Examination of Witnesses (Questions 920-939)
RT HON
ALAN JOHNSON
MP, MR HUGH
TAYLOR, SIR
LIAM DONALDSON
KB, AND MS
CLARE CHAPMAN
18 FEBRUARY 2008
Q920 Jim Dowd: How do we square the
circle of maintaining quality practitioners against the obvious
expectation that anybody who gets a place at medical school will
ultimately get a job working within the NHS?
Ms Chapman: Say that again.
Q921 Jim Dowd: Is there an expectation
that anybody at medical school will ultimately become a practising
doctor within the NHS and if there is then how on earth can we
ensure that we are actually getting the best?
Alan Johnson: That is a very good
point actually because we are just getting to the level of self-sufficiency.
Previously it was a case of trying to get doctors from wherever
we could but now we are coming through to self-sufficiency. There
is a view that says why should the medical profession be different
from any other profession. Nobody who trains to be a lawyer is
guaranteed a lawyer's job at the end of it and no-one who trains
to be a plumber is guaranteed a plumber's job at the end of it,
why should you have a guarantee that there is a job at the end
of medical training. I think it is quite important to get the
balance right, not least of all because we are spending about
a quarter of a million pounds on training undergraduates to be
doctors. I really think we have to try and get it just about right.
I would not personally go for an over-supply issue, but there
are many people out there who would say that if you do that you
get better quality. I think our quality can be guaranteed through
other means rather than by a market forces way but, nevertheless,
that is an interesting argument and we are only just having it
because we are only just talking about self-sufficiency.
Q922 Jim Dowd: Good. As a variation
on that as well, there are recent figures from the Department
of whatever it is called these days that looks after universities
and the rest about the numbers of applicants to universities generally,
they are going up, but there is still this perennial problem of
those from "non-traditional" backgrounds. I saw a release
from the BMA not long ago saying that the most socially exclusive
higher education course in the country is actually veterinary
medicine, not human medicine, but it is closely followed by human
medicine. It is still very much a preserve of those from more
prosperous backgrounds, certainly those from traditional backgrounds,
sons and daughters of doctors who become doctors, et cetera. What
is being done to address that?
Alan Johnson: I am glad you have
raised this as the former Higher Education Minister who introduced
tuition fees and you alluded to the statistics which show not
just a big increase in those applying to university but a big
increase in the lower social classes, so this argument that fees
was going to work contrary to that is not the case. This is the
key profession in terms of attracting people from poorer backgrounds.
There is no profession worse than the medical profession. You
have just pointed out veterinary medicine, which I was unaware
of, but when I was Higher Education Minister all of our efforts
were to get poor kids, bright kids, to go into medicine because
it was not seen as anything that they would be comfortable with.
It was not just a problem of getting them to university, it was
a problem of once they were at university of saying, "Why
not go into medicine?" As Liam just pointed out to me, getting
a medical school in a city like Hull, for instance, jointly with
York and having medical schools in places like that does at least
signal to youngsters in some of the deprived areas that there
is a place nearby where they can train to be a doctor if they
get the required qualifications. I think it does help the education
system, which is key to all this of course, to build up the aspirations
of youngsters to go into medicine.
Q923 Jim Dowd: What about the length
of some of the courses to go into medicine? Does this not militate
against those who do not have quite sufficient independent financial
means?
Alan Johnson: That is true, but
there are bursaries and grants. The new system introduces a bursary
of £3,000 from the Government matched on many occasions by
another £3,000 from the university itself. It is a long course
in medicine as it is in disciplines like architecture, et cetera,
but there is help available. The premium on that investment in
education is huge in medicine more than many other professions.
Q924 Chairman: Could I just say on
that basis, Secretary of State, I know you live quite close to
my constituency and one of my secondary schools is visited annually
by Sheffield Medical School to look at the brightest people there
to talk to them and their families about whether or not they would
like to go into medicine. Would you like to see something like
that throughout places like Hull and South Yorkshire?
Alan Johnson: There is a lot going
on out there and I think one of the problems is we have not brought
this together. Perhaps we could do a piece of work with John Denham's
Department to actually look at this. I was in Birmingham when
I was at Education where they take kids from primary school and
introduce them to things like first aid and take them to a hospital
and gradually as they go to secondary school they become more
and more interested. Some of them go on to be paramedics, some
go on to be nurses, but the message to them is they can go wherever
they want to go if they are interested in medicine, and they have
got structures in place to help that. I am really interested in
the initiative in your constituency and perhaps we ought to look
at this, and perhaps they are doing this work, together with the
Royal Colleges and everyone involved in this as a specific piece
of work to see how we can learn from that best practice and introduce
it much more widely.
