House of COMMONS
MINUTES OF EVIDENCE
Thursday 13 December 2007
PROFESSOR ALAN CROCKARD and PROFESSOR SHELLEY HEARD
USE OF THE TRANSCRIPT
Taken before the Health Committee
on Thursday 13 December 2007
Mr Kevin Barron, in the Chair
Dr Doug Naysmith
Mr Lee Scott
Dr Howard Stoate
Dr Richard Taylor
Witnesses: Professor Alan Crockard, Former National Director, MMC (England), and Professor Shelley Heard, Former National Clinical Advisor to MMC, gave evidence.
Q262 Chairman: Good morning. Could I welcome you to what is our third evidence session of our inquiry into Modernising Medical Careers? I wonder if I could ask you, for the sake of the record, if you could just introduce yourselves and the position that you currently hold; Professor Heard?
Professor Heard: Good morning, thank you for giving me the opportunity to meet with the Committee. I am Professor Shelley Heard, I am a medical microbiologist by training, and despite my accent, I trained in the UK, at St Bartholomew's Hospital, and have been living and working here for the last 40 years. Just to say, I have a wide NHS experience as a consultant, but also as a chief executive in an Acute Trust in east London, as a non-executive director on an SHA, and as a Postgraduate Dean, from which I was seconded to the MMC team. I was the National Clinical Advisor to Modernising Medical Careers.
Q263 Chairman: Fine, thank you.
Professor Crockard: Hello, I am Alan Crockard. By training, I am a neurosurgeon. I was a neurosurgeon at the National Hospital for Neurology and Neurosurgery. I trained originally in Belfast, in the middle of the hot times. I have had a lifelong interest in training, and about the middle 1990s, I was recruited to the Royal College of Surgeons as the Director of Surgical Education, and I co-ordinated the development of the surgical curriculum for all surgeons. It was from there in mid 2003 that I became the Curriculum Advisor and then the National Director of MMC.
Q264 Chairman: Right. I am going to start the session by asking you just some general questions about the current situation and recent past. The Tooke Report shows that there was a very complex governance structure for MMC and MTAS as well. What were your roles, and to whom were you accountable within your roles? Shelley, would you like to start?
Professor Heard: I was obviously directly accountable to Alan as the National Director. My understanding about the accountability of the MMC team was through the Programme Board and the SRO for Modernising Medical Careers in the Department.
Q265 Chairman: Alan?
Professor Crockard: I was recruited at the early stages of MMC to help shape the thinking into what Modernising Medical Careers might be. I then also saw myself as a facilitator to get round all the Colleges, the groups who were involved, and made it my business to make sure that they knew what was going on. Finally, as big headings, I and my team were the implementers of Foundation, and we looked after every bit of that, and we think it was reasonably successful.
Q266 Chairman: You both chose to resign at the end of March/beginning of April, if my memory serves me well. Why did you resign and why at that particular moment?
Professor Crockard: I think the final stage was total frustration, feeling that our views as medical people, and as people with an interest and background in education, was being neglected. I felt that the whole principles of MMC, which I thought were very important, were being subsumed into an attempt to get the workforce running. We saw the situation unfold from fairly well back; I had tried very hard to make this known to the SRO to whom I was accountable in terms of MMC, and to the DCMO. At the latter stages in December, from October to December, I had actually spoken to the regulator, to people from the Treasury, to the advisors to Ministers and to the NAO about my concerns.
Q267 Chairman: Shelley?
Professor Heard: I resigned, I think, for a very specific reason, and that was in relation to the direction of travel of the review group. I really was very distressed at what was happening to young doctors and applicants. I thought that given the high stakes of this, the decisions of the review group, and in particular the proposal to consider appointing only into one-year training appointments for this year, to give everyone the very necessary breathing space in this high stakes arrangement, should have been considered and indeed adopted. I would not like to say it was not considered; I raised the issue, it was considered, and it was rejected, and I felt that in the face of that, it was unsustainable to say. I thought it was the wrong decision to take.
Q268 Chairman: Are you surprised that you are the only people who did resign and that other senior officials did not, over this issue?
Professor Heard: I thought it was unjust that Modernising Medical Careers and the implementing team, which did not have direct accountability or responsibility for a recruitment system which, for a variety of reasons, had not worked, was extremely unfortunate. I am not saying anybody else should have resigned, I think it is unfortunate that we did not find a way of managing it once we were in that situation more effectively.
Q269 Chairman: Do you agree with that, Alan?
Professor Crockard: Yes, I do. I point out that we were, at that stage, the only two surviving medical people on Modernising Medical Careers. There were some medical people in the Foundation programme, but those involved in speciality. I think that was because we could see, shall we say, both sides, and we had great difficulty in getting our escalation route to see that there was another side to what was a very difficult and increasingly desperate situation.
Q270 Chairman: Could I go on to the Tooke Review? That concluded that "... the precise policy objectives of MMC do not appear to have been definitively stated at any point nor agreed by key stakeholders", that is a quote from the Tooke Review. Do you think this is a fair criticism? What did you understand the policy objectives of MMC to be?
Professor Heard: I thought I was quite clear in all the time I was working on the programme what they were. The first was to ensure and develop a system whereby we could develop more trained doctors delivering more frontline care for patients, because at the root of this was an improvement in care for patients. We should not be in the position, which I am sure this Committee is aware of, where young doctors have poor supervision and make very inappropriate decisions leading to significant difficulties for patients. This programme was aimed to address that issue. It was also aimed to be very, very clear for the public, as well as for doctors, and for those training them, about what the standards of training should be; and just as important, what the assessment criteria should be, in order to make sure those standards had been met. I have to say, I think that is clear from the 2003 MMC policy statement.
Q271 Chairman: Do you agree with that, Alan?
Professor Crockard: Yes, indeed. I think what MMC was about, and what the Tooke Report said was that MMC was an honest attempt to accelerate training, and I think what we were trying to do with that was not accelerate the training by making it faster, but by making the training more appropriate to the task that was there. This was the first time, I think, in British medicine that we were putting the standards first, and they were explicit standards. Up to now, it was implicit, "Good chap; my best SHO", et cetera. This was explicit, and we felt that that was the way that it should go. It was the way that it had gone in Canada, it has now been adopted in Australia and New Zealand, so that was the thinking at the time, and that is why we went that way.
Q272 Chairman: Most people in the initial stages thought that MMC was the right way to travel, I think, most organisations involved in this debate.
Professor Crockard: Yes.
Q273 Chairman: The real issue, of course, is when it comes to implementing, there is a level of confusion about what the MMC's objectives were, and as a consequence of that, the policy goals -- were they not agreed coming out of MMC, what it was about, or were they just badly communicated? Because the events before this year do not look very good, in terms of actually driving the policy through, from something that seemed to be acceptable a number of years ago. What happened?
Professor Heard: I think the reason why it was accepted, and this was certainly the very early advice that we gave to the Department, was that this process depended on managing international medical graduates into training. Not managing them out, but managing them in. If you look at the figures produced, I am sure you have, by the Douglas Review and available quite widely in other fora, there were sufficient training programmes available for UK and indeed EU graduates, with capacity for international medical graduates to be managed in as and when on a work permit basis. So this was not around excluding international medical graduates, it was understanding the arrangements under which they could come into training, and I think the long-term intention was that steady state would be achieved, so that we actually matched our medical school graduates into the workforce that we required.
Q274 Chairman: Do you agree with that?
Professor Crockard: Absolutely. If you like, that which had been designed was designed for one size of workforce. We raised concerns right back from February 2006 about what to do with regard to international medical graduates. We were assured that that was all being taken care of; well, unfortunately, as it turned out, it was not taken care of, so the shape and the size of the training programme was not appropriate to in fact the number that applied.
Q275 Chairman: Do you think the failure to set and communicate clear policy goals for MMC was the responsibility of Ministers overall?
Professor Crockard: It is easy, is it not, when you do not have to do it. But it is a very complex situation. However, if we take something like the international medical graduates, it was clear that there were discussions between the Treasury, the Home Office and the Department of Health, but the results of those discussions were never communicated to us, we had no idea. I was so concerned myself that we organised a meeting with senior people in the Treasury to put to them, I think this was in the summer of 2006, the importance of coming to a decision to actually guide us, so that something could be done. So we were aware of the problem. We were aware that there were discussions, but we were given no clear guidance.
Q276 Chairman: That has not quite answered the question. There was not direction there; who was responsible for the lack of direction? You did not have clear policy objectives, else we would not have ended up in this situation.
Professor Heard: I think the policy objectives were clear but were not synchronous, so the policy direction around international medical graduates and around supporting graduates from UK medical schools was clear and set in the late 1990s, when the increase in medical students was organised. It was organised against a background of trying to reduce, I think the phrase was, our reliance on overseas doctors for delivering healthcare services. So that policy was quite clear, and it was clearly implemented, because we had an increase of something like 3,000, a 74% rise in the number of medical graduates coming through, so we knew that policy. The second policy, which turns out not to be synchronous with that, is the MMC policy statement of 2003. Although I do believe it was predicated on managing the international medical graduates, it was never explicit, although the stopping of permit-free training in March 2006 clearly signalled that the intention and the direction of travel was there. If those two policies had actually been convergent, I do not think we would have been in the situation that we are now.
Q277 Mr Naysmith: Professor Crockard, just a supplementary in this section, before we move on to something else. I think about ten minutes ago, you talked about having discussed this with a long list of people ending up with the National Audit Office, and you seemed to give the impression that you could not get through; is that right, no one would engage properly with you about this matter, is that true? Is that what you meant to imply?
Professor Crockard: I was stating that I was very concerned, that my own escalation route was not taking our concern seriously. I realised in terms of the IMGs, and the fact that it was across three departments, that it was difficult, and on that, I wondered, as I had done on other things, that if I could put in something, it might tip the balance so they could consider it.
Q278 Mr Naysmith: But nothing happened?
Professor Crockard: Nothing happened.
Q279 Mr Naysmith: Did that include any senior medical people in the Colleges or anything like that, or was this just the Department?
Professor Crockard: The discussions that I was having were, shall we say, in-house, in the Department of Health and the other organisations; I was obviously having discussions on a very regular basis with the Colleges, but this was something I felt that in-house had to know about. The Colleges had very different approaches and very different ideas on how many international medical graduates they required. For some of them, the workforce was very dependent on a large number of others --
Mr Naysmith: We will probably come to that later.
Chairman: Thank you. We will only look at particular aspects of it now, starting with Richard.
Q280 Dr Taylor: Thank you, good morning. Just before going on to the specific aspects, can I pick up on something you also said, Professor Crockard? You said that when you two resigned, you were the only two surviving medical people involved. One of the huge criticisms we have had is the lack of medical leadership, so when you two went, were there no other medical leaders left in it?
Professor Crockard: There were civil servants who were medically qualified --
Q281 Dr Taylor: No really independent medical personnel?
Professor Crockard: There were no medical people in the speciality team when we left.
Q282 Dr Taylor: Thank you. Moving on to run-through training, it seems to us to have been a sort of policy drift rather than a formal decision. What we want to know is: how was the decision made, and when was it made, to go on to run-through training?
Professor Crockard: It depends what you mean. In fact, if you go and look, and I am sure you have looked at Unfinished Business carefully, recommendation 17 actually says something to the effect that they would look forward to seamless training and run-through speciality by speciality, so that was already in Unfinished Business. That had already gone before I was part of the situation, it had gone to consultation, and I believe what had happened then was the follow-up to Unfinished Business, which was the report of the four Chief Medical Officers, and in that, they were more specific about run-through. But exactly how run-through was going to work is not something that was mentioned in either of those.
Q283 Dr Taylor: Can I just pick you up? My understanding was Unfinished Business did have a division between the basic specialist training and the higher specialist training.
Professor Crockard: Yes.
Q284 Dr Taylor: That did allow a change at that point, so it was more flexible.
Professor Crockard: More flexible, yes, but in fact, I think the very careful wording of Unfinished Business was very important, where they said "speciality by speciality". There are some things, for instance, as Professor Tooke said when he was before you, divisions -- sort of basic and then going to more particular was not appropriate to histopathology. It is my view too, and when I was part of the Royal College of Surgeons, urological surgery was that sort of thing, where there did not seem to be that much that was general and then specific.
Q285 Dr Taylor: You mean you could specialise much earlier in those sort of limited specialities?
Professor Crockard: Absolutely. In the same way, I think as Sir John Tooke has said, it is very difficult for one size to fit all; it is still very difficult, there are 57 different specialities, it may be very difficult to have one training programme to cover all 57 forms of training.
Q286 Dr Taylor: So really, what you are saying was it was not a good idea to have run-through training fixed in every speciality?
Professor Crockard: I think in retrospect, we should have looked at it very much more carefully, but we took considerable advice from those who were in the American training programmes and the Canadian training programmes, and it seemed there that one could design a run-through training programme for the specialities.
Q287 Dr Taylor: Did you say the actual decision was taken by just four Chief Medical Officers?
Professor Crockard: It was following the period of consultation, which is the --
Q288 Dr Taylor: Was there much consultation on finalising it as run-through training?
Professor Heard: May I? I have just pulled off the consultation document this morning actually. There were 254 responses in England from a range of -- many of them organisational and key organisations.
Q289 Dr Taylor: So this is The Next Steps?
Professor Heard: No, this was the response to Unfinished Business. I think there is a story between how we move from Unfinished Business core programmes, time capped core programmes, to run-through training or seamless training. A suggestion in recommendations 17 and 18 in Unfinished Business, and then a year later, in February 2003, following on from this consultation, which raised concerns around a range of issues, but certainly around time capping and how that could possibly work, the policy statement that emerged from Unfinished Business, and that is where the scene was set for run-through training. Indeed, if you look at Modernising Medical Careers: The Next Steps, this is the only evidence I have been able to find by way of a sequence, which says: "'In response to the consultation on Unfinished Business ... we will support and encourage the [PMETB] working with the Royal Colleges to develop competency-based training and assessment and to review the length of training programmes. This will be done on a speciality by speciality basis ... It will aim to provide seamless ... training programmes leading to a CCT'", that is a quote. The Next Steps goes on to say: "This signalled that thinking had moved beyond the basic specialist programmes foreseen in Unfinished Business and reflected the growing view that a single run-through approach was not only desirable but also achievable".
Q290 Dr Taylor: So that is where it came. So The Next Steps took the consultation on Unfinished Business as adequate?
Professor Heard: I think The Next Steps looked to the policy statement, which was Modernising Medical Careers 2003, the response of the four CMOs, which was the policy statement. The Next Steps developed that very high level statement, only six pages, nothing operational, very strategic, which set the direction for run-through training, and added this paragraph, if you like, as an explanation of how you move from Unfinished Business to run-through training programmes.
