UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 25-ii

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

MODERNISING MEDICAL CAREERS

 

 

Thursday 6 December 2007

 

PROFESSOR SIR JOHN TOOKE and SIR JONATHAN MICHAEL

DR RICHARD MARKS, MR MATTHEW JAMESON EVANS

and PROFESSOR STEVE O'RAHILLY

Evidence heard in Public Questions 150 - 261

 

USE OF THE TRANSCRIPT

1.

This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.

 

2.

Any public use of, or reference to, the contents should make clear that neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.

 

3.

Members who receive this for the purpose of correcting questions addressed by them to witnesses are asked to send corrections to the Committee Assistant.

 

4.

Prospective witnesses may receive this in preparation for any written or oral evidence they may in due course give to the Committee.

 


Oral Evidence

Taken before the Health Committee

on Thursday 6 December 2007

Members present

Rt Hon Kevin Barron, in the Chair

Stephen Hesford

Dr Doug Naysmith

Mr Lee Scott

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Professor Sir John Tooke, Dean of Peninsula Medical School, Head of the Tooke Inquiry, and Sir Jonathan Michael, Deputy Managing Director, BT Healthcare, Member of the Tooke Inquiry Panel, gave evidence.

Q150 Chairman: I welcome you to the second evidence session of our inquiry into modernising medical careers. For the sake of the record, perhaps you would introduce yourselves and the positions you hold.

Professor Sir John Tooke: I am John Tooke, chair of the independent inquiry and I am a physician.

Sir Jonathan Michael: I am Jonathan Michael, a member of the panel which supported my colleague in the inquiry. I am also a physician by training.

Q151 Chairman: Sir John, what were the circumstances under which you were asked to undertake an independent review of the implementation of Modernising Medical Careers? Who asked you to do it, and how was your remit described when you were first approached?

Professor Sir John Tooke: The Committee will be aware that the distress caused by the selection system known as MTAS in the spring generated a good deal of anxiety within the profession. That ultimately precipitated the then Secretary of State for Health having a telephone conversation with me and inviting me to consider chairing an independent panel to look into the circumstances surrounding that perceived failure. The terms of reference of the report show that although MTAS was the catalyst of the concerns the issues were much broader than that. It had unearthed real concerns within the profession about MMC as a whole. Therefore, the terms of reference were cast fairly broadly to consider all of MMC with a particular remit to look forward as much as backwards to learn from the past to ensure that postgraduate training in future could be optimised. We were particularly concerned that the report should embrace issues around the professional, service and workforce environments that impacted on postgraduate training and that was also swept up in the terms of reference.

Q152 Chairman: Your report is entitled Aspiring to Excellence, but MMC aims to have "competent" doctors. How do competence and excellence relate to each other in the context of medical training? Are they mutually exclusive?

Professor Sir John Tooke: I do not believe they are mutually exclusive. Nobody can argue with the fact that we want healthcare professionals, whatever their role, to be competent at what they do, but in the view of the panel "good enough" is not good enough and we should aspire to excellence in all the professions, but obviously this focuses on medicine. The problem is that "competence" is a reductionist concept; it says that you can interpret a professional's role as a sum of particular competencies or the things he or she is good enough to do. To be proficient and capable in one's role requires considerable experience, depth of knowledge about one's discipline, experience in exhibiting fine judgment - a lot of medicine requires that - and not just a capacity to undertake certain tasks under defined conditions. I think the idea of proficiency is a more embracing one that wraps up competence but accepts the need to embrace these other qualities that we and society would wish to see in a doctor.

Q153 Chairman: The Chief Medical Officer told us he did not resign over MMC because "the principles and the policy were commended in the Tooke Report". Do you believe that to be correct?

Professor Sir John Tooke: When I started the inquiry it was very difficult to get clarity about what the principles of MMC were. As our interim report makes clear, there was scope drift; it began to embrace wider workforce redesign as well as the principles underpinning an education and training programme. I agree that some of the starting education and training principles in the Chief Medical Officer's document Unfinished Business endure in the minds of most doctors, that is, broad-based beginnings, flexibility and a structured programme.

Q154 Chairman: Obviously, you have conducted widespread consultation with doctors as part of the review. How has this helped you to reach the conclusions at which you have arrived? Do you believe there was a lack of consultation during the development of MMC?

Professor Sir John Tooke: If I take the second part first, during MMC it is clear from the evidence we present that the medical profession was involved in the numerous bodies included in the process and, furthermore, that it turned up for those meetings. Nonetheless, we did unearth evidence that its views were sometimes not taken fully into account. For example, we were concerned that the minutes of some meetings were not going forward to meetings that set policy and strategic direction. There is an issue about the extent to which the structures and framework of accountability allowed the profession's voice to have influence. On the other side, one issue we bring up is that the medical profession has a responsibility to speak with a coherent voice - one voice is probably an over-expectation - about those issues which are of fundamental importance not only to that profession but, more importantly, to the health of the population. In terms of the consultation process we undertook, we were obliged to produce a report in fairly short order so it would have a bearing as soon as possible on thinking about subsequent rounds of recruitment. We had a broad-based e-consultation in which over 4,500 people participated. We generated some 39,000 answers to the questions we posed. One of the most valuable things I did was to co-ordinate a series of eight workshops for trainees throughout the UK, visiting eight cities in the country. That revealed first hand the distress that had been caused and gave us a very real sense of the aspiration of trainees for their future. For me, one of the encouraging things to come out of it was that despite their distress their professionalism shone through. They realised that if we wanted to have excellence it was a competitive process and they echoed the fact that they did not join medicine to be good enough but to be the best possible doctors they could be.

Q155 Chairman: It does appear that your proposals have been welcomed by the profession and organisations like the BMA and Remedy UK are happy with them. Do you think you have achieved a consensus on the way forward or do you believe these groups have united with you because you are not the Department of Health?

Professor Sir John Tooke: What I can say is that based on the e-consultation we have conducted on the interim report there is 87% agreement or strong agreement across the 45 recommendations and only 4% disagreement or strong disagreement, with 9% neutral in terms of the questions posed. For each of the recommendations there is a majority opinion in favour. In my experience of consultation exercises I do not believe I have ever seen that degree of overall support for a set of recommendations. Clearly, there are issues for individual constituencies which we will address in the final report.

Q156 Chairman: Sir Jonathan, do you think that employing organisations are one of the groups that have had too little involvement in MMC up to now?

Sir Jonathan Michael: Yes, I do, and in part that is because the structure of the NHS and the role of employers have changed in the intervening years with an increase in decentralisation, the devolution of accountability and the development of foundation trusts with separate legal status. The view now is that the NHS is no longer a single majority employer in the way it used to be and the role of employers and their engagement has been sub-optimal. Clearly, employers have accountabilities as employers and therefore they need to be engaged not only in employment issues but they have a responsibility to their employees to make sure they are properly trained and their professional training continues while they are in their employ. They also have a responsibility in terms of engagement in workforce planning because the needs of individual employers must be part of the overall picture.

Q157 Chairman: Do you think employers' views are now represented in your report?

Professor Sir John Tooke: We made great effort to try to capture that view. We had a sub-committee that reflected service. We obviously talked with NHS employers as well and tried to capture that. Clearly, postgraduate education and training sit very much at the interface with service issues, education and training requirements and academic aspiration and we must capture that response.

Sir Jonathan Michael: From my point of view as a former NHS chief executive, I am very comfortable that the employers' needs and reviews have been reflected in the report.

Q158 Dr Taylor: I want to go on to MTAS and its implementation, looking first at leadership and then project management. Your abstract which sets out the whole thing on two pages is brilliant. I tackled the Chief Medical Officer about these matters a fortnight or so ago. In No.5 we see: "The medical profession's effective involvement in training policymaking has been weak." The corrective action is: "The profession should develop a mechanism for providing coherent advice on matters affecting the entire profession." I tried to get the CMO to say who should be the leader of the medical profession and he had great deal of difficulty with it but was quite certain it should not be him. I would like to sound you out on this because at the moment among the royal colleges, the BMA, the academy and all the different specialties it is totally confused. I should like to hear ideas from both of you as to who should be the medical leader particularly for this sort of issue.

Professor Sir John Tooke: I agree that it is difficult and goes back to my point about avoiding factional interests that sway things one way or the other. In a sense we are throwing down the gauntlet to the medical profession and saying it has to stand up and exhibit leadership particularly on issues of such national importance and forget its particular constituency and allegiance in the interest of those ideals. Whether one can have one individual or body that represents it is questionable. I believe the Academy of Medical Royal Colleges could create some device which enables perhaps a small representative group of college personnel to reflect the entirety of that professional constituency. That appears to be a sensible way forward, but it is for them to come to the required agreements. Rather than think in terms of a standing group that reflects on everything it may be better to have short-term representative professional groups that deal with particular issues. Inevitably, the input you need will vary according to the issue being discussed. For example, in something like this clearly people with education and training expertise will need to be well represented. I am afraid that is a rather vague answer, but I do not think you can pin on an individual the responsibility for a coherent voice.

Q159 Dr Taylor: There would have to be a spokesperson for the group who in effect would be the leader?

Professor Sir John Tooke: Indeed, if you want to use those terms.

Q160 Dr Taylor: Sir Jonathan, you were very much a medical leader in your job both in Birmingham and then London. How did you manage to steer across all the many different interest groups?

Sir Jonathan Michael: As my colleague says, it is difficult and there is not a one-size-fits-all solution. I would be keen to make sure that the doctors who are involved in the running and delivery of services are also represented in those discussions because there are a number of different constituencies - professional societies, colleges and the BMA - but often the voices that are not heard so well are those that represent organisations that deliver the care. Whether or not one sees that as an employer or organisational voice that needs to be heard. With decentralisation and an increasing number of foundation trusts the views of the delivery organisations for the NHS need to be represented.

