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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

MODERNISING MEDICAL CAREERS

 

 

Thursday 17 JANUARY 2008

 

PROFESSOR DAME CAROL BLACK, MR BERNARD RIBEIRO

and DR BILL REITH

 

PROFESSOR ELISABETH PAICE, PROFESSOR DAVID SOWDEN

and PROFESSOR SARAH THOMAS

Evidence heard in Public Questions 487 - 617

 

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Oral Evidence

Taken before the Health Committee

on Thursday 17 January 2008

Members present

Rt Hon Kevin Barron, in the Chair

Charlotte Atkins

Mr Peter Bone

Jim Dowd

Sandra Gidley

Dr Doug Naysmith

Mr Lee Scott

Dr Howard Stoate

Dr Richard Taylor

________________

 

Witnesses: Professor Dame Carol Black, Chair, Academy of Medical Royal Colleges, Mr Bernard Ribeiro, President, Royal College of Surgeons, and Dr Bill Reith, Chair of Postgraduate Training Board, Royal College of General Practitioners, gave evidence.

Q487 Chairman: I welcome you to the fourth evidence session of our inquiry into modernising medical careers. For the sake of the record, perhaps you would introduce yourselves and tell us the positions you hold currently.

Mr Ribeiro: I am Bernard Ribeiro, president of the Royal College of Surgeons. I am a general surgeon.

Professor Black: I am Carol Black, chairman of the Academy of Medical Royal Colleges.

Dr Reith: I am Bill Reith, a general practitioner in Aberdeen. I chair the postgraduate training board of the Royal College of General Practitioners.

Q488 Chairman: To start with, I ask a general question of all of you. What role did the royal colleges play in the design and implementation of the MMC reforms from 2003 onwards?

Mr Ribeiro: It is fairly common knowledge - it emerged in the CMO's report - that certainly one of our specialties, urology, expressed the view that it wished to change the way it was training trainees. Its perception was that there was not the same need for specialist consultants as in the past and early overtures were made to the department to see how that should be done. The report Unfinished Business which followed in 2003 was one which our college fully supported and the five principles enumerated in the Tooke report, that is, broad-based training, were those to which we all signed up. From 2004 onwards our college put forward proposals for training that would move from foundation to a common stem of four areas of acute care very much as now listed in the Tooke report. We also made recommendations that there should be two points of selection: from foundation to specialty and into core training, which would be the four broad-based stems, and then further selection into specialty. We also believed that with the large number of SHOs in surgery there was no possibility of progressing those people without a transition over five years. Those were the views we expressed to the department at the time and that was our position until Next Steps came along and the movement from broad-based training to run-through emerged. When run-through training was introduced it was across all the 57 surgical and medical specialties. That was something we had not recommended. Even the BMA in its original presentation on selection in 2001 - you probably have that document - identified three pathways: a direct pathway, which is the one that urology and neurosurgery opted for; a broad-based pathway; and then a systems-based pathway which would involve medical and surgical people working together. That was something of which we were all very supportive. Therefore, we supported the initial principles of MMC in Unfinished Business but not what happened subsequently; it was imposed. Many of the comments that our college made were ignored in this situation.

Q489 Chairman: Dame Carol, do you have a wider view of all the colleges in relation to MMC?

Professor Black: It would be quite useful to separate foundation from what happened afterwards. All the colleges and, through them, the academy were involved at both stages. For example, we were very involved in the writing of the curriculum for the foundation. That was perhaps the least contentious and most successful part of MMC. There is absolutely no question that with the MMC itself all colleges had an educational role: to define specialist training, the curriculum and assessment against specific standards which would meet the requirements of PMETB. There was an attempt to ensure that the original principles of broad-based flexibility and structured training in MMC were continued. We know of the problems that arose after that. We probably did not do this as a corporate entity. Each college naturally was concerned with its own training programmes. It was rather like several colleges being reasonably concerned with their own training programmes, so we did not necessarily go in a corporate way to represent ourselves at the department. In the reverse direction, many members of the MMC team had regular contacts - for example, Professors Crockard and Heard - with the colleges. I do not know whether you want to consider MTAS now.

Q490 Chairman: We shall move on to that in a few minutes. Dr Reith, do you have anything to add?