Q291 Dr Taylor: But in retrospect, you are really implying that it should have been more flexible, and there should have been differences between the different specialities?
Professor Heard: I would suggest that there were, and if you looked at the proposals that met the criteria for run-through training, if you look just at medicine alone, there were 28 options out of medicine. Two years very general, and then there were 28 options, some where an allocation would be made, and almost certainly that would have had to be competitive within the cohort chosen to get into run-through training.
Q292 Dr Taylor: I am sorry, at what stage? So you had done general medicine for what, two years?
Professor Heard: Yes, two years of general medical training.
Q293 Dr Taylor: Then after that you would have gone into gastro or cardiology or whatever?
Professor Heard: Exactly, so you were going to do a very general medical programme, and in some but not all arrangements of the surgery, that too was true, you would do a couple of years of core surgical training before settling on one of the -- I think it was seven and not nine, because there were special arrangements made. Whereas in anaesthetics, paediatrics, O&G, where already there was a long-standing tradition, as I am sure you know, of SHO basic rotations specifically in those specialities into which you then competed to get into speciality training, but it was not all that common. I mean, there were variations, because you might move into general practice through those, but most people probably moved from their SHO paediatric rotation into paediatrics or psychiatry or whatever have you. So I think there probably is much more flexibility in what was being proposed for run-through training for most specialities than has been assumed, particularly for medicine.
Q294 Dr Taylor: Anything to add?
Professor Crockard: No, I was just going to say -- well, having said no, the answer is: for the surgeons, it was clear that some branches of surgery felt less of a need for doing basic surgical skills, like urology, like neurosurgery. The view of ENT was the same sort of thing. So a long debate had already occurred, and in the models that we were proposing, as Shelley has pointed out, although it sounded draconian and rigid, we had already negotiated with many of these people to do those sort of things.
Q295 Dr Taylor: So it really was more flexible than we have been led to believe?
Professor Crockard: Far more flexible initially, yes.
Q296 Dr Taylor: Initially? Thank you.
Professor Crockard: The problem then became once the recruitment into those things came along.
Q297 Dr Taylor: So you are coming back to the disasters right at the beginning with MTAS?
Professor Crockard: Yes.
Q298 Mr Naysmith: Professor Crockard, Professor Tooke's review recommended an end to run-through training, but the Secretary of State and the Chief Medical Officer just recently have defended the concept, and said they are going to stick to it. Do you expect run-through training to be abolished?
Professor Crockard: I am not sure what I expect any more. If you ask me, is it appropriate in certain specialities, I still say it is. We have a situation in this country where it takes 12 years to train a cardiac surgeon, and the disease process was changed by catheters and tablets in five years. Now are you going to tell me that we are going to treat them the same way as I was treated as a boy? Inappropriate. What we have to have is some way of looking at training programmes that are appropriate to training in this century now.
Q299 Mr Naysmith: What you are saying is there must be different training programmes for different specialities.
Professor Crockard: Absolutely.
Q300 Mr Naysmith: Even though there is a basis that they all branch out from.
Professor Crockard: Absolutely. My only thing about the Tooke Report or his comments are I am concerned that he is taking away one run-through system by suggesting it goes back to something that has to have three years of this and two years of that. It may or may not be needed.
Q301 Mr Naysmith: Professor Heard, what do you think?
Professor Heard: I think what Alan says has been borne out. There was a document released last night by the Department around arrangements for 2008 recruitment, and in that document, they have produced a small table which says, "Those specialities which are uncoupled", in other words there is going to be a period of a few years and then people will compete for the next stage, and a group of specialities in which run-through training will be maintained. I cannot off the top of my head tell you how the list reads, but, for example, I think the paediatricians are still going for run-through training. I think the obstetricians are still going for run-through training. As far as I know, the general practitioners are. Those are huge -- particularly when you add in general practice, where we would anticipate half our graduates going into general practice. We are looking at the majority, if you like, of medical graduates being accommodated into run-through training programmes.
Q302 Mr Naysmith: So you are in favour of that?
Professor Heard: I absolutely am. Not only am I, but I do think people who have made their career decisions early -- and indeed those specialities which are clear about offering run-through training will have, I think, a competitive edge in getting good applicants, because if you can sort yourself out basically for the rest of your career with an outcome, why would you not?
Q303 Mr Naysmith: Can we look at another aspect of Professor Tooke's recommendations? He has recommended that the two-year Foundation programme be scrapped. Some people think this is the only element of MMC that has really shown some promise, and has been successful. If I could just read you something from my own Deanery, the Severn Deanery, and as you know, that covers Swindon, Gloucester, Cheltenham, Bristol, Weston-super-Mare, Bath, Taunton and Yeovil, and they really think the Foundation programme is superb. They say, "Foundation training is a success story for the NHS throughout the UK and the dedication of the NHS staff involved locally has contributed to that success." They really think it is a good thing. Do you agree?
Professor Crockard: I certainly do.
Q304 Mr Naysmith: So what do we need to do to convince people that it has got to stay?
Professor Crockard: I think first of all, in terms of the Tooke Report, I think he will, I hope, look at the evidence that has been submitted to him. I think he did say when he was here --
Q305 Mr Naysmith: It is only an interim report.
Professor Crockard: That is right. I hope they will take it on board, because this, for the first time, has given young graduates the opportunity to look at six different specialities before making up their minds, and a significant exposure to general practice. We fought hard in the MMC team to convince the Minister of State for this, and we got the funding to allow that. We believe, as many people believe, that primary care, or a revitalisation or a vitalisation of primary care, is what our treatment of patients should be about. So I believe very much that Foundation should stay. I think the argument that it is somewhere blocking people coming from outside, I think if there is a will, there will be a way, in terms of ensuring that the graduates from our programmes get Foundation training. I think what Professor Tooke was saying, if I got it correctly, that the first year was protected, as enshrined in the law; I am sure it would not take a legal team too much trouble to make sure, but in summary, I believe that Foundation is a very good basis for the beginning of treatment. After all, it was possible, when I was a boy, maybe not when you were a boy, but when I was a boy --
Q306 Mr Naysmith: We are probably talking about the same period.
Professor Crockard: -- it was possible to go into laboratory medicine and become GMC-approved and maybe never have seen a cardiac arrest. The whole thing about the Foundation training was not a dumbing-down but ensuring that everybody could recognise the difference from acutely ill and chronic, and over a wide variety. So as you can gather, I am passionately a believer.
Q307 Mr Naysmith: Yes, I can see that. I assume you agree, Professor Heard?
Professor Heard: I certainly do. I wrote the operational framework for Foundation training. I know that competency training does not come in for a very good review from Sir John, but I would like all our doctors to be competent in recognising sick patients. That is the least patients should be able to expect, and that was the overt and clear purpose of Foundation training. It does not prevent us from having absolutely excellent doctors, but I would prefer them to be safe and competent to start with.
Q308 Ms Atkins: The implementation of MMC was divided between two separate directorates at the Department of Health. Whose decision was that?
Professor Heard: The Department's.
Q309 Ms Atkins: You do not have any view about why it happened, why that rather odd decision was made?
Professor Heard: I think there was not a coherent and sustained view from the Department about Modernising Medical Careers. I think there were some very strongly held views from CMO and DCMO about the programme. I think these were not necessarily, through the period of implementation, always held by the Director of Workforce, and there were competing issues here: the Working Time Directive which really has shaped postgraduate medical education enormously over the last eight to ten years meant that frankly, having a very large base of relatively affordable but variably supervised and variably trained SHOs, which could help support the Working Time Directive, quite a big explosion in 2004, we would anticipate that could happen in 2009, meant that trying to align the workforce, which is really what run-through was trying to do, in order to be able to plan better than we had ever been able to plan before in workforce terms, was not necessarily compatible. I do not think anybody had any difficulty about the notions of having explicit standards and clear standards and clear assessment processes, but the structures to support that, I think, were variably believed to be different, because they wanted different outcomes.
Q310 Ms Atkins: So what sort of problems did it cause operationally?
Professor Heard: For quite a while, the direction of travel was not entirely clear. We had, for example, three very comprehensive days, including the Service, various stakeholders, the Royal Colleges, looking at the proposed workforce outcomes and arrangements for Modernising Medical Careers, at a time at which of course we were supposed to be thinking about implementing this. So we heard a lot from the service saying that they wanted the option to be able to employ accredited doctors, was the term they used, doctors with CCT, in a whole range of variable jobs. I think we felt that our responsibility was to ensure that training people to accreditation was appropriate and adequate. It was not our responsibility to say then what jobs they would be offered, that would be really open to a whole range of different forces. It did mean that we were forced to focus perhaps on thinking about issues that were outside the scope, if I can put it that way, of MMC, and which involved people from not thinking about the training arrangements but thinking about the outcome arrangements. Now that is not inappropriate, but it does mean that in project management terms, it is very much more difficult to see how you are going to do this.
Q311 Ms Atkins: Did you want to add anything?
Professor Crockard: No, not at this stage.
Q312 Ms Atkins: Can I ask you about the two areas then which were very much outside your implementation remit, which was the MTAS computer system itself, and the question of international medical graduates. These were run, as I understand it, by the workforce directorate rather than by your team. How did you allow these crucial elements to fall outside your remit?
Professor Crockard: Shall I take that? We were given no option. It began about October 2005, when we discovered that an MTAS board had been set up, and I certainly had not been invited to join it. Then there was the compromise where there was a medical recruitment board where our team were on it, but MTAS was already set up. So it went on. As it went on, it was clear, at least to me, and in my opinion, that the DH had decided that e-recruitment was something they were going for in a big way, and they were not going to allow anything to get in its way.
Q313 Ms Atkins: So judging by the way you have been choosing your words, I assume that there was quite a lot of argument about this at the time?
Professor Crockard: There has been a fair bit of open debate, or closed debate, let us put it that way.
Q314 Ms Atkins: You were not very happy about it?
Professor Crockard: No. And it went on; in the early days, there was a gateway review, I think 2005 was the first one, and then we had another gateway review in 2006, and those who had done the gateway review in 2006 noted the progress that the MMC team had done, in fact were quite complimentary. The only red issue was recruitment, and they pointed out that there was no contingency plan for that. You can imagine that I was, to say the least, a little disturbed, and that is when I tried to make other people aware that we had a significant problem. I attempted to escalate it through my own SRO, I was told that that was being taken care of. How far it went, I have no way of finding out.
Q315 Ms Atkins: So you did try to influence the running of these projects even though you were basically excluded from them?
Professor Crockard: Yes. Well, I personally -- Shelley --
Professor Heard: I was at most of the meetings, I would say, both of the recruitment and selection group and of the higher level recruitment board which looked after a range of things, not just speciality recruitment. I did have and I was fairly clear that I had reservations about the direction of travel. Very early on, I was contacted by the Chairman of the Conference of Postgraduate Deans to say that there were concerns that I was being difficult about things; and subsequently, about a year or so later, a second call from people who were organising this. I would like to think that I am not difficult in committee, but I would like to think I am very challenging. I have had a lot of experience in recruitment; within the London Deanery, we had set up, if you like, a competency-based recruitment system ten years previously, which was based on issues of transparency, fairness, independently reviewed, it was a very good system. It was based on white spaces, I have to say, which in the late 1990s, when we set it up, was the way in which -- and I think still is the commercial world recruits, but we are now, of course, in 2006/7, where the impact of electronic communications is much bigger. It is open to plagiarism, it is open to misunderstanding, and I think we would say that this approach to recruitment needs to be looked at again, and you need to be using much harder and firmer criteria, things that you really can count. This is a very big debate for this country, because we have no metrics, as the Americans would call it, we have no undergraduate transcripts, we have no standard examinations. I think we will see a rapid change with respect to this, so it was difficult to design a recruitment process that was going to actually suit this very, very challenging time. I personally thought that the use of the electronic modality should have been used only to receive and disperse applications, and although the underlying processes, of course, drove the specification for the electronic set-up, I think that there was probably equally a drive from the requirements of how you set up this system to drive the process itself, and I think that was regrettable.
Q316 Ms Atkins: Do you think you were labelled as difficult and therefore your comments were sidelined?
Professor Heard: You know, when you work in this -- there were other people obviously who raised concerns as well. At the end of the day, if you are going to move things on, you either have to leave and then it happens without you and you cannot influence it at all, or you stay and try and influence as best you can. With hindsight, maybe I should have left, maybe that might have said, "Well, we ought to really think about these things again". I cannot say. I do know that there were concerns raised that were difficult to get through, and then in the end, those people who form these committees are complicit ultimately in the decisions that are taken.
Q317 Ms Atkins: So in view of what you have said, are you surprised that no one from the Workforce Directorate resigned following the problems with these particular projects?
Professor Heard: I have to say, I think we probably could have gotten away, and I will put it that way, with the recruitment system, had the international medical graduate issue been dealt with, because it was not so much the electronics, but the overwhelming of the whole system, how we managed shortlisting, how we actually did interviewing, which actually made the huge difference. The fact that there were probably 10-11,000 additional applicants within the system I think was the thing that finally drove this to its failure.
Q318 Ms Atkins: But given that they did not get away with it, are you surprised that no one resigned from the Workforce Directorate?
Professor Heard: I cannot say that. I think resignation like this is personal, it was a personal decision for me, I do not know within Government whether these things are personal or whether or not pressures are applied. I am not in a position to say whether they should have or not.
Q319 Ms Atkins: Professor Crockard, do you have anything to say on that?
Professor Crockard: No, I would just say that my own view was that I had to live with myself and I felt that I had to resign. I cannot predict, in Government or related to Government, what makes people resign.
Chairman: Could I just remind everybody, we are running quite late in terms of time on this first evidence session, we have another two to follow, so could I ask for probably a bit more precise questions and possibly answers as well?
Q320 Dr Stoate: I am going to ask a fairly precise question. One of the reasons we are in this mess is because of the huge number of IMGs that were effectively unaccounted for in the initial planning. When did you become aware that the Department of Health intended to issue unilateral guidance, rather than working with the Home Office, to change immigration rules? That seems to me to be a fairly crucial point.
Professor Heard: I am not entirely sure that would be fair. I think the Department was working with the Immigration Office, particularly in the context of managed migration, for a considerable period of time. I do not think the timescales for this recruitment episode and what might come out of managed migration were coincidental, and that therefore was an issue. I would say that in my experience people in the DH who were working on this issue, they were very, very vexed by it. They were absolutely clear this should be done, hence we lost permit-free training in March 2006, and I think they did believe that the arrangements and the guidance they put into place would be safe.