Q161 Dr Taylor: Very condemnatory statements have been made in some of the letters we have received personally and some of the written evidence. I quote just one: "The very damaging failings in both MMC and MTAS are directly related to the management style and performance of those given the responsibility for implementation. The NHS must learn to identify poor performance at these high levels and be seen to take action." A neurologist writes: "I would very much appreciate a hard-hitting inquiry into the evidence that was used to support the changes in medical training introduced by the Department of Health. This would also require calling all the advisers, medical and non-medical, reviewing their qualifications and their remuneration arrangements." Should we be looking to attach blame somewhere, or will that not be productive?

Professor Sir John Tooke: You will know that it was not the primary aim of our inquiry to attach blame. What struck us and I hope comes out strongly in the interim report is the ambiguity over accountability. To set up something of this complexity and introduce it at the speed required with ambiguous accountability arrangements, deficient project management and woefully inadequate risk escalation processes was essentially the structural fault where much of the blame lies, but the very fact that accountability was ambiguous makes it difficult to pin down singular responsibility.

Q162 Dr Taylor: How do you suggest improving project management at the Department of Health?

Professor Sir John Tooke: I think there is a big question whether the Department of Health should be trying to implement something of this complexity. Clearly, the department in conjunction with professional stakeholders has the key role in determining policy and ensuring that policies which impact on education and training - workforce policies and health policies more generally - are aligned, but at least for the panel there is an open question as to whether the Department of Health has the resources and professional skills to implement something of this nature. My personal view is that for something like this it is probably better conducted by an accountable arm's length body which can have a continuing function in terms of scrutiny of the necessary linkages between national and regional activity, ensuring that the contractual base for training reflects the desire to see optimum training in the workplace and so forth. It is that policy and implementation separation that I think needs to be considered. Whatever happens, there must be more professional project management and better risk escalation processes; and there needs to be better UK-wide co-ordination. There was a perception by the devolved administrations that on occasion the approach was too English-centric or resulted in policy on the hoof to deal with implementation issues in England and that disrupted the cohesion of what was essentially a UK-wide application.

Q163 Dr Taylor: You were critical of split governance between MMC and MTAS?

Professor Sir John Tooke: One of the more alarming features is that the two issues that caused the major difficulties - MTAS itself and the international medical graduate problems - were handled by the workforce capacity unit which did not have direct line accountability to either of the senior responsible officers, so the two pivotal issues, one in catalysing the problems and the other provoking a considerable increase in applications over available places, were handled essentially outwith the main accountability structure, ambiguous though that was.

Q164 Dr Taylor: Therefore, it was chaotic?

Professor Sir John Tooke: That is one word to describe it.

Q165 Dr Taylor: Obviously, communication should be a key part of leadership and the implementation of anything. What did you think of the communication within the department and between the department and the profession and between the department and junior doctors?

Professor Sir John Tooke: Clearly, there were attempts to engage the profession in terms of representation on all the key bodies. I suggest that because the fundamental principles were unclear and evolved over time it made clear communication difficult so that people on the ground who did not pour over the details of the documentation would have been less than clear about what was coming. There was a major communication failure in relation to MTAS itself over the implications, for example, of having four choices. A conscious decision was made not to reveal that to trainees, and inevitably it meant that people were disappointed because very good candidates were not being called to interview. Had they understood in advance the implications of the four-choice structure I think that some of that distress could have been avoided.

Q166 Dr Taylor: Do you agree with one person who wrote to me: "I've just returned from a trip to Malaysia where I spoke to doctors, university educators and other professionals, and the common views expressed were amazement at how the UK got itself into this mess and, secondly, that they would no longer consider it wise to send their bright young people to the UK to train in medicine"?

Professor Sir John Tooke: How we ended up where we were was remarkable. I believe part of that reflects the big bang application of the new system and the fact that once the pipeline was rolling and people were going through foundation there was a sense that something had to happen to accommodate them. One of the graver mistakes was not to recognise there was a group of highly talented SHOs who were the bulge and try to accommodate them at the same time as people coming out of the pipeline. I am sure that in retrospect most people would regard that as an error and some forethought should have been given to how they would feel and how that bulge should be managed effectively and fairly.

Q167 Mr Scott: Last week the CMO acknowledged that the 2007 selection system had caused distress but denied that the system was unfair. Do you agree?

Professor Sir John Tooke: You have to unpick the value statement "fair". If by that word you mean something that allows equal opportunity and selects the best person for the job I argue that there were aspects of unfairness in the process. It was not fair to those SHOs who through dint of their year of graduation were disadvantaged by the system; it was not fair in the sense that it was family-unfriendly to several candidates. In terms of whether it selected the best, we know from the data and in-depth studies done in a number of deaneries that some very good candidates went forward for interview. Whether or not they were the best is a moot point. The fact that there are many examples of people with excellent qualifications and experience who did not get the positions suggests that that is not the case either.

Q168 Mr Scott: Referring to the matters you have just raised, officials cited evidence to suggest a high correlation between candidates' short-listing scores and their interview scores. Does this prove that short-listing works or not?

Professor Sir John Tooke: It is a normal device if you are looking at the so-called predictive validity of a selection process, and if you look at the correlation between that and the next stage it gives you some assurance that you are picking people who are appropriate. I believe that the data from my own deanery in Peninsula show a correlation between the short-listing schools and the interview performance of about .37% which is not bad for that type of assessment, but that does not necessarily prove that the best people are coming forward. Clearly, very good candidates will probably be better at completing any form of assessment and will apply their guile to whatever process through which you put them. They are very bright people and will find a way to score well. It does not necessarily mean that you are picking those with the best skills, knowledge, behaviours and attributes to make trainees of the future. The other aspect of fairness is that what matters to any of us going through a particular test is the face validity of the test. If it seems a reasonable test to you of what you expect of the role you are to undertake you are likely to be more satisfied with the outcome of that test. If to you it bears little relationship to what you think the role is about and it is perceived, as stated on many occasions, as an exercise in creative writing it does not give you much confidence when you are rejected by such a process, whatever the correlation coefficients are.

Q169 Dr Naysmith: Could we focus on the role of the medical profession? I think you agreed with Dr Taylor that we were talking about a chaotic situation. Can we be a little more brutal in a way? Your report shows that the medical profession was closely involved in developing MMC - I do not think you disagree with that given what you have said - yet most doctors appeared to be outraged by what happened in 2007. You have already explained that in advance in answer to Dr Taylor. Nonetheless, should not the medical profession accept just as much responsibility as the Department of Health for what happened?

Professor Sir John Tooke: I would not say that the culpability was equal. I believe the medical profession failed to exhibit sufficient leadership and should have ensured it had more influence. I have already mentioned that I believe some of the influence we might have had was eroded by the structures and processes employed, but the very fact that the accountability arrangements were not organised by the profession puts the weight of accountability on the department.

Q170 Dr Naysmith: From your report it appears as if there was a lot of consultation. You could even argue that the medical profession was over-engaged in the process with so many different voices being heard.

Professor Sir John Tooke: Yes.

Q171 Dr Naysmith: Do you believe that too many people were speaking and perhaps there was not enough clarity about who was speaking with authority and what should happen?

Professor Sir John Tooke: That is a very reasonable perception and it takes us back to my point about the need to have a coherent voice on critical issues which can be resolved and policy and principles can be clarified and collectively we move forward.

Q172 Dr Naysmith: That takes us back to my original question. Is it not up to the medical profession to get itself sorted out? I refer to the leaders of the royal colleges - too many of them - and other voices. It is up to the medical profession to get itself sorted out and decide what its attitude is to this?

Professor Sir John Tooke: I absolutely agree. Just as there is a call here for the department to ensure there are proper accountability structures and project management in place so it is necessary for the profession, if it wishes to have influence in co-developing policy and implementation matters, to find a way of speaking coherently. I have laid down the challenge at every meeting I have attended that this is something that only the profession can address.

Sir Jonathan Michael: There is a difference between the department, which is a single entity with a coherent structure and lines of accountability, and a much more diffuse grouping called "the medical profession" that works across a whole range of different industries, businesses and sub-specialties. It does not mean that having a more coherent voice for the medical profession is not important but, as was said in answer to Dr Taylor, where that voice needs to come from depends sometimes on the issues. I think there is a difference, but it does not however diminish the importance of having as coherent a voice as one can get from a very diffuse population called "the medical profession".

Q173 Dr Naysmith: This is really the nub of the question. How do we get this voice? As someone who is not a medical doctor - I worked in a medical department for 30 years before I came here and sat on this Committee for six years - I observe that there are a number of colleges all of which jealously guard their bits of territory, and yet in order to develop the medical profession properly and modernise medical careers something must emerge which will speak on behalf of the whole profession. You hinted at it. Do you suggest that a new body should be set up to do this on behalf of all the different interests involved?

Professor Sir John Tooke: What I can say is that I know the heads of various institutions are meeting in the very near future to discuss precisely that issue. Whether it is a standing structure or one formed to deal with a diversity of issues as the need arises - a constituency from which one can pull representatives, as it were - is an open question, but we have to do our part to make this process work.

Q174 Dr Naysmith: Are you hopeful?

Professor Sir John Tooke: By nature I am an optimist, so, yes.

Q175 Dr Naysmith: Your report called for urgent resolution of the status of international medical graduates, but a recent decision of the Court of Appeal means that IMGs will be free to apply for training posts in 2008. Will that not make it especially difficult to re-establish the credibility of the selection system in the year ahead?

Professor Sir John Tooke: Indeed; it will cause very real strain on the system because the likelihood is that there will be three times as many applicants as there are trainee posts available. It will probably be a worse ratio than we experienced in 2007. What we called for in the report was a very rapid reconciliation of central policy with conflicting demands for open doors and self-sufficiency and nobody can plan unless that is resolved.

Q176 Dr Naysmith: Can you offer any suggestion to help the situation? I know that another report will be in preparation eventually, but this will happen before you have an opportunity to do that, will it not?

Professor Sir John Tooke: Indeed it will. I think it is a policy question. We are on track for self-sufficiency. We have had an expansion in medical undergraduate education in this country in line with such a policy. We need consistent policies through the rest of training which support that if society is to see the value of the very considerable investment in medical undergraduate education. Another issue is that if we believe, as I do, in the continuum of medical education and the fact that a trainee doctor continues to enhance his skills throughout his training and professional life there is something to be said for ensuring that UK medical graduates, from whatever country they derive, have the opportunity to move forward in their training.

