have currently got with the
medical schools looks adequate. I do think it is going to be critical,
as was mentioned before, that we look at what are the service
design implications coming out of the Lord Darzi work.
Q917 Dr Naysmith: Do you have an
optimum level of competition for training places? Do you have
an optimum that you are aiming for? For instance, should we aim
to produce 5% more medical graduates than training posts? Does
that figure in your calculations?
Ms Chapman: The devil is in the
detail. When you start to look at the detail by specialty there
are some very hard to fill specialty areas and that is where you
would want very different resourcing strategies from those specialties
which are very popular and in very popular parts of the country.
My reaction is yes, you would want some principles but they would
need to be specialty specific.
Q918 Mr Bone: Can I just come in
on that because that is an interesting point. If there is a hard
to fill area would we be turning down graduates who might be qualified
in that area from outside the EEA?
Ms Chapman: No. Firstly, there
would be the opportunity for graduates from English medical schools
to fill the vacancies and where that is not possible we would
be bringing in talent and expertise from outside.
Q919 Mr Bone: This ban in 2009 would
not apply to that?
Ms Chapman: We would still be
able to do that.
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