Q321 Dr Stoate: But they appeared to have gone it alone without the Home Office working with them. The conclusion of Lord Justice Maurice Kay at the Court of Appeal, and I quote, "... it is impossible to avoid the conclusion that the Department of Health decided to 'go it alone'". That was his view. Is that the case, did they go it alone and if so, how could that situation possibly have arisen?
Professor Heard: I cannot say. In the feedback I had, they indicated that there were discussions with the Home Office about this.
Q322 Dr Stoate: Obviously the judge did not believe that.
Professor Heard: I can only report it as I saw it.
Q323 Dr Stoate: As a supplementary really, is it true that the desire to limit applications from IMGs was actually opposed by other Government departments? Alan, do you have a view on that?
Professor Crockard: I have no idea what other Government departments -- we were not privy to those sort of discussions at any stage. However, it is fair to say that even if the Department of Health had decided to go it alone, as you put it, or as the judge put it, it was clear that the Postgraduate Deans had made up their minds that they were not going to necessarily follow the DH line on this, because some of the Deans had decided that they were going to let everybody apply, other Deans did not, so in fact, it was not as clear --
Q324 Dr Stoate: That is the point I am making. The point is we seem to have got into a terrible mess because the Department of Health thought we ought to limit the numbers; it appears the Home Office, from what we have understood, did not seem to be involved in that. We are then faced with a situation of a vast number of international medical graduates applying, the court is ruling that the Department had no right to limit that number, hence the mess we are in.
Professor Heard: Indeed, that is the reason why the Postgraduate Deans were not prepared to accept the DH initial advice that HSMPs should be excluded, because they felt, I have to say, that that advice was unsafe, and indeed, that is what the final view was, it appears, of the courts. We would have been potentially in a much worse situation had the Deans not been very vigilant about this.
Q325 Dr Stoate: Should we not have sorted all this out beforehand?
Professor Heard: Of course, it was intended to be. I will recount a very brief discussion in which we were talking about international medical graduates, it was noted that permit-free training had been stopped, and Alan said, "What about HSMPs?" The response was, "Very few people go into training through use of the HSMP route", and I responded and said, "Well, they do not have to, because there is permit-free training". "It is a very small loophole which we will watch", and three or four months later, there were many thousands of people who had applied, and having applied, we are where we are with that cohort, who are in, and therefore this year will be very difficult.
Q326 Ms Gidley: Professor Crockard, you say in your written evidence, "I am also uncertain how politicians and senior DH were on warning such as the red status awarded to the MTAS project by the gateway review team in August, I doubt they were also informed of the missed drop dead dates in December 2006." Why were they not aware, and why were not senior officials and Ministers keeping a closer eye on them?
Professor Crockard: Or more correctly, why did I have my doubts, which is what I have said. Because firstly, I was surprised that there was nothing that politicians said once there was an obvious red status. We had a meeting very shortly afterwards with the SRO and other people, and I was assured, and we have a document, that that would be taken up to DH board level. However, when I went to see the Private Secretary or the Political Secretary of the Secretary of State, I was not sure that he was aware of the gravity of some of the things. MTAS was another one, MTAS and MPET. At that stage, before the huge release of money which came at the review process, there was a major problem with money as well, and there was the so-called unbundling of MPET where money was going to be given, and for the first time, it was not going to be protected for training. The potential hazards of that, which were very real, August through to December, I believe in the same way as we discovered the HSMP issue, we discovered the MPET issue. So it was those sort of things that made me wonder if it was going up the chain as far as it might or should.
Q327 Ms Gidley: You said you spoke to the SRO and other people. Did you at any time make the Chief Medical Officer aware of the extent of the problems?
Professor Crockard: I spoke on a very regular basis to the DCMO, but I had difficulty in getting it directly to the CMO.
Q328 Ms Gidley: Do you know whether the DCMO forwarded your concerns to the Chief Medical Officer?
Professor Crockard: I hope he did.
Q329 Ms Gidley: But you do not know. Professor Heard, did you raise any concerns with the Chief Medical Officer?
Professor Heard: No, I did not speak with the Chief Medical Officer for I do not think any of the time that I was the Clinical Advisor. Those sorts of communications would have gone through Alan.
Q330 Ms Gidley: Final question to both of you really: what faith do you have that some of the problems with MMC can actually be put right, given that most of the same people are in position?
Professor Heard: I think for 2008, we are likely to have an extremely difficult year again, and I think that is quite clear from everything that is coming from the Department. I think that local recruitment may help to manage some of that and smooth some of the difficult issues out for applicants, but I think it will be very difficult. I think there is now an understanding, however, that policies around international medical graduates in relation to UK EU graduates have to be sorted, one way or other, actually, and I think that needs to be brought into some sort of coherent approach. If we continue to have open availability to the entire world -- anyone, after all, can apply, under the current system -- then I think we will have some serious issues to deal with in the future. If we manage the process carefully, recognise our obligations to current HSMPs, but then using a migration policy which reflects our obligations to our own graduates, then we will have a chance in 2009 and beyond, I think, in managing this.
Professor Crockard: Just briefly to say that the other aspect of all of this, there will still have to be a very radical look at how we train the next generation. Just getting them into jobs is not the same as training. Giving everybody an extra lecture on a Friday afternoon is not training. We were talking about training programmes. My concern is that some of the stuff that we are getting is little top-up trainings that you might get applying for a local health authority evening class.
Q331 Mr Scott: Do you agree with the Tooke report that MTAS acted as a lightning conductor for problems with the MMC itself, or was the MMC a perfectly good system which was undermined by the failure of the selection process?
Professor Heard: I think that what has happened since January 2007 has been a conductor for raising the profile, importance and critical nature of postgraduate medical education in the UK. These sorts of very difficult events often have some positive outcomes, and one of them is that thankfully, postgraduate medical training is right up there on everybody's agenda. It now has become core business, training the future generations, it has now become core business for the NHS, and I do not think I could have said that before. It is on every health authority's agenda, it is on your agenda, and that is one of the positive benefits of this. That is what I think this has done for us.
Q332 Mr Scott: Professor Crockard?
Professor Crockard: Thank you. I do believe it is a lightning conductor, but it was bringing a whole lot of things, there were a lot of things that people were dissatisfied with, shall we say, but would have gone along with. However, the sum of them was such that there had to be a huge reaction. The things I believe that have survived, just to extend what Shelley has said, is for the very first time, we now have curricula for every speciality, and they are explicit curricula. That is a huge advance. I realise that some of the, shall we say, older freer spirits believe that nothing was as good as it was when they were young, and the apprenticeship training; at the end of the day, it is important that there are standards, and I believe the one thing that I hope will survive is standards.
Q333 Mr Scott: Are not MMC and MTAS both characterised by a top-down big bang approach to reform? Is not this overcentralised approach at the heart of the failure of both projects?
Professor Crockard: If I may take that -- and I will speak as an MMC person: the whole point about Foundation training was it may have been a central idea, but I and my colleagues went round absolutely everybody and made sure that everybody was aware of Foundation. The Foundation curriculum was developed by all the Colleges together, with us as the lightning conductor to bring it together. The Chief Medical Officer even proofread and gave advice on it. Everybody was involved at that stage. The worry with speciality training is that was not allowed to happen.
Q334 Mr Naysmith: Could I just ask Professor Heard a very quick question on this area? You said earlier on that the difference between this country and the States and Canada was there were standardised examinations, and there are not here. Is that not something that is really critical and important to sort out? It probably should have been thought about from the start.
Professor Heard: Yes, I think it has been really difficult. There was an educational meeting yesterday with people from the States, talking just about their USMLE and the fact that at the very least, even if it does not say you are going to be the greatest doctor in the world in the future, when you are looking at selection, there is a validity in using it, particularly for shortlisting, and therefore making the system manageable. I would be very surprised now if we do not see some sort of national examination being seriously considered and developed.
Q335 Dr Taylor: Forgive me if this is a question I should know the answer to, but you have said very clearly in your written evidence, Professor Crockard, "Never should a project have two SROs overseeing two parts of the same project." What were the names of these two SROs? Should I know this?
Professor Crockard: I think it is fairly easily obtained.
Dr Taylor: Are you allowed to give it to us?
Chairman: We know.
Dr Taylor: We do know. Could somebody tell me?
Chairman: We will in a few minutes, but remember what I said a few minutes ago about timing. Could we progress, please?
Q336 Dr Taylor: The question is really very simple, that MTAS was an absolute disaster. Why did you not try and pull the plug on it, or did you not have the power to do that?
Professor Crockard: I did not have the power to do that. I suppose the other way of saying it is: why did I not go earlier? I suppose that might be the question. I think that is a very powerful argument. Perhaps I should have gone in September. But we were part of something, we were reassured that the international medical graduates were going to be taken care of, we thought it was going to work, we were trying, we were genuinely trying.
Professor Heard: To be fair, the judicial review, which much of this was hanging on, did not report until after the application process had begun. The fact that the judicial review left things rather open, because appeal was allowed, meant that the action which was presumed was going to happen, which was that HSMPs would have to come in through a work permit arrangement, or after the resident labour market test, did not happen. So there is a bit of, had that happened: we live in hope, we think this is going to happen, let us keep doing what we can to make this work because there was so much at stake here.
Q337 Dr Taylor: Did you imply with an earlier answer that the system of not using CVs would never happen again?
Professor Heard: Personally, I do not think CVs are appropriate. I think application forms, which explore in a structured way the content of what we would have recognised as individualised CVs, is perfectly appropriate. That is just fairer. So my interpretation of using a CV is that you have a CV in which everyone answers the same questions, because otherwise, as sometimes happens on CVs, you just forget to say you have the MRCP, amazingly, but in a structured question, if you are asked what postgraduate examinations you have, you will not leave it out.
Q338 Dr Taylor: So you are not objecting to CVs, you are really objecting to the fact that they are not structured, so people do not say the same thing.
Professor Heard: Yes, exactly.
Q339 Dr Taylor: Obviously we have heard terrible distress stories of really good people who have not got jobs, not got selected. How do you respond to those stories?
Professor Crockard: Of course we are terribly upset that people have been so upset and so disturbed. What the whole process has done, like the lightning, is that it has brought into sharp relief -- we feel that the whole review process prolonged this awful dilemma for the applicants. However, at the back of it all, there are still problems, not everybody will become a cardiologist or a plastic surgeon. In the old days, you got seven years to work it out. It is still going to be the same. There are still a lot of very, very good candidates who may not get their first choice, and somehow or other, in the ethos of medicine, of very, very bright people who apply, not everybody will end up with the job they think they should have.
Dr Taylor: I accept that.
Chairman: Could I thank both of you very much indeed for coming along and assisting us with this inquiry? I know it has probably been a very emotional journey over the last six months for both of you in relation to this issue, and I would like to thank you for your openness and frankness in front of us this morning. Thanks again.
Witnesses: Dr Jo Hilborne, Former chair, Junior Doctors Committee, British Medical Association, Dr Ian Wilson, BMA Consultants Committee and MMC Programme Board member, and Dr Ramesh Mehta, President, British Association of Physicians of Indian Origin, gave evidence.
Q340 Chairman: Good morning. Could I welcome you to what is our third session in relation to our inquiry into MMC. Could I, just for the record, ask you to introduce yourselves and the positions that you hold? Could I start with you?
Dr Hilborne: I am Dr Jo Hilborne, I am the immediate past chairman of the Junior Doctors Committee of the BMA. I was chairman from September 2005 to September 2007.
Dr Wilson: I am Dr Ian Wilson, I am a consultant in Yorkshire, and I am deputy chairman of the BMA Consultants Committee and a member of the current 2008 Programme Board for MMC.
Dr Mehta: I am Ramesh Mehta, a consultant paediatrician. I am also president of a voluntary organisation called British Association of Physicians of Indian Origin, and this organisation is basically concerned with promoting excellence amongst members. BAPIO is the short form.
Q341 Chairman: I think it should be BAPIO this morning. Welcome, thank you very much. I really have a question about this whole issue about the role of the medical profession, and this question is to all of you obviously: the Tooke Review has shown that the medical profession was closely involved with the development and implementation of MMC. Do you all agree with that? Who would like to start?
Dr Hilborne: I will start. I cannot speak for the Royal Colleges, I can speak for the role of the BMA and the JDC. We were involved in the original thinking about run-through training, in fact I believe our committee produced a report in 1999 which first proposed the unified training grade, and we were involved working with Professors Crockard and Heard through the development of MMC as it was going forward. I believe the Colleges also were involved, but we were not involved together, so we were not at meetings with them about run-through training and about Modernising Medical Careers. It has been JDC policy for a long while that run-through training is a good thing, but the run-through training that we envisaged was not the same as what turned out in the end to come out of Modernising Medical Careers. There were some key elements that got lost along the way from what we had proposed, and what Unfinished Business had proposed much earlier on in the process, elements like really good robust careers guidance, so that doctors who were making inappropriate choices in terms of speciality would be able to recognise that, so that doctors would be able to choose specialities that they were suited for. That careers guidance has not yet happened and still is not happening even at the moment. When the JDC was proposing and thinking about a unified training grade, run-through training, we were proposing three broad streams of entry. So the flexibility to start in one speciality, find you hate it, and move to something else, was enshrined in that, because you would start in a very broad-based programme that would gradually focus down into a more specialised area, as both you got to know what you liked and were good at, and as it became apparent how many opportunities were available in different specialities. So run-through training, yes, is something that the JDC has supported, it has been our policy for a long time, but run-through training as it has finally arrived in MMC 2007 is not what we had originally envisaged.
Dr Wilson: Thank you, yes. I think I would take it even further back than that, into the sort of late 1980s, when I certainly started first getting involved and seeing the original concepts of run-through training and single training grades first being developed very much as an educational tool, very much as a way of improving the quality of doctors that we produced at senior level, and improving care to patients. I think the question you asked was: was the profession involved? That is clearly quite a wide spectrum that that word can cover. I think it is fair to say that the point on that spectrum moved from beginning to end, from one end to the other and back again, very much the way as we were listening to Professor Crockard outline, and there were times at which the profession was invited to be included in meetings, and there were times at which the profession was very much not approached and not asked for its input.
Q342 Chairman: Would it be unfair to say that the profession were involved in implementation beside the issue of development?
Dr Hilborne: Again, it is about how you define involvement, is it not? I think I want to point out as well that from our point of view, as JDC thinking about run-through training, we were never thinking of it as a way of aligning workforce particularly.
Q343 Chairman: We will look at some of these questions in a bit more detail. I just wanted to know in general terms about the development and implementation that the profession was engaged in.