Q177 Dr Naysmith: Sir Jonathan, when you gave evidence on workforce planning you argued for a light-touch approach to NHS workforce planning. Are you therefore pleased that IMGs will be eligible to apply for UK training posts? Would that fit in with your light touch? That will give employers more choice.

Sir Jonathan Michael: Yes. In the previous evidence that I gave the Committee on workforce planning I argued for a light touch partly because I believe in principle that is the right approach but also because of some of the difficulties associated with forward workforce planning when there are such rapidly-changing medical and technological advances and a long training period. Therefore, you need to have flexibility in training to allow people to change their direction of training if their perceived or aimed for opportunities either diminish or are not achievable. To give an example, the change in cardiac surgery with the advent of non-surgical intervention for coronary artery disease made a significant difference in the careers opportunities for potential cardiac surgeons. That happened very quickly and a number of people were caught in a programme which was to train them for something which would no longer be so necessary. One needs more flexibility. In terms of the national view, there needs to be national oversight which will then drive the commissioning of training programmes - it is largely a commissioning view - but that needs to be well informed. The difficulty is to make sure that decisions at a national level are informed by people who know about the individual specialties and what is likely to be happening round the corner so they can take a five, 10 or 15-year view. The other element is local workforce training which has to be much more to do with the needs of employing organisations.

Q178 Dr Naysmith: I am still not sure whether or not you think the Court of Appeal decision was the right one in this situation.

Sir Jonathan Michael: Fundamentally, yes, it is the right one; it just makes it more complicated. The incompatibilities at policy level must be resolved because if you have a combination of open access for international - European - graduates and produce sufficient UK graduates to staff our requirements undoubtedly there will be tension there.

Professor Sir John Tooke: In determining policy it is probably worth reflecting on the fact that many people have asked for the medical profession to be more representative of the society from which it comes; in other words, there should be greater access within the UK to people who aspire to be doctors. You cannot do that if you have a completely open-door policy that results in a group of doctors who may be largely unrepresentative of the society from which they derive.

Q179 Mr Syms: Sir Jonathan, you have already acknowledged that there will be three applicants for each post in 2008 which could mean up to 1,500 UK-trained doctors being displaced. Clearly, medical workforce planning has gone awry. Should we not be turning off the tap and reducing the number of doctors coming out of UK medical schools; otherwise, will we not have this continual problem?

Professor Sir John Tooke: We acknowledge the deficiencies in workforce planning which was borne out fully by this Committee's report. My view is that we do not need a knee-jerk reaction in terms of medical undergraduate numbers. Turning off the tap would not have a material impact for many years on the number of people entering training at the level we are discussing here. I do not believe that you can resolve the question of how many doctors you need until you have absolute clarity about the role of doctors and the service contribution they make at each career stage. You cannot do those projections until you have asked that fundamental question or you have aligned health policy with workforce need. Therefore, in one sense MMC was turning a handle to produce what we had ever produced and yet, as this Committee acknowledged in its workforce report, there is a movement of care towards the community and the workforce and therefore medical student numbers and training processes need to reflect that. You need to align health policy with the workforce and education and training policy. I counsel against precipitate action on medical student numbers until we have resolved that equation as best we are able. We all project that things will change in terms of health service delivery, given the demographic and technological developments to which my colleague referred earlier, with public expectation and greater emphasis on sophisticated approaches to preventive medicine which will demand major changes. That is one of the reasons why we strongly support the idea of broad-based beginnings to training. Not only does it provide a better educational foundation but from a workforce perspective it also means that one has greater capacity to differentiate the skills you need as health needs evolve rather than take people all the way back to the beginning again.

Q180 Dr Taylor: Turning to the future structure of medical training and the big bang approach and the single date, is there any way that can be changed? Sir Jonathan, from the hospital trust point of view what are the disadvantages of everybody changing on August 1?

Sir Jonathan Michael: They are significant because of the implication for service delivery and training. Employers are required to provide mandatory training and induction programmes. If everybody changes on the same day employers will struggle to maintain effective services during the initial few days or couple of weeks.

Q181 Dr Taylor: Would your suggestions about the future structure be compatible with a staged change of at least twice a year rather than once a year?

Professor Sir John Tooke: Indeed, and it is incredibly important. It is also another dimension of flexibility.

Q182 Dr Taylor: To go on to your structure, you want to cut down the two-year foundation programme to one year and then go into core training. The BMA have argued that that is perhaps too soon because the first group of foundation people is just finishing.

Professor Sir John Tooke: Perhaps I may give a fairly detailed answer to that because it is one of the structural recommendations that has raised concerns predominantly from the quarters involved in foundation training itself. One understands that. Foundation in comparison with MTAS for the purpose of entire training went pretty well. There is no doubt that the evaluation of trainee experience to which we have had access since the interim report suggests that that is valued. The critical issue here is that unless we disaggregate F1 and F2 in employment terms we cannot guarantee a UK medical graduate can achieve what used to be called the preregistration house officer year (F1) and therefore achieve full registration with the General Medical Council. We cannot do that legally in a defensible way now there is European competition for those preregistration posts. That means universities will be unable to fulfil their statutory obligation to provide placements to get somebody to the point of registration. I put it to you that it is totally unacceptable for the country to invest 250,000 to get somebody to the point of graduation and not be able to fulfil the final bit that gets that individual to registration so he or she can be employed as a doctor thereafter. I anticipate that there would be considerable legal challenge to that situation if we allowed it to prevail. Therefore, the driving force for disaggregation is that issue. I do not believe there is any reason to throw out the good curriculum advances that have been made for those two years of foundation, and in our final report we shall propose how we can retain what has been good about foundation and merge it into what we are talking about in terms of basic training but build on the successful bits and improve on it. I would rather it was perceived that is what we are trying to do than that we are just axing something.

Q183 Dr Taylor: Therefore, the second foundation year would become the first year of your core training?

Professor Sir John Tooke: F2 essentially would become themed and feed into the core training. No curriculum is set in stone and it would be reviewed. My guess is that over time we would revise the core curricula and almost certainly foundation year one curricula to be more fit for purpose. A general concern that we expose in the report is the sense of drift to the right of acquisition of skills and responsibilities by trainees. That is really worrying given the European working time directive and other imperatives which reduce the amount of experience and responsibility that trainees get. One of the devices that we believe is needed is a pulling back of acquisition of responsibility under supervision and the acquisition of practical experience. That is a call on the medical schools to ensure that the current high standards are even better and we put people into F1 jobs who really are skilled up.

Q184 Dr Taylor: Core training of three years would put back the time when people had to make a final decision about which specialty to pursue?

Professor Sir John Tooke: Indeed. It puts back the final decision about the 57-odd sub-specialty areas. Currently, they have to make a decision about half-way through the second foundation year. That is important because most trainees felt that they had to make a choice prematurely. If you get it wrong you are taking a very high stakes decision. Therefore, there are core themes in very broad areas with some flexibility particularly during the first year. If you have got it wrong you can switch, but there is a time-limited core programme so we do not go back to the less desirable aspects of SHO training where people can mill around for seven or eight years. Therefore, it is a time-limited, broad-based and themed process towards the end of which one makes the ultimate career decision.

Q185 Dr Taylor: Can you give us any idea about the split between service and training in those core training jobs? Would you expect a big service commitment from them?

Professor Sir John Tooke: Inevitably. Training and service are intimately combined in my view. They have to be considered separately in some ways, but we must not lose sight of the importance of experiential learning that comes with actually doing the job and a better acknowledgement of that integration is important, just as is the recognition that trainees are doctors who are doing a job of work. We point out in the report that in some areas the perception is that some young doctors saw themselves as trainees rather than doctors first. Our generation probably regarded itself as doctors in training. I think we need to enhance that perception for their morale as much as anything else. Their very real and important contribution is valued by the health service.

Q186 Dr Taylor: What is the effect on run-through training which is said to be one of the advantages? If you are splitting it what effect does it have on such training?

Professor Sir John Tooke: I take issue with that. I believe that "run-through" was one of the fundamental mistakes in this process. We have talked about the principles in Unfinished Business and that morphed into something that involved run-through training. The process by which that decision was made is unclear to the panel. The document The Next Steps simply states that "thinking has moved on". We are not quite sure whose thinking that is and with what policy objectives in mind that new construction came. If there are sufficient training posts available for everybody the idea that one is in one place and comes out as a finished product obviously has superficial attraction. In reality, if it becomes a premature choice onto rigid train tracks in a specialty area clearly that becomes less attractive to trainees. It does not allow future sub-differentiation of the workforce as health needs evolve because they have not had a broad-beginning to their training on which they can build as requirements for change emerge. I believe it is something that as a principle should be resisted. That said, as we harmonise the new with the old there may be a case in the short term for retaining run-through in one or two disciplines for very specific reasons, but as a generality and principle we wish to see broad-based beginnings and very good career advice and intelligence on what the opportunities are within the various specialties starting from before medical school and going all the way through so people can make informed choices and know where they stack up in relation to their peer group.

Q187 Dr Taylor: Where you would retain it are you talking about the very small specialties?

Professor Sir John Tooke: It is an extreme minority of cases. One example I suggest - please do not interpret this as any definitive diktat from us - is histopathology. One could argue that one does not need three years of basic clinical training before one goes into a histopathology school, but that is a special case with a special rationale behind a different approach. The point is the diversity of the profession to which my colleague referred.

Q188 Dr Taylor: If these changes are made what happens to the doctors who are already in the run-through programme?

Professor Sir John Tooke: One must honour the contractual responsibilities one has to those people who have entered into that. Clearly, it would mean that very soon we would have to uncouple the core training from the subsequent step. That competitive step is welcomed by the majority of trainees and viewed as being entirely consistent with an aspiration to excellence. If everybody gets on at the beginning and comes off at the end that is not aspiring to excellence.

Q189 Dr Taylor: If we turn to higher specialist training, you allow what you call the trust registrars or staff grades to get back into specialist training which seems to be an excellent move?