Q925 Dr Taylor: Can I go back to
the question of the number of applicants per place. Overall it
is three applicants per place. Professor Douglas, when he came
to us about a fortnight ago, said very clearly that there were
1,200 excess jobs at ST1, 1,300 too many jobs at ST2 but a huge
deficiency of jobs at ST3. Is there not a tremendous danger that
we are going to pull in non-EEA graduates to fill the spare places
at ST1 and ST2 and then the problem at ST3 is going to be even
worse when, from what you have been saying, we have pretty well
promised them that they can finish their training, so we are going
to have far, far too many people for the few posts at ST3. Is
that accurate? I am quoting Professor Douglas' figures.
Ms Chapman: I do believe that
is what Professor Douglas believes. There are two things worth
saying here. One is ST3 has always been the level where there
has been greatest competition so we need to be careful what is
related to MMC and what actually has always been the case and,
therefore, is amplified through MMC.
Q926 Dr Taylor: Is it possible to
actually look at what it was before and what it is now?
Ms Chapman: We will not be able
to look with as much accuracy at what it has been over previous
years because obviously we do not have the quality of data that
we have now got through last year. I am sure that we could produce
something to show that the toughest competition has always been
at ST3. The other point is there is no point in creating false
expectations by putting a lot more roles in at ST3 than we need
because what you end up doing is creating a dead end for people.
It is a case of balancing it. At ST1 and ST2 what is very important
is that we are creating the right number of roles to reflect the
number of people coming out of Foundation Programmes, et cetera,
so it has been carefully balanced. Because we have got multiple
pulses of recruitment that will go on, if we do find that we have
significantly under-represented one of the levels we do get the
opportunity to come back and recommend to ministers that we adjust
it.
Q927 Dr Taylor: Do you agree that
there is a risk of sucking in non-EEA ones at ST1 and ST2 and
making the problem even worse at ST3?
Ms Chapman: That is one view.
It is certainly something that we should keep under consideration,
but we do know how many people are coming out of Foundation and
how many people are coming out of ST1 and, therefore, it is important
that we provide the right number of opportunities to keep the
doctors progressing.
Q928 Dr Taylor: Professor Douglas
really felt extremely strongly about this and in our evidence
he said: "I took this problem to ministers that day. We wrote
to all the appropriate channels and made full recommendations
as to what I suggested they could do to try to rebalance the situation
just a little bit. Despite taking the papers I had written to
ministers I was getting the impression that there was just no
room for movement on this."
Ms Chapman: I think there are
two things. Since then the Programme Board have discussed this
issue and we have put, I cannot remember the exact numbers, about
156 new ST3 posts in place,[1]
so there was a recognition that we needed to take some action
and we have taken some action. This was discussed at the last
Programme Board and our conclusion was that what we needed to
do was to recognise it as a risk and make sure that as we get
the results from this next round of recruitment we look to see
whether it is an issue. What we will do is continue to talk with
Professor Douglas and the Programme Board about the facts that
we are finding.
Q929 Dr Taylor: Those 150 extra are not
going to overload the potential consultant posts?
Ms Chapman: A good question. There
is sufficient capacity within the service to provide both the
training for those extra roles and also we believe, because we
have worked with the Royal Colleges, we have actually put the
extra roles in places where we know the service has got need.
Q930 Dr Taylor: Just to follow on
from that, we were rather distressed in the first session with
the Immigration Departments to hear that there are still doctors
coming from abroad not going on to actual training programmes,
presumably filling in pure service, possibly dead-end jobs. Do
you see an end to that?
Ms Chapman: I am sure the CMO
would want to comment, but I do not think that doing service jobs
are dead-end jobs on the basis that these are trained doctors
and trained doctors doing very important roles within the service.
We will continue to have overseas doctors coming in to fill—
Q931 Dr Taylor: They are trained
to a certain degree but their training in some of these jobs will
actually stop. Tooke suggests that Staff Grades could have access
to continued development and continued training.
Ms Chapman: Indeed, and that is
being looked at.
Sir Liam Donaldson: If you look
at the figures from last year, quite a substantial number, albeit
the minority, of doctors in those sorts of posts did get on to
the full-blown training schemes which in my view, although we
have not got data from the past, was less common in the past.
Q932 Dr Taylor: So you would try
and find us figures to show that the competition was pretty well
as tough before as it is now?
Ms Chapman: No, my point was different
from that, which was we should recognise that competition has
always been toughest at ST3. Whether the percentage of competition
ratios has increased, I am sure it has bearing in mind that what
we have had is a transition year.