Dr Hilborne: We were involved. Myself and my deputy chairman came to meetings regularly with Professors Heard and Crockard about MMC, so to that extent we were involved. We did not feel always that we were being heeded, and that the points we made were being taken on board. So involved, yes, we were at the table; involved as in being heard and responded to and our concerns acted on, less so, I would say.
Q344 Chairman: Ramesh, do you have a view on that? I know you come in front of us from a different position than this. Do you have a view from your perspective on that?
Dr Mehta: I think it is a very important question that you raised. I have a role in the Royal College of Paediatrics and I have to say that the college was involved. However, volunteer organisations like ours were not involved, and I think it was a very important omission, and perhaps eventually it would be realised that the wider consultations were not carried out, which is one of the reasons for the failure of the system. We were not consulted as an organisation.
Q345 Chairman: Right. Do you think that the involvement that the profession had, and they had some responsibility in what has been pretty much a disaster in terms of the outcome of this year, do you think that the profession should accept blame or responsibility for this disaster?
Dr Wilson: I do not think anybody has covered themselves in glory in all of this. The fact that the profession allowed what has happened to happen is something that needs to be looked at again. Certainly John Tooke's recommendations are very clear on that, he throws down a challenge to the profession that is one we will certainly pick up and work with him on, and work with our colleagues in the Colleges and elsewhere. To say whether, if I can put it from the BMA perspective, the BMA were responsible in some way, that is a much more complex question, when we had been demanding reforms in training for a considerable period of time, so to that end, it is kind of: be careful what you wish for, you might actually get it. But at the time when implementation started, and this is kind of rehearsed a lot in Sir John's report, we moved so far from the original principles that everybody had signed up to something that became almost entirely based on workforce planning, and very little to do with quality of training and education. Professor Heard's comment about having education well up there and an important part of people's agendas, I think it is now part of people's agendas, but I think it is so seriously subjugated by the catastrophe of the total absence of workforce planning that I am not sure that we can settle and say no, we have had a positive outcome that it is on people's agendas. So yes, the profession must acknowledge that things need to be done differently, things need to be thought about differently, our approach needs to be different, but no, I do not think it is entirely responsible in that the process so carefully and possibly in a calculated way removed the ability of the profession to do much about the problems that it persistently raised and persistently brought up. If I might finish by saying I am very clearly recalling a call at the Joint Medical Consultative Council to call for a delay to explain why a delay was necessary, and being told this was typical BMA shroud waving.
Q346 Dr Naysmith: When this was deviating and it was going away from what you say were the basic principles you were signed up to, should not the medical profession - and I do not just mean the BMEM - have said, "No, we have to stop it here" and walk away from it?
Dr Wilson: The calls were fairly constant on that one. I have just highlighted my own personal rather unpleasant experience in that one, but Jo is probably better placed because she knows much more of the detail of what actually happened and what was said to whom.
Q347 Dr Naysmith: I was just picking up what you said; you were saying that it went wrong and that you more or less stayed in there.
Dr Wilson: At that stage we were saying, "Enough, we have to stop; we have to stop." There were a great many letters, including letters to the Secretary of State, which was why I was suggesting to call Jo in, but there is only so long you can keep calling repeatedly for something that seems, forgive me, blindingly obvious, and eventually if people are not listening to you, and in fact actively exclude you from conversations because you are raising concerns ---
Q348 Dr Naysmith: There were senior representatives of colleges and paediatricians, as you have just mentioned - they should have walked away and they should have said, "We want no more to do with it."
Dr Wilson: That is an interesting viewpoint and I think it is probably one we might have shared at various times throughout what has happened over the last couple of years.
Q349 Chairman: Jo, did you want to respond to that?
Dr Hilborne: It is very difficult when you are involved in a process that you have been involved with for a long period of time and it is often harder when you are in the middle of it to realise when you have got to the point of no return, where it has changed because when it is a gradual process, to pick the point of that gradual process where you have got to the point where it is too different is very hard. I think as individual bodies, the separate colleges and the BMA, certainly the position the BMA took was that in order to do the best for our members it was better for us to be engaged and trying to improve things than to just throw up our hands and walk away and say, "It is all crap and we do not want anything more to do with it!"
Q350 Chairman: We hear all the time in terms of the future of the Managed Health Care System and the future of the National Health Care System, that it should be clinically led and Anasazi and many others are going around the country engaging with you all the time on that. Does this not suggest that probably if there had not been this type of engagement and if they had concentrated more on project management we would not have had the disaster that we had earlier this year.
Dr Hilborne: I think that is the MTAS MMC divide, is it not because I think in terms of MTAS, the actual technical system, there was a massive failure of project management in that things that were meant to be ready were not ready on time; elements that were meant to be built in were not built in, it was not properly tested, there was not a back-up system. That is the project management side of it. But in terms of what it was looking for, which was recruitment into specialities, which instead of having a few broad-based entry points had something like 13, some of which were very focused. Urology, you cannot get more specialised than urology and having to choose to do urology when you have done one and a half years out of medical school, which may never have included any urology, it is not what run-through training was supposed to have been about. So that is the policy side of things that was also not going right, if you see what I mean?
Q351 Sandra Gidley: A question to all of you really. The MTAS crisis led to the formation of new groups to represent the medical profession, such as Remedy UK and Fidelio. Would it be fair to say that these highly critical groups are now more representative of the profession than the BMA?
Dr Wilson: No! Clearly you would expect me to say that, would you not? We welcome pressure groups; we welcome single issue pressure groups because it allows you, as I think Jo was explaining, to do things that you cannot necessarily do as the representative organisation when you are within the body of the Kirk trying to sort things out. We have examples of when the BMA did up its criticism rate we were actively excluded from key parts of the process, including being actively excluded from the writing of the Gold Guide to Training, as a direct consequence of raising concerns about the process, which is pretty poor. We have worked extremely closely with other organisations to build up the campaigning side of the world, which has always been useful. I do not see a conflict. In terms of representativeness, there is a debate one could always have there about who has what members, who does what for whom, but the association is a very, very broad organisation covering a great many aspects of medicine and trade union work and has a very robust democratic structure.
Q352 Sandra Gidley: So has your membership gone up or down since?
Dr Wilson: Our membership is actually pretty static. I stand corrected but I believe it is actually higher than it was when the MMC MTAS process started.
Q353 Sandra Gidley: Would either of the other two of you like to comment on the initial question?
Dr Mehta: Could I say that, yes, BMA remains a very important organisation, it is a trade union, but the success of Remedy UK is something to be taken note of and it shows that a large number of junior doctors actually revolted to join this organisation, and I think that Remedy UK has done a very good job of it. But, at the same time, yes, BMA continues to have a role and should have a role.
Q354 Sandra Gidley: Dr Hilborne, you said that when you are in the middle of something it is sometimes hard to see when you should withdraw. With the benefit of hindsight do you regret that the BMA were not more critical throughout the process, particularly MTAS?
Dr Hilborne: I do not regret the JDC's actions in this; I think we did everything that we could do to draw attention to the fact that there were major, major problems. In our meetings with the MMC team we tried very hard to engage constructively and when we found things that we were not happy with to suggest a way forward, and very often the answer was, "That would be great, but we do not have time." As a result of a number of those meetings our conference called for delay in June and in the August or September, I cannot remember which, we published our very detailed case for delay, which was basically all the things we wanted to do to make it work properly, that we were told there was not time for. We published that very broadly; we sought support from the Medical Royal Colleges, from the Joint Consultants' Committee and the only body that supported us in that call was the Trainees' Committee of the Academy, which then very publicly withdrew their support in October last year. We launched a campaign for "Train not Drain" when the numbers of posts that were going to be available were announced; we had organised Mess meetings throughout the UK. We had a power point presentation that was drafted essentially and was presented to junior doctors in Mess meetings throughout the UK, explaining our concerns. We had letter writing campaign to MPs and I am sure that many of you will have received letters from constituents at that time expressing their concerns. I think as a Committee we did everything we possibly could. I think sometimes we did not get the support, from which perhaps we would have benefited, from the higher echelons of the BMA and, as you know, James Johnson resigned earlier this year over issues around MMC and MTAS, and I suspect if he had been more proactive in supporting us we may have seen more movement. But I do not see that we could have done anything differently; and I really do not see that us as the JDC disengaging from the process would have made any difference, except that when it did all go horribly wrong there would have been no doctor representatives there to lobby for and work for improvements in that Rescue Group, in the Douglas Review Group, which again we had to fight very hard to get involved with. The Colleges really were not keen to have the BMA involved in that group at all, the Douglas Review Group. We fought very hard to get in there against the opinion of many people who thought we ought not to because they thought that by engaging we were selling them out; but we did achieve significant improvements in what was an awful situation. It was a terrible time; it was a terrible situation for those doctors caught up in the middle of it.
Q355 Sandra Gidley: Why did the Colleges think that you should not be there?
Dr Hilborne: You can ask them obviously, but I think it was because they believed that this was an education and training matter and that is their remit. But we fought really hard; we did get concessions; we were criticised for being in that group, but I do believe if we had not been there we would not have got some of the things that we did get in terms of the ability to re-preference an interview, an extra interview for everybody in their first choice post. We got an extended round two; we got an employment promise while that extended round two was going on, and we got over 1000 extra posts for people who were still unemployed after round two, to keep them in employment until next year's process. If we had not been there, if we had just said, "This is terrible, we cannot possibly engage because it is awful," I do not think as much of that would have been achieved, and we would have let our members down worse by not getting involved.
Dr Wilson: Expertise resides in a huge number of places; it does not necessarily reside in only one body or one organisation, which is why it is so important that organisations communicate and work with each other, and I spend a great deal of time at the BMA with another hat on working on processes to improve the way that the profession talks to each other and works with each other. One has to remember, though, when asking questions like why did the Colleges think this or why did they think that, that the Colleges are actually educational charities that are set up to improve education, they are not representative organisations - they never have been and under their current charters they never will be, they are charities support for educational purposes. Remedy UK was set up with a specific purpose in mind - it may have morphed into something rather different but it was set up with a specific purpose in mind and worked extremely closely with the BMA to achieve those goals. It was a symbiotic relationship where there were benefits and losses from both parties in that relationship. You have hinted at the question about membership earlier on and, yes, the BMA did and does have people who have resigned membership over that - there is no point in pretending otherwise. But if you think about it in a slightly different way, that was a symptom of the desperate frustration that members of the profession felt by what was happening, the absence of communication, the absence of engagement, the absence of any genuine involvement, and the bottom line too is where else can you resign from?
Q356 Sandra Gidley: So who is actually to blame for that absence of communication?
Dr Wilson: That is a very important question. If you are feeling that frustrated where else can you vent your frustrations other than the march that Remedy organised on that one occasion with the BMA, or indeed resigning your membership from somewhere. You cannot resign from the GMC because you are no longer a doctor; you cannot resign from your Colleges because that has no standing and it is not possible then to career progress. There is only one place left to vent your spleen and unfortunately the spleen was often vented at the organisation that was actually doing the most to help junior doctors. In terms of the communication - you may well move on to what is happening in 2008 - but the difficulties with getting clear messages out from the process are well documented and well expressed. It was impossible to persuade the Department of Health to trainees and to tell trainers exactly what was going on, what the numbers were, when they were happening; what the process was going to be.
Q357 Sandra Gidley: You say the Department of Health. Are you able to say more specifically? The Department of Health is a big organisation, are you able to say more specifically who was not listening?
Dr Wilson: Would it be fair to ask to bring in Jo on that because Jo was actually in the room - I came subsequently?
Dr Hilborne: Nobody was listening as far as I could tell! In terms of communications in particular I think the trap that the BMA fell into last year, certainly once things had started going wrong, was that we felt that the Department of Health, the MMC team, the workforce team, whoever, trainees were not being told what was happening and so we tried to step into it and tell people what was happening, and because these communications were coming to them in mass emails from the BMA we became associated with them as if it was our idea. Do you see what I mean?
Q358 Sandra Gidley: Yes.
Dr Hilborne: I know that this year on the programming board Ian and his colleagues from the BMA are working quite hard to make sure that these messages come out with the DH badge on them because doctors need to know them, but when we tell them it is our fault. In terms of communications and whose fault it was at the DH, the trouble is that there was no clear responsible person. You have heard already from Sir Liam Donaldson that there was no person in overall charge. I take that to be a significant failure of his because I believe that as the Chief Medical Officer it is his job to make sure that there is somebody in charge of a process as important as this, and if he has not done that then it is his responsibility. Even the MMC team - you have heard already from Professors Heard and Crockard - were they negotiating with the other people on the MMC team, were they responsible? The lines of communication were so vague and it was so difficult to know where responsibility rested that I cannot tell you who should have been communicating, except to say that this is a Department of Health initiative, absolutely led and implemented by them, and therefore they as a department should take responsibility for telling doctors what is happening.
Q359 Sandra Gidley: Very quickly to finish, you have hinted at the way you communicated that might change; how are you going to re-establish the trust of the medical profession, some of which has been lost?
Dr Wilson: Being on the board now we are trying to get communications regular and thorough, open and honest. That last word is probably the most important word at the moment - honesty in what expectations should be. We have established a communication from the Department of Health, very recently signed off by the Chairman of the programme board, as a first stop to telling people what the numbers are. We regularly as an association after every meeting post our reports of the board widely; we have established other groups like Doctors.Net.UK, the online web forum, and have a regular and lively debate through that, and we regularly liaise with Remedy, who have their own lines of communication. The important thing is regular, accurate and honest.
Q360 Chairman: Did you want to add anything to that Ramesh?
Dr Mehta: Yes. I just wanted to say that we feel that the BMA was in a position to exert an influence which they did not do as well as they could have. To be fair to JDC, I have to say that JDC tried their best; we know that they were trying to work very hard. But the BMA leadership had unfortunately to change course and they did not use their influence as well as they should have. As Jo said, eventually the resignation of the Chairman amplifies the fact that things were not done as they should have been.
Q361 Dr Stoate: I want to put on the record at this stage that I am a member of the BMA and a Fellow of the Royal College of GPs, just in case there is any confusion. The BMA seem to be painting themselves a nice picture of, "Nothing to do with me guv!" but one of the reasons that we are in this mess is because of the very large, unexpected number of non-EU medical graduates who have applied for posts, and that has certainly caused a huge pressure on the system. Yet, despite the fact that the Department of Health has made several attempts, unsuccessfully, to limit the number of non-EU graduates applying for jobs the BMA has opposed that position; why is that?
Dr Hilborne: I do not think it is fair to say that high numbers of non-EU overseas applicants is anything more than a very small part of the whole problem that is MMC and MTAS.
Q362 Dr Stoate: Really? 12,000 more graduates than were expected have not caused any problems?