Professor Sir John Tooke: Indeed. Our workshops with junior doctors involved people in those grades. There may be a debate about the nomenclature but that is second order. What was required was rapid resolution of the contract so there was certainty about what the roles meant and to get away from the sense that it was a dead-end career or cul-de-sac. Part of that is to ensure first that there is an opportunity to compete for entry into higher specialist training. It may be you limit the number of times you can do that just to introduce some reality into the equation, but we feel that is very important, as is the maintenance of a route to completion of training through the existing so-called CESR route. All of those things are important. The other matter that comes through very strongly is the separation between training and non-training grades. In our view no doctor should be in a position where he receives no training, even if it is just updating him on advances in his particular disciplinary area. Therefore, some ongoing staff development and training opportunities, though clearly not of the intensity that specialty training demands, should be provided for people in those roles.

Q190 Stephen Hesford: To pick up your thinking on run-through, arguably does it not militate against what you say about flexibility and where the profession should go in future given that there may be more community service? As I understand it, run-through will give maximum flexibility in terms of that kind of thinking. Are you not answering the question already by moving away from run-through about what the profession is for going forward?

Professor Sir John Tooke: To take the "community" question first, there are those who regard community or primary care/medical activity as the easy bit. I can say as a hospital doctor that that is the difficult bit and it will become even more difficult with an ageing population with multiple chronic diseases or comorbidities requiring 15 medications. To deal with those sorts of problems in a community setting, particularly if it is a vulnerable individual, requires great skill and a general-based depth of experience so one has a hope of interpreting the range of problems with which one will be presented with the sophistication that the public will expect in future. This is not simple medicine; it is difficult stuff, and we have to prepare a medical workforce that is able to cope with it. I believe that the broad-based beginnings are absolutely key to that, as is our suggestion that GP training should be extended. In our view, it is simply inadequate to have people who have had only three years' training taking on the type of role I have sketched.

Q191 Stephen Hesford: As I understand it, there remains tension between what you have been outlining and where the CMO is on this. How do we resolve that tension?

Professor Sir John Tooke: I think you resolve it by aligning the health policies, workforce and education and training policies which reflect future health needs. I know that some of that is going on as part of the NHS review but ultimately workforce and therefore education and training need to be driven by health need. We are there to respond to health need and we require clear policies to enable us to meet it.

Q192 Mr Scott: Sir John, some proposals such as extending GP training from three to five years will have significant cost implications. What has been done as a priority to assess the cost of implementing your recommendations?

Professor Sir John Tooke: Clearly, there are financial implications for that particular proposal but, as we point out in the interim report, having trainees delivering a service element as part of their GP training clearly will be cheaper than having more principals in general practice, so the costs are not like a direct expansion of general practitioners. There are also potential cost savings if you enhance that element of the workforce along the lines I have just described. You may achieve a lower rate of referral to secondary care for more expensive interventions or treatments. There is also the possibility of using extended training to align trainees with areas of great need or where it is difficult to retain general practitioner services. Therefore, one can begin to influence the distribution of primary care activities through careful placement of such posts. At the end of the day, it comes down to resources being aligned with the health policy that you want to effect. You cannot have pleas for more care in the community, which is where the public want to see it, and more sophisticated care in the community, which the public will demand, unless you provide resources to match those expectations.

Q193 Mr Scott: Do you think there is a risk that the Government will agree to changes that it cannot afford to avoid further embarrassment, or for any other reason, and they will be gradually watered down as time goes by?

Professor Sir John Tooke: Some of the recommendations are pretty fundamental and nobody would want to see a continuing process of restructuring. We will need certainty as soon as possible about what the future framework will look like. As a panel we would be extremely disturbed if our recommendations were watered down to any significant degree, not least because of the 87% support we have for the recommendations across the board. Therefore, in terms of engaging the profession with the solutions and aligning them with an aspiration to excellence it is absolutely critical that the report is carried through in almost its full extent.

Q194 Dr Naysmith: Sir John, one of the matters we have already mentioned is that your report highlights the lack of resources and expertise for workforce planning. You pay quite a lot of attention to workforce planning in your report. We raised the issue in our recent report on the same subject. Do you think the Government will now address these problems and, if so, what do you think it should do? How should it go about improving workforce planning?

Professor Sir John Tooke: As you say, we believe that it is an absolutely critical and interrelated issue. I am conscious that through The Next Steps review there is a process of looking at the future structure of workforce planning and how that is aligned with education. For me, an absolutely critical issue, which has not come up yet, is role clarity. We must have clarity about what the medical professional contributes to the multidisciplinary healthcare team. For that matter, we need similar clarity for the other professional clusters involved. You cannot do effective workforce planning until you know what those contributions are. That is the starting point. Any future structure needs to deal with the tension between demand-led local planning, in which SHAs are now heavily involved, and national oversight to ensure that shortage specialties are covered, quality of commissioning and training structures is up to a national standard and that the service perspective is also embraced within that. An integrated approach rather than the idea that all of it must be decentralised is crucial. We need better databases of existing skills. We think that having the GMC as the overarching regulator will cost-effectively help us achieve that. We need better modelling capacity than exists within the department. That may mean calling on academic expertise or expertise from other sectors to enhance that. We then must have the sharp end professional viewpoint; in other words, we must have doctors who are at the front end of their profession in terms of driving forward developments to provide foresight to get over the great difficulty of trying to anticipate future needs and technological and other solutions. There is a strong case for reconstituting something like the Medical Workforce Standing Advisory Committee which was stood down fairly coincident with the development of many of these changes. Despite the difficulties inherent in workforce planning - we all appreciate that it is an inexact science - that committee did a pretty good job of rationalising medical student numbers, for example. We need to ensure that some structure such as that is imbedded in future arrangements.

Q195 Dr Naysmith: Is there not a danger that that would enhance the isolation of the medical workforce planning bit as opposed to the team approach that is being followed?

Professor Sir John Tooke: If you have clarity of role any danger inherent in that can be avoided. Your previous report identified the shortage of doctors which led to a number of other solutions being employed, particularly role substitution. That report points out the need for evidence that substitution works. From our perspective what is important is that each professional cluster, if I may so describe it, needs an appropriate educational foundation on which to build. A healthcare professional, whether a therapist, nurse or doctor, is not simply a sum of competencies or good enough skills. We will get a second-rate health service if that is the model we pursue.

Q196 Dr Naysmith: It is interesting that you raise the question of clarity of the role of the medical professional. Elsewhere in the report you recommend a wide-ranging debate on the role of the doctor in healthcare. Leaving aside for the moment your views on the subject - you can add them in if you like - should not the Government already have a very clear idea of the role it wants doctors to play? Should not the medical profession really know what it is providing when it turns out a doctor?

Professor Sir John Tooke: One cannot disagree with that. Inevitably, the roles of all professional groups evolve over time. If one is to aspire to something better one must look at each group and how to enhance the roles and get the most out of each professional contribution. This is not about medical elitism but asking: what does this major foundation in medical education equip somebody in a medical practitioner role to do? How do we get the most out of that? How do we ensure there is a good contribution of doctors to management and leadership, which is something we recognise as a potential problem with the existing structures? How do we ensure that healthcare which is so important to UK Plc science flourishes in this country and that doctors have a key role to play in that, and so on? It is about enhancing the role of each professional group and looking clearly at the educational foundations and training necessary to do that.

Q197 Dr Naysmith: Part of this is due to the feeling that there will be more trained people than there are jobs for them in future. I am talking particularly about consultant grades. When he gave evidence the Chief Medical Officer said that the United Kingdom was only 21st in the table of doctors per head of population; in other words, we are under-doctored compared with some other advanced countries. Would your specialist grade provide a mechanism for breaking the linkage between consultant and training numbers and help in this situation?

Professor Sir John Tooke: It is likely that there will need to be some differentiation at the top end of the profession. It seems unlikely to me that you can have the majority workforce made up of autonomous practitioners operating in precisely the same role. I use the analogy of my experience. When I became a consultant in a district general hospital nearly 20 years ago I was the only specialist in the two specialties that I served. There were only six physicians of whom I was one. Therefore, I had to lead the profession and run the training. I also ran a research programme. I was embracing many of the enhanced roles to which I have referred with which people have historically associated the consultant position. In my service there are now five of me. We do not all do those things; some operate as sub-specialists, some major on research and so forth. I believe that there will be greater differentiation. A useful analogy that has been put forward is that in clinical academia you recognise at consultant level that you can have a senior lecturer, reader and a professor. Therefore, there is a differentiation within that hierarchy. We need an open debate. What we have done is to expose the need for resolution of that issue. It will not go away.

Q198 Dr Naysmith: You open up a very interesting debate, if I may say so.

Professor Sir John Tooke: Even if one had not, one suspects that foundation trusts will be making decisions because they have a responsibility to provide the skill mix and layers they need to do the job.

Q199 Mr Syms: When and how do you expect the Government to respond to your final report? Do you expect the majority of your recommendations to be accepted?

Professor Sir John Tooke: I wish I knew the answer to the second bit. As to the first part, we plan to get out our final report before Christmas. We hope that we shall receive a response in very short order. I am conscious that some of the work streams we have identified are already being drawn into some of the work streams associated with Lord Darzi's review of the NHS, that is, some of the issues around workforce planning, the architecture in terms of regulation, the management of commissioning and so on. We welcome that. We shall watch it very closely because we are concerned that things are not diluted in translation. I did not wish to join the national board taking forward that work because I want to be able to stand back and monitor how things are going, but I have agreed to advise on that process as it goes forward.

Chairman: Thank you both very much for coming along to assist us with our inquiry. We shall not be reporting quite on your timescale and we hope that is quite useful to us.


Witnesses: Dr Richard Marks, Head of Legal Team, and Mr Matthew Jameson Evans, Press Co-ordinator, Remedy UK; and Professor Steve O'Rahilly, University of Cambridge, member of Fidelio, gave evidence.

Q200 Chairman: Gentlemen, for the sake of the record perhaps you would introduce yourselves and the positions you hold.