Q933 Jim Dowd: Ms Chapman, this is
for you. Immediately before we undertook this inquiry we concluded
one into workforce planning in the Health Service and also during
the course of this inquiry many of the witnesses we have had have
criticised the lack of planning for the overall medical workforce.
Do you accept that planning has been poor? Whilst obviously the
focus, certainly of this inquiry, is on the medical frontline,
if you like, the National Health Service has a wide variety of
specialties and disciplines and although doctors have an unerring
ability to generate the most attention and get the most attention
devoted to them, they are just one significant part of an overall
pattern that we need to address. Do you think that we are actually
addressing it adequately now?
Ms Chapman: I think I am probably
going to repeat the evidence I gave last time. An increase in
a workforce of over 250,000 since 1997 is certainly the largest
increase of workforce that I have seen anywhere else in the world.
There have been difficulties with that and they were well-documented
as part of the Select Committee's report. In terms of both Sir
John Tooke's findings as well as our own review as part of the
Lord Darzi work, I do think there is evidence that the service
has been good at doing the supply side of the planning but I think
what it has been poor at doing is the demand side. Just over a
year ago the demand side of planning was made the accountability
of the strategic health authorities and they have been in the
process over the last year of actually building capability to
do that demand side planning much more. Certainly that has been
the focus as part of the Lord Darzi work. There is more work to
do and specific focus on improving demand side planning.
Q934 Jim Dowd: What about getting
the balance between medical training and the wider workforce?
Ms Chapman: Again, when you look
at the increase in nursing and other clinical areas what you have
seen is a lot of those commissions actually get done not centrally
but within regions. The evidence is that those commissions are
far more effective the closer they are to where the people are
needed. I do not think that there has been a distraction because
they are done differently and done at different places within
the service.
Jim Dowd: Do you think we need to break
the link between training places and consultant posts? Do you
think that is misleading us? We can wait for the Tooke Report
and you can put it in there if you want.
Q935 Mr Bone: Take the Fifth!
Ms Chapman: It does get covered
as part of that. What is very important is there is a connection
between the number of training places and the supply and demand
assessments that go on as part of the service planning. That is
the key bit of analysis that needs to get done.
Q936 Jim Dowd: Sure, but my question
was do you think we need to break that link? The purpose of training
places is to keep consultant numbers at the levels they are at.
Ms Chapman: And GPs. To be honest,
I am not sure I entirely follow your logic, which is why I am
not sure that I am giving you a correct answer.
Jim Dowd: That is okay, I do not follow
my own logic very often myself.
Chairman: Quite a few of us have problems
with Jim's logic at times!
Q937 Dr Naysmith: Do you agree that
the plight of Staff Grade and Associate Specialist doctors has
been overlooked during this crisis about MMC and the other ramifications?
If so, do you have any plans to reform this forgotten part of
the medical workforce?
Alan Johnson: Not only have we
plans, we are actually implementing them at the moment. They are
forgotten no longer. That was a very important question in the
past.
Q938 Dr Naysmith: But they have been
neglected in the last few years.
Alan Johnson: Where are we with
the deal, Clare?
Ms Chapman: The Government has
agreed the new contract terms and has offered to implement them
over two years which would be an increase of about 10% for Staff
Grades and 4% for Associate Specialists. That is going to ballot
in March.
Q939 Dr Naysmith: Do you not think
in modern times it is a little bit past it to talk about a training
system and non-training posts where people are in posts where
they are not expected to get training of any sort? Is it not time
we ended that?
Ms Chapman: One of the benefits
of MMC is that the career path for the non-consultant grade doctors
has been brought within MMC because appropriate career paths and
development opportunities needed to be clear for both. That has
been one of the benefits of MMC. There is more work that needs
to be done to make that reality and to take forward the choice
and opportunity agenda that was laid out by the CMO.
Alan Johnson: This group was not
part of Agenda for Change so all the discussions that were aimed
at lifting the pay of GPs, for instance, consultants, all the
stuff around nurses and paramedics, those huge changes in Agenda
for Change which dealt with lots of longstanding grievances, this
group of around a bit more than 5,000 were left out of all of
that. The deal has got to go to ballot and I am not suggesting
that everything now is coming up smelling of Chanel for this particular
group but I do say that we have paid some attention to their concerns
and sought to get a fair deal with their representatives which
means that they are not forgotten or left out of the huge changes
and improvements that have gone on in the NHS over the last ten
years.
1 Note by witness: The actual figure is 165 Back
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