Dr Hilborne: It did cause problems. That is the problem about the numbers - the numbers of posts compared to the numbers of applicants. That is not in any way to do with all the problems that have precipitated this crisis: the problems with the short-listing, the criteria and the questions, the inability of short-listing to pick out good quality candidates.
Q363 Dr Stoate: We know all about that.
Dr Hilborne: All of that stuff. So I just want to make it clear that although this is an issue it is not by any means the only issue or even the most important issue about the whole thing that went wrong with MTAS. Now to come to the numbers; the Home Office changed the visa rules in March 2006 absolutely completely out of the blue as far as we were concerned, and we have already heard that that was an attempt to ensure that UK graduates got first go, going through the application process through MMC ---
Q364 Dr Stoate: But that was the intention of the system at the beginning. That all went wrong.
Dr Hilborne: That went wrong.
Q365 Dr Stoate: The Department of Health tried to put that right and you opposed them. I still do not understand why you are opposing the Department's attempt to put that right.
Dr Hilborne: We opposed them because what they were trying to do, they were trying to change the rules not only to prevent new doctors from coming into the UK who had not previously worked here, but also for those doctors who had already come to the UK in good faith, who had been enticed here by campaigns abroad saying, "Come and work in the UK, it is fabulous; we really want you," either expecting to be able to continue their training on a permit-free basis and then go back home when they had completed their training, or who had come here on the HSMP, expecting to be able to stay and settle because HSMP is very definitely explicitly a route to settlement. By allowing people on to HSMP you are saying, "We want you to come and live in our country for the rest of your life with your family and work here and be part of our community."
Q366 Dr Stoate: But HSMP is only a relatively small part of the numbers. The point I am making is that the Department of Health, in good faith, increased the number of medical undergraduate posts in this country with a view to Britain becoming self-sufficient in medical graduates in the fullness of time. That went wrong and we all know the reasons why it went wrong, but what I do not understand is why you have opposed the government's attempt, the Department's attempt to put that right?
Dr Hilborne: Because it was wholly wrong, immoral, unethical and unfair to entice doctors here on a promise, make them spend a fortune getting here, sitting the required exams, uproot their families and then when they have been here for six months, a year, two years, say, "Actually we have changed our minds, we do not want you; go away again." It is a wholly unethical and immoral position to take, which we could not in any way support.
Q367 Dr Stoate: I am disagreeing with your position, I am just asking for your position. What I want to know then is do you feel any responsibility for the disadvantages that UK graduates may undertake this year and next year because of that decision?
Dr Hilborne: No, I do not because the whole issue about workforce planning, about numbers is something we have been raising - even with yourselves, and I believe I wrote to you as a Committee last summer, and in the past we have raised it as well - issues to do with workforce planning, the failure of this government over a long while now to actually grasp the issue of medical workforce planning, to look at very objectively the numbers in, the numbers out, who you need and what you need them for. You have already alluded to the increase in medical school places. Surely at that time when you are deciding, when the government is deciding to increase the number of medical students in order to be self-sufficient in doctors, would that not have been, "By the way, we need to think about what to do about all the overseas doctors?" Surely if you are going to think about it you do it then. The fact that this all happened in a big rush at the end, all of a sudden, "Oh, dear! We are so far down this process, we have all these overseas doctors, how are we going to manage it? I know, we will just shut the door now and we will kick out the ones who are already here." It is not our fault. We have consistently said that workforce planning is a disaster and you need to sort it out and it is not our fault that the government failed to close the door soon enough and then tried retrospectively to kick out people they had already invited in.
Q368 Dr Stoate: I am not blaming the BMA for that ---
Dr Hilborne: You said did we feel responsible.
Dr Stoate: I am simply saying that you have done your best to block the attempts of the government trying to block that right, and that is the point I am trying to get to. I just did not quite understand why you were trying to block what the government was trying to put right. I have the picture clearly now, so that is fair enough.
Q369 Dr Naysmith: Can I just ask has the BMA ever opposed the expansion of medical school places in the past six or seven years?
Dr Hilborne: No, I think it has been our policy.
Dr Wilson: The BMA originally called for an appropriate, balanced and planned expansion in medical student numbers accompanied ---
Q370 Dr Naysmith: It is inevitable that there are going to be a lot more UK graduates.
Dr Wilson: Forgive me, accompanied by a reform of training and accompanied by a careful and planned expansion in consultant numbers. We come back to the regular statements from the Department of Health that we have more trainees than we need fully qualified doctors. This is not true; we have more trainees than we are prepared to pay for fully qualified doctors - they are very different things.
Dr Naysmith: Thank you for clarifying that.
Q371 Chairman: Jo, do you see the moral and ethical argument that you put there - and I understand it very well - do you see a difference between somebody who is actually working in this country now and looking to staying here, as opposed to having a policy where people can still come in when we have this position that we have?
Dr Hilborne: I think there is a difference between a doctor who has already established themselves, spent the money, brought their family on an expectation, and as long as it is absolutely clear what the position is I have no problem with doctors from anywhere in the world applying to work in the UK. But I think what is really important is that they understand the strictures and the environment, and I think it is reasonable to have different rules for doctors from different places. We are stuck with the European legislation.
Q372 Chairman: Did the JDC argue that position earlier this year?
Dr Hilborne: I believe we have said that, yes.
Dr Wilson: It was BMA and JDC policy.
Dr Hilborne: It is our policy that if we are going to become self-sufficient in doctors, if we have more medical students, then we will have to review the position of overseas doctors coming into the UK. But reviewing the position and changing the rules for doctors who have not yet come here is a completely different matter compared to doing it with people who are already here.
Q373 Dr Stoate: That does make the position very clear and that is what I wanted to do, to get on the record exactly what the position was. To Ramesh Mehta, obviously you are very pleased with the latest appeal that your organisation effectively won against the Department. Are you confident that that will hold up on the Department's appeal that is coming up soon?
Dr Mehta: I am pleased that the three-Judges' bench in the Appeal Court agreed that what the government had done was wrong, and that is true. I think what Jo has been saying, I do say that it is absolutely true. This problem came because things were not planned properly. The workforce planning has been so horrendous that we have come to this situation, and we are not really pleased that we are in this situation. We want home grown doctors to be looked after. We are very keen that the British training continues in the best possible way. The world over British training is taking as the best training. I think it is the workforce planning that has been messed up.
Q374 Dr Stoate: That is a fair answer. Are you aware of any agreement between the Foreign Office and the Indian Government to guarantee access to Indian doctors to come into this country?
Dr Mehta: I am not aware of any guarantees but I am aware that there have been discussions between the governments about the questions of Indian doctors being allowed to come into the UK because we know that there was a time when countries like South Africa, for example, had objected to Britain draining their brains, but with India the situation is very different and I do not think that the Indian Government and Indian people have any problem in Indian doctors coming here for training, as well as some of them wanting to stay on.
Q375 Dr Stoate: A question on the same area. Remedy UK have told us that all parties, including BAPIO - and I would also like to know what the BMA feels - feel that there would have to be much tighter restrictions in future on the number of IMGs coming in. Is that a fair position that you are all agreed to?
Dr Wilson: The short answer is yes; the slightly longer answer is that there need to be all sorts of plans and restrictions put at all levels, not just at that level. It is unreasonable to focus just on that one. We need some workforce planning.
Q376 Dr Stoate: You are saying that we do need some restrictions. So my next question obviously is what is the best way to manage this situation so that we do not get into this mess again?
Dr Wilson: I earlier said that expertise comes from all sorts of places and I am fairly certain that our expertise is not in the field of immigration.
Q377 Dr Stoate: I am not talking about immigration; I am talking about whether we should have some restrictions on medical graduates. Should there be some entry criteria beyond the ordinary immigration criteria - this is a bit wider than that? Are there ways that we could, for example, limit the number of IMGs coming in? Or should we just do it purely on visas?
Dr Wilson: I think we are still straying into territory in which I have no expertise, I am afraid.
Q378 Dr Stoate: Fair enough. Ramesh, do you have any views on that?
Dr Mehta: We have had discussions with Remedy UK. We cannot really continue in this mess for any longer. If we do not want to be in the mess there has to be some sort of regulation of overseas doctors coming into the country - there has to be some sort of regulation. However, we also need to think of globalisation; the world is changing very fast, the movement of professionals throughout the world is huge. We must think of mediocrity. Professor Tooke mentioned excellence; excellence will come from competition, so we and our graduates have to be open to the competition. We as an organisation believe that our home grown graduates are trained extremely well and there is absolutely no reason why they should fear any competition. However, coming back to the question of regulation, of entry of overseas doctors, which should include EU doctors as well - why not? Indian doctors have been the backbone of the National Health Service since its inception and suddenly out of the blue you are saying, "Pack up and go." This is like saying to somebody who is on the flight to New York, half way through, "Get down." This is absolutely wrong. There has to be proper workforce planning, there has to be some regulation for the entry of these graduates. We know that British graduates are not very keen to enter in certain specialities; for example, in ONG the application was only 0.5 for each post of the graduates. In certain areas of the country - Wales or in some other regions - some people do not want to go and IMGs are quite happy to work in these areas because they want to train in Britain. We need to consider all these aspects. So there are several aspects, and that is why it is so important that the government must consult organisations like ours to understand what is going on and how things could be improved.
Q379 Dr Stoate: I entirely agree with you, you are absolutely right that the NHS would never have succeeded at all if it had not been for the huge number of Indian graduates that came in in the 1950s and 1960s, so you are absolutely right. It is just the matter of how we manage the future; that is the difficult bit.
Dr Hilborne: I think it is really important that we do continue to have overseas doctors coming to work in the UK. I think that those links are very beneficial; I think the professional relationships that ensue from them are very important. In terms of how you manage that, first of all you have to know your numbers; you absolutely have to know how many posts you have and how many doctors you have applying because you cannot do anything unless you know your numbers, and that has been a major failing in recent years. I agree with Ramesh, I think it is very appropriate that it should be possible for overseas doctors to compete to come into the UK, and whatever criteria you set for entry to work in the UK as a doctor should then be accessible to anyone who choose to compete for that on merit.
Q380 Chairman: How does that square with EEA doctors, who have the right beyond what the government is able to do as a government to restrict when they have rights of freedom to come in from the European Commission. It is a very complicated picture, is it not?
Dr Hilborne: It is and my understanding is that there is absolutely nothing any of us can do about EEA doctors; that it is an issue about European law and it is a situation we are stuck with. They do have the rights to compete on an equal basis with UK graduates and that is just the way it is. Anything you think you might want to do to make it harder for Polish jobs to get jobs in the UK would instantly be unlawfully discriminatory. So it is just where you are, I think.
Q381 Stephen Hesford: For the BMA what proportion of your membership is IMG?
Dr Hilborne: I have no idea but we could get that information for you.
Dr Mehta: I think it is 40% as far as I understand it.
Q382 Chairman: I would be surprised if it is not that type of figure.
Dr Wilson: It is significant; it is not a small number.
Q383 Chairman: Ramesh, your members; did the majority of your members graduate in the UK or in India, and do most expect to stay in the UK permanently after completing training?
Dr Mehta: Most of our members at the moment are graduated in the Indian Subcontinent. We as an organisation say we are British, basically - we are a British organisation of Indian origin. At the moment 40% of medical students are of Indian origin; they are born and brought up in this country; they are our next generation, which includes my daughter as well. So the reason we said our organisation exists is not only to promote clinical excellence, but also to support these doctors regarding their cultural background. At the moment, yes, the majority of our doctors are trained overseas.
Q384 Chairman: What would be the likely difference in cost to an Indian medical graduate doing postgraduate training in the UK rather than in India?
Dr Mehta: I think it is not right to compare cost in that way because the cost of living here is not the same as the cost of living, for example, in India. I think the perception should be that it is extremely expensive; for a doctor to be trained is hugely expensive, whether it is in India or here. In my submission I have given some figures but I cannot otherwise answer an exact figure in Indian rupees, for example.
Q385 Chairman: Has there been some sort of agreement, transparent or not, between Commonwealth countries like yourselves in terms of having an expectancy of the numbers of doctors coming into the UK for training? Has there been any sort of agreement between government departments and the countries that you know of as being just understood for many years?
Dr Mehta: Thank you for bringing up the Commonwealth. I am sorry; I am digressing a little bit.
Q386 Chairman: No, I am specifically asking about whether there has been anything that is a Commonwealth issue between our countries that meant that we have had 40% of your members at the BMA - I am surprised it is as small as that, quite frankly.
Dr Mehta: The Commonwealth has been connected with the National Health Service since its inception. The EU is connected with the National Health Service very recently. To answer your question, I am not aware of any understanding between the Commonwealth and the UK, but I would like to make a point that it does not make sense that EU graduates can come and work in the UK, without any problem, while they are not really the most suitable doctors to work in the UK, for various reasons including the language, which we know. The Indian medical system was started in the days of Raj, and it is similar to the British system. The language is not a problem and we know that people who come here are bright, the cream of the doctors, who want to get medical training. So whether there is an understanding between the Commonwealth and the UK or not the differentiation between the EU and the Commonwealth is not right for this country.
Chairman: Thank you for a very challenging view. I will move on to Stephen now.
Q387 Stephen Hesford: This question is to Jo. I know you touched upon this earlier on and can I apologise for not being in quite at the beginning of this part of the session. Why did the BMA Junior Doctors Committee support the creation of a run-through training grade? Did you prioritise job security for your members over the flexibility of the new training system?
Dr Hilborne: It has been our policy for at least eight years to support a unified training grade and the basis for this within our policy was always based on a very broad-based entry system. In our policy we have three streams of entry and it starts with very general professional training that gradually focuses you down on to a speciality, so that flexibility to change speciality as you develop and your interests develop and your skills develop was built into the system. Within our policy there is also the requirement for very robust, earthy and continuing careers guidance, so that the doctors have the abilities, have the skills and the training to make the right choices for their own nature and skills in terms of the speciality they choose. So it has always been our policy to support run-through training from 1999 onwards. Never in any way as a protectionist thing but because we believed this was an appropriate way to train doctors, to give them more job security early on rather than the old system where you changed jobs every six months or a year and never quite knew where your next job was coming from, certainly for the first few years. But also within that security of knowing you were going to be employed to an end point of ability to apply for a consultant job, to still have the information you need to make choices and the flexibility to be able to make those choices as you go through your training. I believe you are referring to something that was said in the Remedy UK evidence session, where I have read some of what they have said, and they talk about protectionism and they talk about us supporting run-through training, and ignoring the fact that for every doctor who got run-through there would be another doctor who did not. I think they were referring specifically to the numbers issues on this particular year with this particular process task this year. Run-through policy has been our policy from way back, long before we ever had any idea about numbers and numbers of applicants. In this application process even as recently as autumn 2006, just over a year ago, Lord Warner announced 23,000 posts. At that time it was believe that there would be 20,000 to 22,000 applicants and the ratios looked fine. It was only when the actual numbers of applicants who had actually applied to MTAS were revealed when the whole thing went horribly long and we realised how badly underestimated that number of applicants had been. Also, how the 23,000 posts that had been announced included some 5000 that were not actually available for competition because they were GP SHO posts that would become GP ST posts, so there were new ST posts but they already had an incumbent who was on a three-year GP training programme so they were not actually in the competition, and that was not made clear until vey late on in the process. We supported run-through training not out of protectionism but because we believed for those doctors who had been through this incredibly traumatic and difficult process, for those ones who were successful and were appointed it would be wholly unfair and inappropriate to make them do the whole thing again next year when they had just been through such a terrible time this year.