Mr Jameson Evans: My name is Matthew Jameson Evans, a co-founder of Remedy UK, the group that opposed a lot of the processes that went on this year.

Dr Marks: My name is Richard Marks, a consultant anaesthetist. I have been involved in postgraduate training for 15 years. I am a programme director for the London deanery and I am deputy regional adviser for the Royal College of Anaesthetists.

Professor O'Rahilly: I am Steve O'Rahilly, a consultant physician at Adenbrook Hospital in Cambridge. I am also a professor at the University of Cambridge where I research and teach. I was part of the spontaneous group that got the name Fidelio attached to it. We were horrified at the evolution of MTAS and MMC and have continued to be horrified ever since.

Q201 Chairman: Maybe we can start there. Both of your organisations were formed specifically to respond to the problems of the implementation of the 2007 training reforms. Whom do you represent and what do you hope to achieve by formation and activity?

Mr Jameson Evans: My experience of going through the process of MMC and MTS was that there was a sense of helplessness among my contemporaries about lack of information, powerlessness and the fact that they had not really been consulted at grass roots level about what was going on. Remedy happened just as a result of a few emails which suddenly mushroomed into the 15,000 doctors now on our list. Essentially, it is a source of information. We also encourage reaction to events that in previous years has not occurred.

Professor O'Rahilly: I suppose that Fidelio represented a spontaneous eruption. It was perhaps a Prague spring-type response to the events of the spring of last year when a number of us - many physicians and doctors with international reputations busy doing their work - concerned mainly with teaching and research suddenly realised that this had been sprung upon them somewhat unannounced. They had perhaps been rather nave about how this process had evolved. The full horror began to dawn on us as our junior doctors told us what they were going through. The number of reports started to turn into an avalanche. We felt that we could not stand back. Essentially, we formed ourselves into a ginger group, as it were. We do not try to usurp the functions of the royal colleges or any of the established organisations, but we feel we can be a useful ginger group to stiffen the spines of our more formal representatives in their deliberations.

Q202 Chairman: I just query why both organisations did not use the traditional route of the royal colleges or even the BMA. Did you attempt to do that or did you decide not to go down that traditional route in order to make your views heard?

Mr Jameson Evans: Our perception was that almost every medical institution was a stakeholder in the conception of MMC and MTAS. There was a feeling that they had dug themselves into a situation they could not get out of and were going deeper and deeper. I suppose the value of a group like Remedy was that it had nothing to lose and could, if I am not being disingenuous, express what the vast majority felt at the grass roots.

Professor O'Rahilly: Similarly, we consulted people at the royal colleges and the BMA. We felt that it was a professional issue. The BMA is largely a trade union and we did not feel that it would have the public legitimacy to engage at that stage. The response of the royal colleges initially was very disappointing. Many of us are fellows of the royal colleges and are associated with them in some way. There was an issue about the colleges having been involved and consulted at least in part throughout the process. They were in effect partly steeped in it and found it very difficult to extricate themselves even when changes of leadership led to the appointment of people who perhaps might like to extricate themselves from it.

Q203 Chairman: On the basis of the answer to that question, do you think that the profession is as much to blame for this situation as the department?

Professor O'Rahilly: I think the profession has participated in this. To some extent it has been rather hoodwinked and blind-sided, because a lot of the worst aspects of MMC and MTAS were thrown in at the last minute through this process. Initially, the whole purpose of MMC was to solve a particular problem of training of SHOs. Rather rapidly, towards the end of the whole process other issues started to come in, such as medical manpower and the use of the MTAS questionnaire which really was not discussed at all. I believe that the profession was brought along and at the last minute was somewhat hoodwinked. I believe that is a reasonable way to put it.

Mr Jameson Evans: I agree with that. I think that Unfinished Business looks pretty good on paper to anyone and it contains a lot of truisms. Sir Liam Donaldson makes three important points about flexibility and the fact we must have an excellent transition period. All of those crucial points were slightly brushed under the carpet and it was very much railroaded through. I believe the BMA objected to it, or certainly wanted a postponement of the process.

Q204 Chairman: Obviously, the Junior Doctors' Committee of the BMA seems to have been especially involved in the implementation decisions. Do you believe that they failed to represent the interests of the majority of young doctors, or is that too harsh?

Mr Jameson Evans: I think it is a difficult job to be involved at a high level. In some ways we had an easier job to identify it as a bad way forward at the point we entered. The BMA has been involved from the beginning. I agree with Professor O'Rahilly that the whole profession was hoodwinked and it changed very much along the way.

Q205 Chairman: Hoodwinked in what way?

Mr Jameson Evans: The core goals of Unfinished Business bear no relation to what happened this year.

Dr Marks: The time at which a lot of these things were in development was very different from now in terms of manpower requirements. At the time there was an expansion of SPR numbers and the idea that you could go from what was the SHO to the SPR grade seamlessly seemed like it could happen. Since then the numbers have all become tight and the system which would have worked if there had been a shortage, or the right number of doctors, does not work in the present climate.

Professor O'Rahilly: Neither of the two elements that the profession has emphasised, flexibility and careful piloting, has happened. Those were set by the professional members of the MMC as key elements.

Q206 Dr Naysmith: I should like to come in on the suggestion that the leaders of your profession were hoodwinked. You are talking about a number of the most powerful people in the land; some are members of the House of Lords; some have knighthoods and they are professors of this, that and the other. Some have multiple degrees. They could not have been hoodwinked. Who would have hoodwinked them? Do you not think it is more sensible to take the attitude that perhaps they should have played a much more rigorous role in the whole process as it was offered to them?

Mr Jameson Evans: There are two ways of looking at that. All the reports we got were that the Department of Health was not listening to the objections being made by key members of the profession. Whether you call that a failure by the profession to engage or blindness in the Department of Health to genuine concerns is an open debate.

Professor O'Rahilly: Professor Ian Gilmore, President of the Royal College of Physicians, produced a four or five-page paper documenting the college's objections to the evolution of MMC, all of which were completely ignored.

Q207 Chairman: Your organisations have responded to the events of this year. Do you go as far as to say that the leaders of the medical profession have lost touch with doctors to some extent, or again is that too harsh?

Mr Jameson Evans: I do not think that is too harsh at all. It was obvious, given our success as an organisation this year, that there was a failure of communication between the leaders of the profession. Certainly, there was a feeling that the whole of MMC had been conceived behind closed doors, and that is why we have succeeded. We have seen changes in the way the BMA and the colleges communicate with their members. There have been changes, but there was a failure at that stage.

Professor O'Rahilly: You are right that there was a fragmentation of doctors' responses. In Britain there is a fragmentation, given the number of royal colleges, almost to a Ruritanian level of complexity and too many individuals speak for the profession. If you take Canada which has a single college of physicians and surgeons with a powerful voice for all specialists the communication with government is far more effective. We suffer in this country from a multiplicity of bodies. There are some very good examples. The Academy of Medical Sciences has developed into one of the four learned academies and is a wonderful body that focuses on biomedical science, but in a way it took a lot of the more senior academics eyes off the ball in this important issue which is basic to doctors' training. Therefore, at a period of even further fragmentation with the biggest challenge to the quality of medicine in the country in 50 years as a profession we took our eye off the ball.

Q208 Chairman: Mr Jameson Evans, earlier you said that you had 15,000 doctors on your list. Would you call them members?

Mr Jameson Evans: We describe ourselves as a community. Essentially, we came into being through the Internet; it certainly could not have happened without that. We have a lot of communication with those 15,000 people. We certainly do not call them paid-up members. We raise money through various means including subscriptions but we are inclusive to all those 15,000 people.

Q209 Chairman: Do you think either of your organisations or both has a future role to play in all of this?

Mr Jameson Evans: One thing that has been levelled at us is that we are a single issue group, but if you look at our original manifesto workforce planning was at the top of it. There is a huge number of issues in which Remedy can be involved. We certainly agree with Sir John that this is the big issue for the future and it needs an urgent review and certainly the resources to be allocated. A massive amount of this country's money is being used to pay for doctors and their training and it needs to be done efficiently.

Professor O'Rahilly: The benefit of our group is that we are an unaffiliated loose gang, if you like, that can continue to act as a ginger group, but if you are talking about distinction a look through the list of individuals who signed the letters will show that they are among the most distinguished clinicians and clinical scientists in the country. From an international perspective they would be seen as Britain's leading doctors, far more so than many of the people who have formally taken on those leadership roles.

Q210 Chairman: Do you believe this ginger group has a long-term role to play?

Professor O'Rahilly: I sincerely hope not. A lot of the recommendations in Tooke seem very sensible. A lot of the things happening in the academic world with the NIHO seem very sensible. Some sensible solutions are on the table, and we are just as keen to get back to our patients, labs and students as everybody else. This has been a terrible waste of time. We could have been discovering new treatments for diseases.

Q211 Dr Taylor: I go back to the reforms of the SHO grade which you mentioned. The original principles were built on that. Mr Jameson Evans, in your written evidence you say that reform of the SHO grade was necessary but implemented badly. How do you react to Sir John Tooke's suggestions about reform?

Mr Jameson Evans: We broadly support Sir John. Obviously, quite a lot of work needs to go into various aspects of what he suggests and a good deal of that will be to do with people who do not get into training. I refer to core training and then a break between the old SHO and registrar grades to allow individual doctors flexibility so they can perhaps do some research, work in the developing world or do something like that. The rigidity of the current plan is an absolute disaster. For that reason, that would be a much more preferable solution.

Q212 Dr Taylor: You support the core training and say that it is roughly equivalent to the old SHO grade?

Mr Jameson Evans: I think it is roughly equivalent to a well structured, basic surgical training that you would have got. It was not across the board and would have been a goal to aspire to. What we had was a lot of disparate SHO jobs with a few structured rotations which in many ways were excellent. Sir John advises that that should be a standard, not just an exception.

Q213 Dr Taylor: The GPs were ahead of the hospital doctors in the rotations?

Mr Jameson Evans: Yes.

Professor O'Rahilly: I think the SHO situation was a problem but a limited one. The MMC is a bit like giving someone cholera to cure his dysentery. It was a very manageable problem. The problem was that there were unstructured elements in some parts of the profession and medicine was doing much better. Most of the SHO rotations in medicine were structured and educationally-based. There was a perception that thousands of people were applying for SHO jobs. Yes, there were. It was a bit difficult, but 400 or 500 of those would always have struggled to get appointments. It was the same 500 coming around time and again. There was some difficulty with the appointment systems but it could have been solved by an American-style matching programme which works perfectly well at residency stage in the US. It does not mean that we have to take on US-style healthcare, but their training and organisation of training is a model of efficiency when it comes to that stage in a person's career. That could have been solved easily by a matching style programme. Finally, the problem was really restricted to surgery where there were permanent surgical SHOs rotating around for ever and ever. If you have a fixed residency with a fixed exit point that cannot happen. The solutions to the SHO grade were therefore straightforward. The problem was used as a means to have a radical restructuring of the profession with all sorts of long-term views of what should happen in terms of sub-consultant grades, number of doctors and so on. This whole process which should have been used to fix a simple problem was used as a way to restructure the entire medical profession and it overreached itself.

Q214 Dr Taylor: I do not know whether you were here for the first session. We probed Sir John on the training and service parts of the jobs of junior hospital doctors. He said very clearly that primarily even a doctor in training was a doctor and therefore had a big service commitment as well as a training element. Do you agree with that?

Mr Jameson Evans: I do and I think it is nave to suggest otherwise. I come from a craft speciality, orthopaedic surgery. One of the problems we identify with the European working time directive is that you do not get that continuity of a mixture of service delivery and training because essentially you are punching in and out of shifts and do not see it. But training is intimately linked to service. One of our big concerns for the future is that we will not have that experiential learning. All the surveys we have done with 3,000 or 4,000 people suggest that we are not the only ones who feel that way because there is grave concern about the skill base of specialist doctors in future.

Dr Marks: Medicine is an apprenticeship and people learn by working with their boss, seeing how things happen and gradually taking on more and more responsibility. I think that has been damaged by MMC because it has increased the number of training posts. The problem that was always there in the past and one of the reasons that the SHO grade needed to be reformed was that in some jobs people did not get any training or supervision; they were left. A lot of them spent their time filling out forms and doing stuff where they were not supervised or looked after. That has not been addressed and has not changed very much. One of the fundamental things that this was supposed to do has not been addressed.

Q215 Dr Taylor: Going up to the more senior levels, Sir John makes it quite clear that staff grades should not really be dead-end jobs; people should be in training as well. Presumably, you would agree with that?

Mr Jameson Evans: That is one of the areas that needs to be clarified. Obviously, he cannot make any detailed analysis of exactly what that structure will involve. How easy will it be to implement that, and who is to provide the service if they are to be trained? The people not in training are also a crucial part of the delivery of service. The crucial element of what went wrong with run-through is that essentially the people who will be staff grade in the current system will come out with only two or three years' experience in training and that is just not a level at which training can be cut off. They have no specialist skills whatsoever and it is nave to think they will remain low-grade SHOs in their fifties, for instance.

Q216 Dr Taylor: I do not know whether it is fair to ask you about the BMA, but it supported the introduction of run-through training. Do you think that it was putting job security above flexibility?

Dr Marks: It perceived at the time that it would be getting security for its members. At the time this was introduced people would apply for an SHO job, do it for a year and then apply for another SHO job and then a registrar's job. There was a constant applying and reapplying. What it thought would happen is that there would then be job security and people would know where they would be for seven years and everything would be hunky-dory. What I do not believe it took into account was that for every one that got in some did not and they were locked out. It is almost like bringing back the 11-plus. They were locked out from an early stage. It has become very hard for those people to get in. Worse, they are selected to be in or not in before they have even had any chance in that particular specialty. Therefore, they would get in or not get in at a very junior level.

Q217 Chairman: Professor O'Rahilly, do you agree with that?

Professor O'Rahilly: I agree with most of what has been said. I am more sympathetic when I hear what my colleagues from Remedy say about the issue to which Sir John referred late in the session, that is, the idea of the sub-consultant or specialist grade going in at different levels - lecturer, senior lecturer, reader and professor - and the possibility that current staff grade doctors could apply and the more ambitious or able ones could even progress fully up that ladder. Therefore, the notion that all consultants are the same at the age of 30 and stay that way until 65 does seem a little strange. Personally, I have more sympathy. I am aware that certain members of the original Fidelio group are uncomfortable about the notion of a sub-consultant grade. I speak here in a personal capacity. I think it makes quite a lot of sense.

Q218 Dr Naysmith: Both of your organisations have said that introducing run-through and FTSTA posts would create a two-tier system, but last week the Chief Medical Officer told us that there would be plenty of opportunities for FTSTAs to apply for long-term posts in the future. Does that reassure you?

Dr Marks: That was not what he said. I believe he said that they would be trained so they would be eligible. The posts would not be there because the posts that would have been there have been filled by the people coming up from below.

Q219 Dr Naysmith: So, it does not reassure you?

Dr Marks: Not at all. I think it was inherent in the design of the system that the people who took FTSTA jobs would not progress unless they could get into dead men's shoes.

Q220 Dr Naysmith: Does that mean you think they will become a new lost tribe if this happened?

Mr Jameson Evans: Currently, FTSTA equals lost tribe.

Q221 Dr Naysmith: My next question will interest you, Professor O'Rahilly. One of MMC's principles was to improve career paths for academic medicine, which is something that both you and I want to see happen. To what extent do you think this has this been achieved?

Professor O'Rahilly: I think that if MMC is allowed go ahead it will be a fatal blow to the quality of academic medicine in this country. This country has led the world. It is second only to the United States in clinical academia and the quality of research that comes out of its medical schools. I sincerely believe that MMC means rigidity and an inability to take our brightest young doctors and put them into research posts, because there will be nobody to fill the gaps. The unbelievable rigidity that run-through has brought about will be a terminal event for the quality of academic medicine in the UK and will not be fixed at all by the wonderful NIHO and the integrated academic training path. There is a myth that in effect academic medicine has been solved by the ghetto-isation of a small number of posts and the little bit of new money that has been put aside and therefore it will keep all of us quiet to allow the rest of the things to go ahead. That is not the case. The number of academic posts required in this country that will be provided by new money is a tiny fraction of what we require.

Q222 Dr Naysmith: I worked in a medical school for 30 years, not as a medical doctor.
There is constant tension between medics employed as academic lecturers and lecturers also working for the National Health Service. This would have sorted out all of that. What happened was that the NHS said they did not get value for money from them and the academic side said that their people did not get enough time to do their academic medicine. Do you think that was a better system?

Professor O'Rahilly: I have worked in academic medicine in the UK since I came here over 25 years ago and I do not recognise what you are talking about. I have worked in pretty splendid institutions; I have been very fortunate to be able to work in Oxford, Cambridge and London. What I see in the UK is a very well functioning relationship and if there is a tension it is a creative and productive one and is essential. What we have here and does not happen so much in other countries are dedicated and world-leading academics who are actively involved in clinical care and bring that research into new treatments and patient benefit. Therefore, I do not recognise the scenario you describe.

Q223 Dr Naysmith: I did not have the opportunity to work in Oxford and Cambridge but I did work at Bristol, Edinburgh and Yale. Yale does not count for the purpose of this discussion, but there was always that tension there.

Professor O'Rahilly: Perhaps I am very fortunate in my experience.

Q224 Dr Naysmith: Do you have any observations on academic medicine?

Mr Jameson Evans: I go back to what I said before. There are formal degrees for which one can take some time out, but one of the things that run-through obliterates is the opportunity. Research opportunities are not always predictable and you react to something that you encounter in your clinical practice. There is an opportunity to take out six months or a year perhaps to do just a few good papers on something, as I did last year. It is a great part of the old system. That enhances the clinicians of the future. They do not have to become academics, but there is also value in research done by non-academics, and that is not really allowed for.

Q225 Dr Naysmith: The department has repeatedly tried and failed to exclude international medical graduates from applying for training posts. Do you think that is so, or do you believe that the recent judgment of the Court of Appeal was right?

Professor O'Rahilly: It is a very difficult issue. As an international medical graduate myself who came here 25 years ago I would have been in very much the same position as the other IMGs. Now I would be an EU graduate. I did put in about 50 job applications before I got one, so I have a great deal of sympathy for these talented people who come from abroad and who over many years have been the bulwark of the National Health Service and produced wonderful work. It is an extraordinarily painful scenario. We have now produced vast numbers of new medical graduates at 200,000 a pop. It is a judgment of Solomon.

Q226 Dr Naysmith: What do you believe should happen?

Professor O'Rahilly: My view in this case, which is based more on emotion than rationality, is that the court judgment should stand and they should be allowed to compete on an equal footing.

Mr Jameson Evans: The writing was on the wall as to what was going on with the joint goals of self-supply and an open-door policy. In your report of last December you said that the ratio of GMC registrations in 2004 was 70% IMGs and 30% UK graduates. It does not take a genius to work out what will happen at this point. To hold the IMGs responsible for that failure of government policy is completely unacceptable. We all work together and do not differentiate at a clinical level. I think it is insulting to everyone, not just IMGs, that government is prepared to say they can go home and it will not honour what was said to them when they arrived. If it had been made clear along the way - it was not - that it was a fixed-term contract and they would have to return at that point that would be completely appropriate. It is also very interesting to note that Fidelio, ourselves and pretty much everyone would agree there has to be an incredibly tight closed-door policy from now on. That is the consensus. We hope that the Government has got its act together on that.

Q227 Dr Naysmith: The alternative would be to reduce the number of UK medical training places, would it not?

Mr Jameson Evans: We would support that. The problem is that there is a 10-year lag on a ballooning medical workforce. That is why we need funds urgently to create a body that acts in a slightly more intelligent way than it has done in the past five or six years.

Q228 Dr Naysmith: People argue that the UK is under-doctored; per head of population there are fewer doctors here than in many other countries of the world.