Q388 Dr Naysmith: Following that up - and probably these questions have really been answered but we will ask them again just to get them on the record - you called on a number of occasions for the implementation of speciality training to be delayed by a year. Why? What was it that made you drop your opposition to implementation in 2007?
Dr Wilson: The point leads on from what Jo was saying before, that the concept of run-through training and other parts of the original genesis of MMC goes back way into the dark ages. As I was saying earlier, it was a package not a shopping list where you could pick bits off. In particular Jo has talked about competition at higher entry points and multiple entry points within the original envisaged model of run-through training and how that would be highly flexible. Other parts to that were the vital importance of building in transferability of skills and the absolute importance of having robust assessment that could also manage poorly performing trainees sideways or indeed out. Those were key parts of what the BMA called for, so supporting what Jo said about protectionism. The difficulty was, as I was saying, that not all of that was built into what run-through training became. Jo has more detail and better detail than I on that one.
Q389 Dr Naysmith: Is he right about that?
Dr Hilborne: Yes, absolutely. You were asking about the call for delay and why we stopped. Let me tell you what happened. We have always had policy - it is still our policy that MTAS 2007 should have been delayed by a year because it was not going to work. Every meeting we went to we said, "Of course, if you delay this then these issues which we are raising will be able to be dealt with in time." On 12 January the adverts for the run-through training posts appeared in the Press and we decided at that point that we would no longer publicly continue to say that it should be delayed because we thought that we would look stupid. We felt that was the point at which we could put our finger down and say, "This is the day on which we know you have now formally ignored our call for delay." So we did not continue to say, "Of course you should delay it" because we would just look stupid because they had already advertised and of course they are not going to delay. On 26 February when it became clear that the short listing process first of all had been extremely flawed in terms of the process in that consultants had 600 sets of CVs two days before the process was due to close, but the ---
Q390 Dr Naysmith: You must have known that was going to happen.
Dr Hilborne: We did not. There was a fortnight for the short listing to happen. Through that fortnight we were getting reports coming in all the time about this problem, that problem and the other problem. On 26 in the morning all applicants were meant to have been told what interviews they were being offered, and on 26 it became plain that loads of doctors had not heard, and on 26 I wrote to the Secretary of State again calling for her to suspend the process, not to start the interviews because it had not worked, and to suspend it until either it could be demonstrated that short listing had been done properly or until a different system could be put into place. So I do not think we ever stopped calling for a delay, apart from that one short period after the ads had gone in when we just thought it would look stupid.
Q391 Dr Naysmith: Would it be fair to say that you made the best of a bad job and it turned out to be even worse than you thought it was going to be?
Dr Hilborne: I do not know whether "made the best of a bad job" is completely fair. What else could we have done? I think we did everything we could and it turned out to be worse than we thought it was going to be.
Q392 Dr Naysmith: Something else that you mentioned a little while ago was about the numbers, you thought the numbers were going to be not too bad but that was because you were focused on the wrong part of the system, is it not? You were focused on the fact that there would be too few training posts created, when in fact it was an excess of applicants that was the real problem, and you were focused on the other end.
Dr Hilborne: I think it was a combination, to be honest. The original announcement of posts in - I cannot remember when it was, but a couple of months prior - had been 9,500 entry points in MTAS and that obviously would be wholly inadequate. I remember being on Radio 4 on the Today programme and being told by Lord Warner to stop panicking because it was all going to be fine, which just goes to show, does it not, how wrong you can be?
Q393 Dr Naysmith: I think you were both wrong, Lord Warner and the BMA.
Dr Hilborne: I guess. We do not have a crystal ball; we do not know what is going to happen. We thought the match between posts and applicants was going to be closer than in the end it was. The trouble is whenever we ask anyone for numbers in government they cannot tell us. How many doctors are employed in the NHS? Try that one; you will not get a right answer. How many SHOs are employed in the NHS? Last year nobody knew that; that data is not collected. How many Trust grade and non-standard grades are employed in the NHS?
Q394 Dr Naysmith: I think some of that is available but it may not have been available to you.
Dr Hilborne: No, they do not collect SHOs; they collect people working at SHO level but that includes Trust grades and non-standard grades. They cannot tell you exactly how many of those are in training posts. So as numbers are very difficult to get hold of it is very difficult to know whether the numbers you are being given (a) are right and (b) are adequate.
Q395 Sandra Gidley: Another question to you, Jo. We were told by officials at an earlier session that the JDC had actually insisted that each candidate should be allowed four applications, even though it was pointed out to the union this would mean that a significant proportion of doctors would not secure an interview. Is that a correct statement of the position?
Dr Hilborne: It is a correct statement but it is rather economical with the reasoning and I will explain the reasoning to you. Originally the proposal was that doctors would be allowed to apply to one job; so one process a year, one job, and if you did not get that job you would go into some kind of clearing process and you would just get anything. We did not believe that that would be acceptable to junior doctors and we negotiated hard to increase the number of jobs that a doctor could apply for through this process to four.
Q396 Sandra Gidley: Why four, having been told that that would mean a lot would not get an interview and that would obviously put quite a lot of stress on a junior doctor if you think you have had your chance?
Dr Hilborne: The only reason you will not get an interview with four choices is if fewer than four people are shortlisted per available place, so to some extent that decision is in the hands of the Dean. If they choose to interview five per post then everyone will almost certainly get an interview. If you are only interviewing two per post and people can make four choices then strong candidates who get four interviews are balanced by weaker candidates who do not get any. However, this would not have been a major problem had things worked as they should have done because the original plan was that round one would happen and that doctors would be appointed through round one; then a round two would happen, which would be a very similar process and the doctors who had not been appointed in round one would have an opportunity to look at the posts that had not been filled in round one, make a new application with a new form to four new jobs out of the ones that were left, and after that process there would be a clearing to mop up what was hoped to be very few people who were left. All of that was meant to have been completed in good time for everything to be ready for 1 August start. So if the process had worked as it should having four interviews may have meant that fewer doctors got interviews in round one but it would have meant that all doctors felt they had a better opportunity to apply for jobs they wanted and not restricted.
Q397 Sandra Gidley: But that was not really communicated very well to the doctors, was it, because it was after round one that MPs were flooded with emails from doctors who had been unsuccessful.
Dr Hilborne: Now we are in the difference between what should have happened and what did happen. What I have described what should have happened; what did happen is some doctors did not get any interviews, but also because of the failing of the short listing process to accurately pick out the doctors what happened was that really strong candidates were not offered interviews.
Q398 Sandra Gidley: That is unfair to blame the Deans ---
Dr Hilborne: I am not blaming the Deans; I am blaming the questions and the process.
Q399 Sandra Gidley: But you blamed the short listing process for being unfair. Surely you were part of deciding on the nature of that short listing process, or not?
Dr Hilborne: No. The JDC and the BMA had absolutely no input into the design of the application form on which the short listing was based. We were very specifically excluded from the group that was doing that work because they felt that having junior doctor representatives involved in that group might mean that those individuals would be unfairly advantaged or that some doctors, maybe JDC members, might be unfairly advantaged in the application process. So we had absolutely nothing to do with the design of the questions and we were not privy even to the domains that were being questioned about until the form was available online as it was for everybody else.
Q400 Sandra Gidley: So you do not accept that having four applications per candidate was a mistake?
Dr Hilborne: No, I do not, and I think if you tried to introduce that system with fewer than four junior doctors on the ground applying - they were distressed enough only to have four and if they had only had one or two it would have been completely inappropriate, it would have been completely impossible.
Q401 Sandra Gidley: But would they not have had more interviews because 17% got four interviews, so did that not skew what was available for the rest? 17% of applicants had four interviews so does that not skew what was available for the rest and a lot of the doctors did not realise that they might have a better chance next time around?
Dr Hilborne: That is a communication issue, is it not, and that is the Department of Health communication issue because it is their initiative; it is up to them to explain to doctors what is going on.
Q402 Sandra Gidley: You told us that you were communicating as much as possible ---
Dr Hilborne: After it had all gone horribly wrong I think we probably were not communicating as well as we could have done before; but, again, to some extent how much is it our job to tell doctors what the Department of Health is doing?
Q403 Sandra Gidley: I am trying to sum up the Department of Health to the JDC. The Department ignored you when you called for implementation to be delayed to 2008, but officials blamed the JDC for the decision to offer four applications to each doctor. Does this not show a rather fickle and contemptuous attitude towards the profession, or would you not like to comment? I think Ian Wilson might like to comment on that.
Dr Wilson: It is probably appropriate we look at 2007 and if you want to explore 2008 that is a separate question.
Dr Hilborne: I think when we were saying things that the Department agreed with they were happy to do it. The decision about four interviews was actually taken quite early in the process as well. By the time I was involved I think that was already pretty much finished. It was as we got nearer and nearer to go live to January 2007 and we were still continuing to raise grave concerns about how this is not ready, that is not ready, the other is not ready, but they started listening to us less and less - and I think it is because they really had this idea that they absolutely had to do it then - and I am sure they believed there were practical reasons why they could not delay it but I am sure there was an overwhelming political reason why delaying it could not be seen to happen and they just ploughed on regardless.
Q404 Sandra Gidley: So none of you would like to describe the Department of Health as fickle and contemptuous then?
Dr Wilson: I will use the words fickle and contemptuous to help you along, yes. That is the way that the Department of Health has responded to the medical profession over a number of years of late, but we have been working increasingly well with them more recently and have much better communications with them than we ever did, so it would not be fair to describe them in that way now. It would be fair to say that I have concerns about process from hereon in. There are dangers of us slipping back into some of the territory where things went wrong in 2007; but fickle and contemptuous is not right for the current period. Engaged, constructive, difficult and being extremely careful with each other.
Q405 Charlotte Atkins: Why did you oppose Remedy UK's legal challenge to the decisions of the Douglas Review? Who made that decision?
Dr Hilborne: There were a lot of aspects of Remedy's legal challenge that surprised us, to be honest. We were first of all surprised when we heard that they were taking a challenge at all because we had taken extensive legal advice and that had been that there was no reasonable legal challenge that could be made to MTAS. We were again surprised to find that they were not challenging MTAS itself, they were challenging the review group that was trying to fix what had gone wrong with MTAS, of which the BMA was a member, and we did not feel that we had behaved unlawfully in being a member of that group. The proposals that they were bringing forward as a way of fixing things, the two that were in the documents were to stop everything and start again, or to appoint everybody to one-year posts and do it all again next year better, and after a great deal of heart searching we did not think that we could support those as being in the best interests of the junior doctors who were already by this time - this was in the end of April - well through this difficult and traumatic time. We were surprised again in court when one of the arguments the barrister put forward for only giving temporary posts was that that would allow the BAPIO problem time to be dealt with, and we were even more surprised in court when in oral statements they came up with another possible solution, which in fact was one we could have supported if we had had the opportunity to know about it in advance. So in summary there were two main reasons: one was that we had been quoted as an interested party and we were implicated in the group they were bringing the action against, we were involved in that group; two, we did not believe the two suggestions that were in the papers were in the best interests of doctors.
Q406 Charlotte Atkins: What was the reaction of your members? Did they see that as some sort of betrayal of their interests?
Dr Hilborne: I think a lot of members were very upset about it and I think the perceived remedy was as the brave underdog battling against the mighty horror of the government, the DH and MTAS, and I think there were some members who felt that we had let them down. I am sure that there were other members who felt - I know there were members of the committee who felt that they did not want Remedy's solutions to be implemented, and if we had not gone to court and that had happened I am sure there would have been a cohort of members who would have turned round to us and said, "Why did you not stop this happening? This is horrendous; we do not want this."
Q407 Charlotte Atkins: Presumably you would know about the opposition of your members because they would have contacted you. I do not believe that doctors are particularly slow in coming forward and presumably at your offices you would have had quite an influx of comments from your members?
Dr Hilborne: Yes, we did.
Q408 Charlotte Atkins: And they were largely opposed, were they, to the BMA position?
Dr Wilson: Can I join in? My recollection, from having looked at some of the letters myself, was that it was fairly mixed, to be honest. We kept a very close eye, as I mentioned before, communicating through Doctors.Net.UK, and there was a mix; it was not entirely balanced but then it is a relatively small number of people that throw in the most forthright comments. We had a significant number of people supporting what the BMA had done.
Q409 Charlotte Atkins: So what was the balance? You said that it was not entirely balanced; so what was the balance, which way was it?
Dr Wilson: Inevitably with these things the criticisms always outweigh the positives, so there were more criticisms than were positive; I could not give you a proportion.
Dr Hilborne: We have talked to Remedy - and Chris is here in the audience - about this afterwards and both sides have acknowledged that both sides could have handled the whole situation better, and I think that afterwards we did maintain a working relationship with them, and we have worked together with them and there have been meetings with them. It has not brought down the shutters; it has not turned into a huge schism between Remedy and ourselves.
Q410 Dr Taylor: Just to relieve you, I have the last set of questions and they are on the absolutely huge topic of the Tooke Review, so I am going to crystallise them. First, I want a very brief comment from each of you on your feelings in response to the Tooke Review and then we will go into detail a little bit about the postgraduate training programme that they recommend. First of all, general comments: do you welcome the Review, do you think it is rubbish?
Dr Mehta: Certainly it is not rubbish and I think Professor Tooke has taken a lot of trouble and done a lot of work on it. There are some very good suggestions and solutions. I think as far as run-through training is concerned our view is that it is a good system. Having had a two-year foundation training and then getting into the speciality so that you have decided what speciality you want and you train in a shorter period is a good idea, and we are quite happy with that system of training. The concept is right. The application of it has been a major problem and the reason for that is that discussions have not been done properly and I think that there has to be some flexibility brought in for earlier years, but on the whole we are very happy with the concept.
Q411 Dr Taylor: Fine; we will come back to postgraduate training. Just a general comment, Ian.