Mr Jameson Evans: The BMA's 1999 figure was 1.7% versus 3.4% as the European average. We have now moved up to almost 2% which is still 60% of the average. The Government promised a consultant-delivered service and that is one of the goals that has now disappeared from the agenda. The expansion of medical students was part of that policy. The people who are now paying the price for that change in policy are my generation of doctors.

Q229 Dr Naysmith: The Chief Medical Officer told us that every effort would be made to help UK-trained doctors who could not find training posts in 2008. Is that a reassuring guarantee?

Mr Jameson Evans: No, not really.

Q230 Dr Naysmith: Are you happy with what was done to help the 1,200 misplaced doctors who did not get jobs in 2007?

Mr Jameson Evans: I am sorry; I do not know where that figure comes from.

Q231 Dr Naysmith: I apologise. It is a misprint in my briefing and should be 12,000.

Dr Marks: Over the next few months something will happen that will change that. For the first half of next year we will see a shortage of doctors.

Q232 Dr Naysmith: To make it clear, that is not a misprint; it is the Department of Health's figure. Therein lies something that needs to be explored!

Dr Marks: During the second half of the year we shall begin to move to a period when there is a shortage of doctors and hospitals will find that they cannot fill places. Because of the change to yearly recruitment at the beginning of the year, August, all the jobs were filled and the people who did not get jobs either left the country or went off and did something else. As the year runs from August 2007 to August 2008 people drop off the top because they have finished their training and have started out of step with one another so it is a gradual trickle rather than a deluge at the end and we have no way to recruit people back into those places.
Therefore, as the year progresses we will move from a period of doctors without jobs to a period of jobs without doctors. I anticipate that in July we shall be down by about 20%.

Q233 Dr Naysmith: We heard in the previous session that there was difficulty in getting locums.

Dr Marks: We have a terrible difficulty which will impact on patient care. In the programme for which I am responsible in February we shall be down by about 16%. You cannot get people from anywhere. Anyone who got a job last year will now be locked into an FTSTA which does not finish until August so, whereas under the old system there was a constant turnover of people at SHO grade, now there is no one available to apply for these jobs as they become vacant during the year.

Q234 Chairman: Clearly, potentially that has serious implications because locums are used for temporary vacancies on occasions because of illness or because doctors are on maternity leave or whatever. Is the national picture that the availability of locums is not like it has been in years gone by?

Dr Marks: I have three pieces of evidence for that, although I do not have any national figures. There was an article in the Eastbourne press in which one of the hospitals said publicly that it had a problem. I have heard that some locum agencies have closed down. At a meeting of our colleague I raised the issue and said we were about 10% down. There appeared to be agreement around the room that 10% was about the national figure.

Q235 Chairman: You said that potentially this could affect patient care. Is there any evidence of that?

Dr Marks: It has not happened yet but it will start between January and August.

Q236 Mr Syms: Do you agree with the overall findings of the Tooke inquiry? Do you believe that its initial report gave the Government an easy ride?

Mr Jameson Evans: We absolutely sanction Sir John's report. We suggest that although different areas of the profession have different points to make there is a consensus. I did not realise that Sir John had received 87% broad-based support. That reflects what we think and it should go through. The main issue we are concerned with is what happens to the FTSTA cohort and whether there is a decent and realistic provision for their future.

Dr Marks: I do not think that Sir John's report was soft on the Government; it was quite critical. It started off by saying that no one really knows what these reforms were for and there was a big loss of direction and now no one quite knows what it was all about.

Professor O'Rahilly: It is a remarkable piece of work carried out over a short period of time and it has achieved more than the mandarins over the years. I believe that it should be supported almost in its entirety. We desperately need something to take us forward and get us out of this mire. This presents most of the solutions. There will be some dissenting voices but very few, for example perhaps postgraduate deans. It will be widely supported by the profession.

Q237 Mr Syms: Many of the problems in 2007 were caused by poor project management, communication and leadership. Should not addressing these problems be a greater priority than making further structural changes?

Mr Jameson Evans: Accountability is one issue that I hope the Committee will look into. I do not believe that it is the job of Sir John Tooke and I do not believe that was the agenda of Professor Neil Douglas. To have at grass roots level what has been described by Professor Douglas as the biggest disaster in a generation of doctors with no significant impact on the architects and implementers sends out a poor signal to the people who went through this and look forward to years of trouble. I hope that some accountability is achieved by this Committee.

Dr Marks: Accountability is an issue but the underlying structure of modernising medical careers was seriously flawed. We need to go back to the drawing board and say that this was wrong from the start.

Professor O'Rahilly: I agree. I think the outcome is bad and it will not be changed by fiddling with project management. It is fundamentally flawed.

Q238 Mr Syms: If the Department of Health accepts all or most of the recommendations it will be responsible for implementing the Tooke proposals. How much confidence do you have that the department can do it successfully?

Mr Jameson Evans: It is difficult to quantify it. Our experience is that intermittently the Department of Health has been helpful in communication, but by and large the manner in which MMC was conducted was very much top down and it did not listen to anyone. If it adopts the same approach we are lost. I see no evidence that it has changed its approach, so I am very concerned about it.

Dr Marks: Success or failure depends a little on whether or not what it tries to bring in works at local level. The problem with MMC and its structure was that the programme directors, deaneries and people who had to implement it could not devise a way to make it work. I do not believe the situation will be comparable. If people at grass roots level are presented with something that can be made to work the outlook is quite good.

Professor O'Rahilly: To date, there has been a rather lethal brew of high-handedness and incompetence and one hopes that will be fixed. I fear there is a fundamental distaste for the medical profession in the centre of the Department of Health. The business of cronyism, patronage, anti-elitism and portraying the profession as thousands of Sir Launcelot Spratts is a complete travesty of what the UK medical profession is about. The profession is a remarkable group of people dedicated to patient care and in the main to working within the structures of the National Health Service. There needs to be a restoration of trust that the medical profession is not a self-serving group of individuals who always put themselves and not patients first. That restoration of trust is essential before any working relationship can be restored.

Q239 Mr Syms: Given the events of 2007, are you surprised that nobody from the Department of Health either resigned or was disciplined as a result of this process?

Mr Jameson Evans: Yes. There have been three votes of no confidence in Sir Liam Donaldson by the BMA. As a group we have tended to avoid calling for people's heads, but we would have loved to see the assumption of responsibility at the highest levels. Sir Liam Donaldson did not apologise for initiating such a disastrous process until pretty much the summer following quite a lot of pressure from Channel 4 News. There does not seem to be any recognition that this process was not inevitable but was pushed forward and individuals were responsible for it.

Dr Marks: If it had been successful those people responsible for it would be queuing up for merit awards and knighthoods. Because it has been a failure the converse should apply. This has been a very damaging thing for the whole of medicine and medical education. People should be seen to be responsible so that the message gets out that in future you cannot do something like this and expect to get away with it.

Professor O'Rahilly: Fidelio is a gentle academic group and tends not to become involved in blood lust, but I am afraid that the points made by Remedy are cogent and hard to ignore.

Q240 Chairman: You are both very critical of the short-listing process. We have received data from the department which shows that the initial short-listing was a good predictor of how successful candidates would do. Do you accept that the short-listing was not as consistently flawed as you first thought?

Dr Marks: Let me tell you my personal experiences as a short-lister. A box of cvs arrived on my desk on Friday and I had to have them looked at and done by the following Monday. I had a weekend to do it. As it happened, it was half-term. There were 650 cvs to go through. Many of the answers were virtually indistinguishable. It was impossible. When I got about half-way through I realised that I had not been consistent and started to do them again. The answers were so difficult to assess that I had absolutely no confidence that I was giving people the right answer and I did not have time to do the job properly. There was a meeting of those of us responsible London who had been short-listing and a whole bunch of forms had not been scored. We divided the pile between six or eight of us and went through them. We could not agree on the scoring we should give to some of the questions, so I had no faith at all that we were doing our job properly.

Q241 Chairman: Unfortunately, I do not have the data in front of me; otherwise, I would quote it. You say that the data are incorrect?

Dr Marks: What the data did was pick out the very good and the very poor, but there is a big grey area in the middle which is not identified. At the judicial review we presented evidence, which we do not have here, from a statistician. He pooh-poohed the data. The correlation was very weak.

Professor O'Rahilly: It is absolute nonsense. If you take 100 cvs and throw them down the stairs on Monday and then throw them down the stairs on Tuesday there will not be randomness; there will be some association. You might then say that to throw them down the stairs provides a positive correlation, albeit a very weak one. We are told that the data are no better than that. I am not reassured at all that there was any validity in the short-listing procedures.

Q242 Chairman: Do you accept that the use of the "white box" questions was suitable for less experienced candidates for STI posts? Was it not the decision to apply the same selection methods to more experienced doctors that was the real mistake?

Dr Marks: I was involved in ST3 selection. We have had white space boxes for many years and they have worked quite well. The difference this time was that you had the white space boxes in isolation and so you did not have the rest of the candidate's cv to look at. To give an example, one of the questions was, "How have you coped with a stressful situation?" The first thing you need to know is whether that is a stressful situation for someone with that level of experience. Something that a junior would find stressful could be coped with by someone who was a little more senior. One did not have that so one was marking them completely in isolation from the rest of the cv.

Mr Jameson Evans: From a trainee's perspective I was horrified about the white space questions. The fact that there is a rash of courses where you pay 300 to bone up on the relevant buzz words which get you points is a complete travesty of what selection should be for professionals. Whether it is ST1 or ST3, the white space questions are very questionable. The other issue is that with ST1 selection essentially you are trying to select people for run-through training at a very early stage in their careers. You do not have any experience of the value of white box questions. Therefore, it is probably the wrong time to select them for the rest of their career.