Dr Wilson: Overall it is an excellent report in many, many ways. I have encouraged the people reading it not to simply read the recommendations because the commentary that leads to the recommendations is actually so far more insightful and so more important for people to read than the list of recommendations themselves, many of which are actually well advanced in terms of actioning them. As you would imagine, there are a few bits with which we would take issue, and quite a lot that we would like to know more detail on. That is my brief picture on that.
Q412 Dr Taylor: Thank you; we will come back to the issue bits. Jo.
Dr Hilborne: When the Tooke Review was announced we were delighted that the government had heeded our call that it should be a real, thorough independent review of the whole of MMC, and I think that Professor Tooke has done a fantastic job in looking in great depth at the whole idea of MMC. Again, as with Ian, some of the recommendations are more welcome than others but on the whole I think it is an excellent report and it has obviously been really carefully and thoroughly researched.
Q413 Dr Taylor: So coming down to the actual postgraduate training details, foundation year cut from two years to one year; comments on that?
Dr Wilson: That is one of the areas where we take issue. We actually think that of all this period the foundation year appears to have been one of the successes - the two years. I think we disagree that separating the two parts out would be a good thing. I have read what Sir John wrote in his submissions and I fail, despite repeated readings, to understand the legalities. It was Professor Heard or Professor Crockard who outlined that and I agree entirely with what they say; that it should not be too big a job to finesse the legalities, to make it a two-year post. That year is about assuring quality and assuring a general good standard that we know not just about acute problems and chronic problems, it is actually knowing whether the problems are serious or are less serious. But we would like to stick with the two years.
Q414 Dr Taylor: Do you agree with Ramesh who felt that at the end of the two years that is the right time to decide whether you want to specialise and what speciality it is going to be. I think that is what you said, is it not?
Dr Mehta: Yes. Could I just also comment very quickly on two years of foundation? I have personal experience; my daughter has just finished the second year of foundation training and starting ST1, and I have been watching her from this general broad viewpoint as to the effect on the training. I know that initially she was quite stressed with being thrown in at the deep end, but I have observed her as growing into a very competent doctor, and I think two years of foundation training is a very good idea. To answer your second point, run-through, we were quite happy with the run-through.
Q415 Dr Taylor: Do you not think that Tooke's core speciality training includes enough of the general stuff to actually cover the second year of foundation training?
Dr Wilson: No because he is very early on starting people down the road of sub-specialisation still. I partly agree with what Ramesh said about it being the time for considering specialisation, but it is only the early stages. Whether it is for a run-through system or whether it is a decoupled system becomes irrelevant if you have the first part with enough flexibilities, transferable skills - and I keep emphasising the desperate need to get transferable skills pointed out. And that matters little at that stage. Then there has to be the flexibility to make the choices for the doctor, but far more importantly make sure that you have the right people in there for the patients.
Dr Hilborne: There is no evidence that the foundation programme has failed in any way. The two aims of the foundation programme: one, care of the critically ill patient, recognition of the critically ill patient, but also exposure to specialities that you would otherwise maybe not have encountered, not necessarily to know exactly what speciality you want to go into but to give you a bit more of an idea of the range that is available to you. I think both of those are important benefits and I think it merits retention.
Q416 Dr Taylor: Coming to the other end of the training, from higher speciality training Tooke goes to specialist consultant and he also includes the Trust registrar job - whatever you call it, the staff grade job, whatever - and allows that a way back in to the training system, which strikes me as a good thing. And the College of Surgeons separately have said that rather than call, as it were, the junior consultant just specialist they would rather call them junior consultant. What are your comments on that end of the training?
Dr Wilson: I think that the Royal College of Surgeons are still working up their thinking of this one, and having spoken to Mr Robeiro very recently on this one I know how changed their position might well be by the time you get the chance to talk to him. The thing that interests me about this, as I said, reading the text rather than the recommendations is important because an awful lot of store has been set by a single diagram in the Tooke Report, and in fact looking at it - and I have it here as well - it is not a recommendation; it does not appear as a recommendation and nor - and I have asked Sir John this direct - is it actually a model for workforce planning, and yet it has been interpreted by many as a model for workforce planning. In many ways, if you simply move the box marked "specialist", the left hand side of the dotted line, it is simply a statement of fact because once you achieve your CCT you are, in European law, a specialist - one cannot change that. The difference in view we would have with some of the parties is whether you should create a new grade called specialist in order to bring in those people. What we believe and what I understand Sir John is quite sympathetic too - although the final report, I believe, goes to Press in the morning - is rather than creating a second grade which actually achieves nothing and delivers nothing and has no place that cannot be dealt with in existing structures is to create a portfolio within the consultant grade, which is something we have called for and certainly something that was central to our thinking throughout the negotiation of the consultant contract, and is certainly something that the BMA is working very hard on persuading employers to use far more effectively. I think that is an answer to your question, but I was rather hoping you might mention the word "governance" to me at some point, but that is your choice!
Q417 Dr Taylor: The table in the edition we have does say "Inquiry recommendations" but obviously we have to wait for the final edition to see if these are recommendations.
Dr Wilson: Forgive me, what I was actually suggesting is that there is not a numbered recommendation which says, "I believe it should create a sub-consultant grade" and indeed Sir John does not believe, having spoken with him indirectly, that a sub-consultant grade should be created. What he says is that in some areas it has become an inevitability, although I would dispute that, but actually believes in the portfolio model of a consultant career, and certainly that is the work that the Royal College of Surgeons are working on as well with us and others, and the BMA is working very closely with the Department of Health and the Director General of workforce planning to that end.
Q418 Dr Taylor: What do you think of the question of the necessity to break the current fixed link between the numbers of doctors in training and the numbers of consultants in the future workforce?
Dr Wilson: We need flexibility in what we do; there is a clear need that you need to match the skills to the patient. I am not sure that we have ever really and truly had a fixed link, if we are honest - I think there is a perception of one. In practice what we need is to train doctors up to the right standard so that the best skilled doctors with the best portfolio of skills are treating the most complex cases earlier on, and that refers back to what I was saying earlier about numbers of consultants.
Q419 Dr Taylor: Were your comments on governance relevant to this?
Dr Wilson: They are relevant to the Tooke Report; they are relevant to 2008.
Q420 Dr Taylor: Very quickly to the Tooke and 2008.
Dr Wilson: Tooke makes it very clear that he was extremely concerned about the governance arrangements in 2007 and we must never allow that to happen again. I think there are many members of the current 2008 programme board, the clinical side in particular, that have grave concerns that the governance of 2008 has dangers - it is not there yet - is in danger of slipping back into some of the territory that 2007 slipped into. If I may, I have asked on many occasions what exactly is the role of the Chief Medical officer in the board in 2008 and have been specific saying, "If we get into the circumstances we are currently in and if your Committee were unfortunate enough to have to look at this again in 2008 would the answer of the Chief Medical Officer be the same as he gave you when you interviewed him fairly recently?" I see no direction of travel within the Department to appoint a Director for Medical Education or for standards of quality in training, and I see grave concerns amongst my College colleagues that we are slipping back to the 2008 board being about workforce rather than about standards and quality. I do not think that is irreversible but I have concerns that that is the way things are slipping. Being at the table does not necessarily mean that we are making the decisions as clinicians.
Q421 Dr Taylor: What should our recommendation be for 2008, in a nutshell?
Dr Wilson: Much clearer governance involving a senior clinical within the Department and that this should be about quality and standards and not about workforce planning and that the clinicians around the table should actually be part of the decision-making process, not simply turning up to agree or disagree with Department of Health driven policies.
Q422 Dr Taylor: So we are back to independent medical leadership that is really taken notice as opposed to Professor Crockard?
Dr Wilson: I think we have the potential to get back there but I am worried that we need to make those moves now, and I really mean within days and weeks and not within months.
Q423 Chairman: Does that not contradict what you said earlier about the lack of workforce planning as far as doctors are concerned?
Dr Wilson: Not at all. I think we need robust workforce planning but I think that the 2008 board should be about quality and standards and building on the frameworks that have been outlined that Tooke has suggested, not simply and only about delivering on a workforce model that is decided by others.
Q424 Chairman: Workforce planning is important in all these respects.
Dr Wilson: Workforce planning is vital but the board should not be about turning up to agree the decisions of what strategic health authorities have decided they will allow us to do in terms of numbers.
Q425 Dr Naysmith: That is just not fair to say that because training is an intrinsic part of the workforce planning in the National Health Service and the two are inextricably linked.
Dr Hilborne: That is the point I am about to make. The whole idea of training up junior doctors you have to be training the workforce that you need, but you also have to be training them to a standard and with training methods that are appropriate in skills that they need to have and assessing them as they go along. The two are essential.
Q426 Dr Naysmith: It is the three because you are actually using them as a workforce whilst they are being trained.
Dr Hilborne: Absolutely, but what we perceive is a shifting of the balance too far towards workforce and away from the importance of training itself and standards and education.
Dr Wilson: Forgive me, I am not suggesting at all that workforce should not enter into these discussions; I am suggesting that I have a concern and I know that the Presidents of the Colleges have a concern that it has shifted entirely to workforce.
Dr Naysmith: I would disagree with that.
Chairman: We will have a look and see comes out of this because this because there is an issue about workforce planning and quality of training as well and that is how we got here and that is how we got the lost tribe and everything else. Let us see what Professor Tooke makes of it and us in due time. Could I thank all three of you for coming along and giving evidence before us this morning?
Witness: Mr Mark Johnston, Managing Director, Methods Consulting, gave evidence.
Q427 Chairman: Welcome. First of all, can I apologise for the lateness of this start. For the sake of the record, I wonder if you can give us your name and the position you hold.
Mr Johnston: Certainly. My name is Mark Johnston. I am Managing Director of Methods Consulting.
Q428 Chairman: When you were initially contracted to provide the software to support the MTAS application process, how long were you given to build and test the new software? What was the timescale on all this like?
Mr Johnston: The contract was signed on 8 March and the first deliverable was the Foundation supporting the software. That went live in October, so from May through to October to get the Foundation element started. Then in terms of Specialty, the applicant side of that went live in January. Prior to that it was the elements of the software to allow the posts to be put on and so on. I cannot exactly recall the date of that.
Q429 Chairman: How many applications were you originally asked to design the system for? Did the number change while you were building the system?
Mr Johnston: Yes, it did indeed. The number of applications per round was contracted to be 15,000. In Specialty there was originally planned to be two rounds plus a clearing round. There were various other metrics in terms of volumes as well. I can check the date, but partway through we were asked whether that could be increased to cope with 40,000 applications in a round. We did an assessment on that and we came up with an increase in the specification of the hardware predominantly and that was created and implemented.
Q430 Chairman: I know enough about technology to know that you need to put more memory into a system if you need to hold more information. What were the implications for lifting up the number of applications in the way you have just described in terms of the contract? Were there any time constraints or pressures created by that?
Mr Johnston: Not directly by that, no. Clearly a larger number of applications means more tension in terms of those applying, which is a completely separate issue, but it was a fairly straightforward change at a cost of, off the top of my head, about £10,000, so not a significant change.
Q431 Chairman: As far as the Foundation programme is concerned, that is up and running and still running now as I understand it.
Mr Johnston: Indeed.
Q432 Chairman: It is the Specialty one. Was it that the system for selecting candidates for Specialty Training was more sophisticated or what were the problems which came along with it from your perspective of getting it up and running?
Mr Johnston: It is probably worth putting it in context in terms of the MTAS project itself because there are a lot of things described as MTAS which have got into general terms but, in fact, the MTAS project itself was there to design, build and run a solution against a set of detailed requirements which would be provided into the project, things like rules, processes, questions on the application form, methods being used for the selection, advice and guidance given to applicants, overall timetable, the behaviour of deaneries and everybody else who are participating, so the overall approach was all to come into the project. In terms of our challenges, it is fair to say, as you say, that the Specialty software was more complex than Foundation, although there are shared elements clearly in that. There was a timetable to build those elements, but they completely relied on us receiving those detailed elements which we required by certain dates. Our largest challenge was getting that information to us in those dates. Fundamentally, technically, no particular challenges should have faced us which could not have been delivered on time.
Q433 Sandra Gidley: What did you think of the project management arrangements at the Department of Health?
Mr Johnston: I can only talk in an informed way about the project itself and that was run in a very formal way according to PRINCE 2 project management methodologies. There were project initiation documents, formal timetables, progress reports, risk and issue logs very formally run as you would expect.
Q434 Sandra Gidley: There was a formal timetable, was it adhered to? How frequently were you asked to change it? How frequently was something added in from the initial specification?
Mr Johnston: It is fair to say that as time went on more and more changes were coming in to us. In terms of how we managed the project, it was very formal for much of the project. I cannot comment on the overall arrangements other than, as Tooke makes clear, they were very complicated. Our concern was from wherever in that set-up we needed in what we needed to get our part of the project done. It is fair to say those things throughout the project at various times arrived and were changed later or because of all the other things which were going on in terms of judicial reviews and everything else, things had an impact on our ability to deliver the system.
Q435 Sandra Gidley: You did not quite answer my question about how frequently were you asked to change something, and were you ever put under pressure that you felt, as someone having to deliver the project, it was undeliverable but you obviously tried hard to please your paymaster?
Mr Johnston: We will always try and please our clients, but we will always try and work within a structured project management. If you take Foundation, for instance, there were a few things which were not delivered on time, however we saw that was going to be the case and we took mitigating arrangements to say, "Yes, if we re-arrange this and this we can still do Foundation successfully". We knew what we were doing on both sides. Those changes in timetable of delivery in to us were accommodated and that element went live and ran right through. In Specialty the same applied, that in September we were supposed to have a set of detailed requirements which we could work against, if we could then do a design activity, so the difference between requirements and design, design being, "Well, if that is all the things the application form has to have on it, et cetera et cetera, this is exactly how it should look and feel on the system". When we ran our design exercise it became clear that quite a lot of those requirements had not really been thought through in enough detail or were still subject to external issues. From that point onwards we were faced with changes. We did assess the impact of that. We re-organised the project to say, "If you can give us these decisions, we can get this part of the project built, which is the first part that would be used". That is an acceptable approach to start with. It is fair to say that as time went on and we got into December, January time, those changes were becoming somewhat overwhelming and then the Douglas Review effectively stopped formal project management because then decisions were coming on a daily basis, you might say.
Q436 Sandra Gidley: Your company obviously provides systems to other paymasters. Would you say there was an unusual level of churn and change in what the Department of Health required of you during this project or does that always happen?
Mr Johnston: No, there will always be changes in a project for sure.
Q437 Sandra Gidley: Or an unusual degree of change? I accept there is always change.
Mr Johnston: Yes, I would say there was definitely an unusual degree of change towards the back end of this, very unusual.
Q438 Sandra Gidley: You mentioned the Tooke Review and in that the governance arrangements for the MMC and MTAS were criticised. Who do you report to at the Department? Did you have any contact with the MMC team itself?
Mr Johnston: The MTAS project itself was a Department of Health project and I think that was chaired by the Deputy Director of Workforce Capacity.
Q439 Sandra Gidley: Is that who you reported to?
Mr Johnston: Yes, that was the senior responsible officer for that project and that was who we reported to. In terms of more informal engagement, yes, at various times we might have been talking to lots of other groups. Probably the one we were most regularly in contact with was the Rules Group who was there to define the process and that sort of thing, but project management-wise, it was a very formal defined process.
Q440 Sandra Gidley: There was not any formal contact with the MMC, if anything it was a bit more informal?
Mr Johnston: When I say informal, I mean as part of the process we may have engaged in a workshop or whatever.
Q441 Sandra Gidley: Can you say categorically for certain whether you did or you did not have contact with the MMC team?
Mr Johnston: Yes, I am sure we had contact with the MMC as part of the project. I am making a distinction between our project management reporting lines and the involvement in design activities or whatever with the MMC.
Q442 Sandra Gidley: Would it be possible for you to clarify the contact you had because it sounds a bit vague.
Mr Johnston: Certainly. I am not avoiding the question, I am just pointing out that it is quite a wide area of governance and I am not altogether sure about all the people we contacted, but certainly we can do that.
Q443 Dr Naysmith: On that last question, how many times did you personally go to the Department of Health and speak to the people involved?
Mr Johnston: My role was as senior supplier. The project itself was headed by one of our very senior project managers who was not physically there every day but was involved every single day. I would have been there formally once a month and at various times there would be a meeting in between that.
Q444 Dr Naysmith: You did not take part in meetings at the Department?
Mr Johnston: I personally was not involved in things like the design sessions and that sort of thing, no.
Q445 Dr Naysmith: You were there once a month to talk about things?
Mr Johnston: There was a formal project board once a month.
Q446 Dr Naysmith: That is where you were, you were there once a month?
Mr Johnston: That is correct, yes.
Q447 Dr Naysmith: Can we move on to the question of piloting. Was there any attempt to pilot the Specialty Training selection software before it was used? It is good practice to run pilots, is it not?
Mr Johnston: It can be. It is not necessarily a silver bullet to all solutions. The decision in terms of piloting was taken even before our involvement. We got involved when there was a tender to deliver the project against certain timelines.
Q448 Dr Naysmith: Was there piloting or was there not?
Mr Johnston: There was no piloting of the project, however it was our understanding that elements of what had been done in terms of concepts had already been piloted in a certain way, such as Foundation had been tried out using a different system, but in terms of white space, the concepts had questions not in our area of expertise but we understood that had been done before.
Q449 Dr Naysmith: You were staking your reputation on something which you were taking somebody else's assurance on that it had been tried out before. Is that sensible?
Mr Johnston: As a company we would always like to be involved from the start in solving a business problem, however every client is different and every project is different and you make an assessment as to whether what you are being asked to do is doable. Our assessment at that time was, yes, it was doable because we understood the discussions about Specialty and Foundation had been going on a long time before even the tender came out.
Q450 Dr Naysmith: There were some stories about how the software was not very user-friendly. For instance, when you set up a candidate's application, the number only appeared on the front page and did not appear on subsequent pages, which meant there was a possibility of confusion between applications or people had to laboriously add the number on to each page to make sure because these things would be read by lots of people. Is that not a fairly simple thing to pick up early on?
Mr Johnston: Undoubtedly, like all systems when you go live, you will always find things that you can improve on.
Q451 Dr Naysmith: You sort them out usually by piloting and testing them.
Mr Johnston: Some things could have been improved if this had been gone through but, bear in mind, a pilot would have been live anyway, it would have been with live people.
Q452 Dr Naysmith: Yes, but they would not have their careers on the line, would they? They might have done, but they would be piloting the system.
Mr Johnston: I do not know how you could have piloted it unless you used real people. Therefore, if you think about the challenges, everybody would have been able to apply to even a piloted system. As I say, it was not my call to pilot or not, but a pilot still would have been open to the entire set of people who applied this time to a pilot.
Q453 Chairman: With a pilot you could try it out in small sections, could you not?
Mr Johnston: Yes. I am only making the point that you can restrict the number of applications that go on but you cannot restrict the number of people who apply, so any pilot would have potentially involved just as many people applying, et cetera.
Q454 Dr Naysmith: The Tooke Report shows that the MTAS system was given a red risk rating by officials from May 2006 onwards. Were you aware of this at the time?
Mr Johnston: I personally was not aware of a red risk in May 2006.
Q455 Dr Naysmith: Do you not think you should have been?
Mr Johnston: The project itself?
Q456 Dr Naysmith: Maybe you should have been made aware of it.
Mr Johnston: Possibly. What I would say is the project itself had its own risk assessment on an ongoing basis. I was aware of a red flag set in September 2006 which was around Foundation predominantly in terms of, first of all, there not being a date set by which an alternative arrangement should be decided, in other words a go/no-go date and, secondly, one of the items we required into the project had not been delivered on time, but we had already come up with a mitigation approach to that and resolved it. That is the only red I was aware of.
Q457 Dr Naysmith: You are saying you did not know until September 2006 that there was a red risk when it became known to some people in May.
Mr Johnston: I am saying I am fairly sure I did not know that. I am fairly categorical that I did not know that.
Q458 Dr Naysmith: You did not become aware that the project was seen by the Department as seriously at risk until six months after they said it was?
Mr Johnston: Not that I can recall because May was when the contract was let.
Q459 Dr Naysmith: Was anybody doing anything to mitigate that in May 2006, somebody in your organisation who may not have told you?
Mr Johnston: In May 2006 when the project started, the project was formally initiated, it had a formal risk log and an issues log and within that each risk was assessed in terms of impact and potential likelihood with a mitigation approach. That was formally run right through from May onwards and the risks evolved over time, so the risks started mainly around Foundation and then they moved towards Specialty. As you would expect within the MTAS project itself, that is the way those risks were managed.
Q460 Dr Naysmith: Are you saying the risk which was drawn attention to by the Tooke Report is what you are talking about now or was it something similar?
Mr Johnston: I cannot comment on May. I can only say that the risks which were identified were at a reasonably detailed level, as you would expect, and mitigation was put against them. What I am aware of is the September 2006 red.
Q461 Dr Naysmith: We will go from there then. We know the system was thought to be risky by officials, what was being done to lessen the risk and mitigate the risk?
Mr Johnston: There is no question, all projects have a risk. The main risks were that we required elements of the requirements by certain dates. The other risks are more traditional in terms of making sure the development happens on time, et cetera. There were formal project management activities put in place to ensure that, so there were very clear timescales by which we needed decisions.
Q462 Dr Naysmith: Finally, you are saying that all projects have a risk, a risk rating or are a bit risky, did you think this was a more risky project than any others you had worked on?
Mr Johnston: I think in hindsight the environment in which this project was being undertaken, which was not necessarily imparted to ourselves to start with, meant that there was undoubtedly a risk that there would be an adverse reaction, regardless of what happened on the system, to what the system was trying to achieve. That was a much higher risk than most projects we work on. Other than that, on the actual implementation side of things, no, there was no additional risk from our perspective in terms of the time we had to develop the software and things like that.
Q463 Stephen Hesford: Mr Johnson, can I check some dates because they are crucial to the question I am about to ask you. If we do not nail them down, my question becomes slightly irrelevant. When did your company first become involved?
Mr Johnston: The contract was let on 8 May. We were tendering for it prior to that, but we signed the contract on 8 May 2006.
Q464 Stephen Hesford: By the time there were security breaches a year later, your company was still involved?
Mr Johnston: Yes.
Q465 Stephen Hesford: Your company was in control of the project as you would want them to be at that time?
Mr Johnston: As I said, it is important to understand the scope of that project and our deliverables, the technical elements of the project to do whatever had been decided to be done, yes, that is correct.
Q466 Stephen Hesford: There were two breaches in April on consecutive days, when did you become aware of those breaches?
Mr Johnston: Immediately as they happened, within two or three minutes.
Q467 Stephen Hesford: Were you surprised by those breaches?
Mr Johnston: Yes, very surprised.
Q468 Stephen Hesford: Why did they come about?
Mr Johnston: First of all, I would like to apologise that there was a security breach, and the feature of the system which allowed people to see things, although not particularly of any use, had it been spotted in testing would have been changed. It is clearly not something we would have wished to happen. The context of it happening was that by the time these came about there were a huge number of changes coming our way which could not be subject to a formal change control process or anything else, we were in the midst of days count and I guess our choice by that time, in fact for some time, was either to have walked away from this in terms of, "Sorry, we're not responsible for this" or to try and work at the problem along with everybody else to get through it. It did mean I had a team that was working extremely hard - and I am not making excuses for this - and really had been working around the clock. We had a situation where information needed to get to the medical schools or the deaneries, I apologise, I am not altogether sure which. The original methods had been that they would be able to access the system, but there was no agreement on standard formats for doing that in terms of the programmes themselves, therefore we needed to get that information out. The method we used to provide that information, which was an acceptable method, had problems at the far end in terms of the ability for these organisations to take that information, in some cases because of their security arrangements, unfortunately. There was an alternative arrangement put in place for these files to be obtained and through a very untypical mistake a senior member of my team put them in place in a way which was not secure enough because they did not check enough as to what they had done. It was a simple mistake in terms of he made a call in doing something, which was very untypical of him and he was very tired from working very hard, and that is what caused it.
Q469 Stephen Hesford: Was that the same for both?
Mr Johnston: The second one is slightly different. The second one is the ability, if somebody so chose, to go in and manipulate the web address while they are logged into the system and see other messages. Those messages are anonymous and you cannot choose what individuals would have seen them and they are of no value to anybody. However, had it been picked up in our test or user acceptance testing, it is fair to say we would have probably said, "No, let's change that to make sure somebody can't do it".
Q470 Stephen Hesford: They were very embarrassing breaches.
Mr Johnston: Clearly, yes.
Q471 Stephen Hesford: Because you understand the sensitivity of the whole MTAS thing, we all do now, MTAS was suspended and never reopened for selection purposes. Do you think that was a reasonable response to these security breaches?
Mr Johnston: The applicant side was suspended, the system itself continued to be used. I think by that time these were on top of a great many issues in terms of the likes or dislikes of the agreement as to the whole approach to this in terms of how selection was being done and everything else, and I think we had already gone past the point of the original concept of everything happening on the rounds and everything happening on the same day. At that point a suspension did not have huge implications in terms of being able to complete the round which was being done, so I think it probably was a sensible thing to do. In the context of that, plus everything else, the heat had got such that there was not a lot of choice.
Q472 Chairman: There was an inquiry about the second breach which you mentioned. Did that ever come to any conclusion or did it just die out?
Mr Johnston: The conclusions were almost as I have stated, that was the functionality which existed and it was changed very quickly.
Q473 Chairman: They were not trying to find the individual who had done it having accessed the website and then going into it.
Mr Johnston: That I do not know because that investigation was taken over by the Department.
Q474 Dr Naysmith: The Department has decided not to use the central computer system for this current year, this 2008 application process, but they have said they are going to look at using a similar system again in 2009. Do you think that was a fair judgment or decision given the problems experienced by the system in the first year of its operation?
Mr Johnston: An awful lot has been attributed to "the system" which is not "the system", it is the way the system is used or the rules which the system applied. I think it is fair because there is no common agreement as to how this should be done and, unless there is, no system of any sort can support it. That is the central issue and that is what became quite apparent as we got close to going live and after we went live, that there were deep-seated disagreements as to exactly how it should work.
Q475 Dr Naysmith: As in it was not fit for the purpose that it was going to be used for?
Mr Johnston: No, this system was fit for purpose.
Q476 Dr Naysmith: Why not use it once it is fixed?
Mr Johnston: Because there is no agreed process against which that system could be used. There are too many nuances and too many other things. To put it in context, there may be agreements at a higher level, but when you look at the detail of exactly how this works, that detail is not necessarily agreed, therefore there is no agreed process this year which could be systemised, so to speak, so I think it is absolutely the right decision.
Q477 Dr Naysmith: Do you have any ongoing contracts with the Department?
Mr Johnston: Yes, we do. We continue to provide this service. The application side of Foundation has just completed using this system. The system is still used for the information which it has on it from last year.
Q478 Dr Naysmith: Do you intend to seek to be involved in developing the system for 2009?
Mr Johnston: That is the Department's call. We have a contract to provide it.
Q479 Dr Naysmith: You already have a contract to provide it in 2009, do you?
Mr Johnston: Yes, the contract was for a period of five years. If you look at the lowest risk approach, if a national solution is right the lowest approach is the one which has already gone through this exercise that now has a security level which is very far above what would normally be required and with a team that really has a very deep understanding of a lot of the issues. As I say, the system itself in the round was delivered on time and performed as it should have and as it was asked to.
Q480 Dr Naysmith: You are being paid to run the system in 2008 or have it up and ready to run even though it is not being used, is that what you are saying?
Mr Johnston: It is being used, it is being used for the Foundation.
Q481 Dr Naysmith: That is a fairly simple exercise compared with what it was for.
Mr Johnston: It is not necessarily simple, it still requires to have the whole application process running through it and so on. To a certain extent, the number of applications that come through is not the defining element of costing.
Q482 Dr Naysmith: Sorry if I am dense, but you have got a contract for five years to run something and you are still running it even though it is not being used for the Specialist impact?
Mr Johnston: That is correct.
Q483 Dr Naysmith: You are still getting paid the same as you would have been getting paid if it had been running.
Mr Johnston: Not quite the same. There are elements which are attached to running around but, in general, yes, the system is there and it is being used.
Q484 Dr Naysmith: It is really for the Department to use but it has chosen not to use it, so they have got to pay you for the system.
Mr Johnston: What our contract is for is for the build and running of the systems which can support any round and it is being used actively just now.
Q485 Chairman: The information it has got in relation to the Specialist Training is available for deaneries and everybody else, but it is not doing it in the way which was envisaged earlier this year, that is what you are saying basically, Mr Johnston.
Mr Johnston: Correct, as well as running Foundation.
Q486 Chairman: I realise that is ongoing. Can I thank you very much indeed for coming along here and helping us with our inquiry this morning. It is probably not something a company of your size does every day, every week or every year!
Mr Johnston: We are a reasonable sized firm but it certainly has been a first.
Chairman: You will be able to put it on your CV anyway! Thank you very much.