Professor O'Rahilly: Sometimes it is important to put a human face on these things. At 8.30 this morning I spoke to a doctor from Scotland. He graduated from the University of Edinburgh, one of the finest in the country. He came second place with honours in all subjects throughout medical school and then applied for a senior house officer job rotation in the south of Scotland, and out of 600 applicants he came second. He passed all his exams and was given extremely good reports by all his clinical supervisors for his quality of patient care, communication skills and so on. He had a lifelong desire to become a cardiologist and decided to take some scientific training in cardiovascular medicine. He took a PhD and got a competitive fellowship from the British Heart Foundation. This chap is not a nerd; he is an international athlete. He represents his country in a major sport, so he is a remarkably rounded person. This person went through the white box procedure and got short-listed for one set of interviews. At that interview there was no cv and no reference made to his academic achievements. He was unsuccessful in obtaining a cardiology training post. All good people occasionally are unlucky, but this is his last chance. He will never be able to do cardiology again. He was bitter and his voice was shaking. I do not say that he is a destroyed man, but he is in serious distress having given all his life to this. He has superb intellectual and academic credentials. That is what results from the system. I attended a wedding last year where I sat beside a man who said he thought that MTAS was great. His son and mate had failed their finals twice. They were layabouts to some extent but they had paid for a course and learned to fill in all the boxes and both got jobs of their choice. I know these are anecdotal examples but sometimes committees like yours need to feel the pain of real individuals who are affected by this when a system goes so badly wrong that it ruins lives and results in inappropriate choices.

Q243 Chairman: There are courses for filling in cvs - quite a lot of them are paid for by the Government - for would-be job applicants, as it were. You tempt me on that basis. Do you believe that people with first-class degrees make better doctors?

Professor O'Rahilly: Yes, I do. I think it is a nonsense to say there is no correlation between academic activity and quality. To get a first-class degree you have to work hard, be committed and know what you want to do. The idea that on the one hand you are Dr Finlay and on the other Dr Mengele is a complete nonsense. In my experience, by far the best people I have trained - the ones who communicate best with patients and the most compassionate - are those who are also fired up by a desire to understand the disease. They work hard to understand it so that treatments can be better in future. It is a very common misconception throughout much of this debate - and it is a pernicious suggestion - that what we need are nice warm, woolly caring doctors who do not need to be clever or able. Medicine is difficult; it is about handling complexity and making difficult, life-changing decisions at three in the morning on the basis of complex information. That needs a high IQ and smart people to do medicine. If we get dumb people doing medicine we are all in trouble, and I do not look forward to my own future healthcare.

Q244 Chairman: I am a lay member of the General Medical Council. Based on my experience, I would probably take you up on one or two issues. Dr Marks, do you have anything to add on the relationship between first-class degrees and good doctors?

Dr Marks: When you assess someone's suitability for a job and try to pick out how people will do in their future careers the only thing you have to go on is their track record. By and large, one can pretty well predict the people who have done well at medical school and in the jobs they have done up until the one for which they are applying.

Q245 Dr Naysmith: Getting into medical school in this country is the second most difficult academic course to follow, so there are very few dumb people getting degrees in medicine. Even though they may have had some trouble in their finals they can still turn into excellent doctors. What is it that makes doctors so special that there is such a fuss about not being able to get the job of their dreams when they qualify? In every other sphere in this country there are clever people who graduate, go for interviews for jobs and do not get them.

Professor O'Rahilly: That is the second myth that is constantly discussed, namely that all doctors are smug, fat and happy and believe they can get exactly the jobs they want for the rest of their lives.

Q246 Dr Naysmith: That is not my question. I am asking: what is all this fuss is about.

Professor O'Rahilly: You asked two questions. First, what is special about medicine compared with the other healthcare professions?

Q247 Dr Naysmith: Not just other healthcare professions but the other sciences and so on?

Professor O'Rahilly: They are all very important professions. The handling of complexity and making important decisions on the basis of complex inputs is the characteristic of most high-level professions such as law, medicine and science. We value medicine because it is close to our survival. The doctors we have to deal with make decisions or help us make decisions which are concerned with our very existence, so of course we consider medicine to be important; it is very close to who we are.

Q248 Dr Naysmith: Does the fact that one doctor is married to another doctor mean that they need to get jobs close together? That was argued by somebody who gave evidence to us just two or three weeks ago from the chair in which you are now sitting. It was suggested that one of the faults of the system was that it did not allow the matching of spouses for jobs.

Professor O'Rahilly: No one ever expects to get the first or even the second job that he applies for. What one expects is to be able to enter into a competitive system that looks at one's abilities and provides multiple opportunities over a period of time.

Q249 Dr Naysmith: It should be fair.

Professor O'Rahilly: If after a couple of years one does not get a job in cardiology or neurology somewhat reluctantly and perhaps in a slightly disgruntled way one chooses a less competitive discipline about which one makes a positive choice. We face a future with MMC where there are multiple individuals forced prematurely into disciplines not of their choosing. I would not wish to be a patient of theirs in 10 to 15 years' time when they are bitter, twisted and disgruntled.

Q250 Dr Naysmith: That is an absolutely ridiculous statement.

Professor O'Rahilly: It is not. Why?

Q251 Dr Naysmith: Because thousands of pounds have been spent on these people and they have been trained in every specialty under the sun at a basic level. You say that because they cannot be cardiologists they will not be good at something else.

Professor O'Rahilly: I spoke to a doctor this morning who was one of the best graduates. He said that so far what he had been offered was psychiatry or obstetrics and gynaecology. Neither of those was on his radar.

Q252 Dr Naysmith: But general medicine and all sorts of things are open to him.

Professor O'Rahilly: There are no general medical posts open to him. These are the two options he has at the moment. Under the old system there were lots of ways. There is a myth that there was a golden era when we all got exactly the jobs we wanted.

Q253 Dr Naysmith: You are putting out that myth, not me.

Professor O'Rahilly: But the golden era was not golden; it was a perfectly rational competitive era in which people did not get all the jobs they wanted but it evolved over time in a way that allowed them to look at a broader range of choices from which to select. It is a bit like saying that every lawyer who comes out of law school is made to do either conveyancing in Coventry or matrimony in Manchester and is geographically and specialty-placed by central government diktat.

Q254 Dr Naysmith: It is not central government diktat; it is choice, is it not? Nothing forces you to become a doctor.

Dr Marks: One of the good things about the old system and very bad about the new one is that people had a Darwinian chance to find their level. If you decided that you wanted to be a cardiologist in London and you had applied for it three or four times and did not get anywhere you could reassess the situation and change what you wanted to go for. One aspect that people find hard about the process is that it has all happened in one go. People have not had a second chance or been able to match what they want with what they will get realistically; and they also perceive that the selection itself is unfair.

Mr Jameson Evans: There are data to show that only 25% of doctors really know what they want to do definitively at the stage when they have to make irrevocable decisions. I do not know how they will end up in 10 or 15 years, but I do not think it is the best way of selecting the right doctors for the job. That will probably impact on the patient population in some way.

Q255 Dr Taylor: Because of the problems of selection lots of people called for the whole thing to be abandoned early on, particularly Fidelio. Looking back, do you still think that would have been the preferable thing to do?

Professor O'Rahilly: If we had all had the courage of the surgeons in Wolverhampton we would have stopped it in its tracks and that would have been a good thing to do. The notion that it could not have been reversed and things fixed was given the lie by the fact that between June and August medical staffing officers of the trusts managed within three weeks to find 45% of those jobs. It required incredible work but they managed to do it. It was all fixable and at the time we felt strongly that it should have been stopped. Looking back, I see absolutely no reason to change that judgment.

Q256 Dr Taylor: Earlier today you said that the whole of MMC should be abandoned. Have you said that in the light of the fact that the Tooke report is addressing all your concerns?

Professor O'Rahilly: The Tooke report substantially addresses the concerns in that it breaks the inflexibility and run-through element. It provides a period of time of core training with multiple experiences after which there is an opportunity for individuals to reassess it and decide on what course to apply for at specialist level. I think Tooke is a very sensible document and addresses the vast majority of questions.

Q257 Dr Taylor: It means the same thing as abandoning the original scheme?

Professor O'Rahilly: Effectively, it means the abandonment of MMC.

Q258 Dr Taylor: The department has told us that those who wanted the process to be abandoned were noisier but less numerous than those who wanted it to continue. How do you think it made that assessment?

Dr Marks: There were four people who wanted it to continue.

Professor O'Rahilly: And they double-counted them!

Dr Taylor: I had literally hundreds of letters not one of which asked for it to be continued. There was one brilliant condemnation which I must read: "MTAS means that whether a doctor is competent or dangerous, hard-working or lazy, experienced or green, a team-playing communicator or arrogant sociopath, has no relevance to whether they get the next job or not." I think that sums it up very well.

Q259 Mr Syms: Remedy brought legal action to challenge the changes to the recruitment system introduced by the Douglas review. Were you surprised that your legal challenge was not upheld, or was your main aim to raise awareness of the problems with MTAS?

Dr Marks: The answer to the first question is that we were advised by our barristers beforehand that judicial review was a very blunt and unpredictable instrument. I do not think we were disappointed, although we were upset. Did we do it because we wanted it to happen or because we just thought it would create publicity? We wanted it to happen because we felt that the process was so unfair that the stakes should not be as high as they were going to be. We believed that this year particularly the stakes of getting a job or not getting a job were much higher than they had ever been. Therefore, this year more than ever it should be fair, not unfair, and that it could be delayed for a year.

Q260 Mr Syms: Your legal challenge was opposed in court by the BMA. Did you regard the BMA's stance as a betrayal of junior doctors?

Dr Marks: The BMA has for many years opposed pressure groups. Did we regard it as a betrayal of junior doctors?

Mr Jameson Evans: We were very surprised. We did not expect it. The BMA had its own reasons, which we have since discussed. Essentially, we listed it as an interested party in the case. I believe that it regarded it as some kind of attack by us, which is certainly never was. The BMA was involved in the process and we felt that it should be involved also in the judicial review, but certainly not on the other side of the fence.

Q261 Mr Syms: Officials told us last week that the judicial review upheld the approach and recommendations of the Douglas review group. Is that correct? Did not the judge uphold the review's right to take its decisions but not the decisions themselves?

Dr Marks: Yes. The judge said that its decision may or may not have been the right one but it was one which it was entitled to reach.

Chairman: I thank all three of you for taking part in our second evidence session. I believe you were in the room earlier. We certainly shall not be making our report this side of Christmas.