Dr Reith: One of the problems of MMC is that it has become muddled up with MTAS which clearly is a difficulty particularly for MMC. As a college we were supportive of the underlying principles of MMC, and continue to be so. General practice is different in some ways, certainly in the way that historically training has been organised. Because the aim of our college is to promote high standards of patient care we have always helped to develop standards of training, curricula and so on for general practice training, but it is implemented in a rather different way. There is a professional cohort of what are called directors of postgraduate general practice education and that group of individuals, not by that name, was set up in the early 1970s when vocational training was first established. One of the reasons we signed up to the principles of MMC was that the extension of the pre-registration house officer year to a two-year foundation programme seemed to us to provide a better opportunity to ensure that at the end of that programme doctors were competent in certain generic skills. Clearly, we were delighted that general practice was to be a key component of that mostly in the second foundation year. However, historically only about 50% of doctors entering general practice training though a three-year programme had done that kind of vocational training programme. The legislation at the time allowed a mix of doctors to do a patchwork, if you like, of hospital jobs and then 12 months in general practice to become GPs. To us that was not logical, so MMC with the run-through programme allowed us the opportunity to make sure that everybody had a proper integrated programme. Therefore, the main reasons were: the competencies that it would provide to doctors at the end of FY2 and also the benefits to us of having an integrated programme.

Q491 Chairman: Moving to the development of the MTAS recruitment system, is it a correct analysis that the royal colleges supported the introduction of a national centralised recruitment system?

Mr Ribeiro: I am not so sure about that statement. I think that in answer to Q312 Alan Crockard in his evidence to you said that his responsibility within the department was for MMC and he was not involved in the early committee structure for MTAS which was the national selection programme. He also went on to say that it was almost a given that this would happen. Therefore, I believe it was a departmental decision to have a one bang national selection process through MTAS. I had warned the secretary of state at one point that we had a problem with MDAP, which was the system used for foundation, when some 200 UK doctors had not been placed. I expressed the hope that that would not happen in the specialty system. Therefore, this was presented to us as a fait accompli rather than that the colleges welcomed a national programme.

Q492 Chairman: Did they accept it?

Mr Ribeiro: Yes.

Q493 Chairman: They did not say they did not want it?

Mr Ribeiro: We accepted it on the assurance that it would work.

Q494 Chairman: That is what happens with most things in life. Dame Carol, did the academy have a view about what the royal colleges thought about MTAS?

Professor Black: There was a group called JACSTAG.

Q495 Chairman: Could you spell that out?

Professor Black: Briefly, it was a joint academy postgraduate dean group. Therefore, it brought together the deans and president of the academy in order to discuss such issues as MTAS. It acquired membership from the Department of Health. If you read the minutes of that particular group it is quite obvious that every college had major concerns. It is well recorded that these concerns were repeatedly brought to the attention of the Department of Health. There were repeated assurances to all of the questions. It is worth recording that I do not believe any college ever saw the completed application form. I believe it saw parts of it, but I do not think that as an application form it ever went to all the colleges for their approval. People saw things in bits. It was discussed and certainly many questions were asked, but I understand that at the final meeting of JACSTAG there was overwhelming support particularly on the part of the deans to proceed, but many of the presidents had severe reservations.

Q496 Chairman: Do you agree with that, Dr Reith?

Dr Reith: General practice was different. We had been working on a national selection process for many years, again through the directors of postgraduate general practice education. Each postgraduate deanery in the UK as well as having a postgraduate dean has a director of postgraduate general practice education. They have very close links with the college and all our members are fellows of the college but they are not ours, as it were; they are employed by the strategic health authorities. They are responsible for implementing training in general practice. Over a number of years they had developed a national programme for recruitment which all the directors of postgraduate general practice had bought into. I believe that is one of the key features. It had been developed and had been brought over by them. It used a computer system successfully for a couple of years before MTAS came in and it had worked successfully. It is suggested that in many ways things have worked very well for general practice, though it is not without its glitches, and therefore it can be just translated for other specialties. I caution against that. Some of the principles would be similar. Obviously, some of the other colleges have tried to work to those principles, but there are differences. Basically, what the directors did with us was work out the defining competencies of a GP and they then set about designing an appropriate assessment method so that standards could be set and everybody who got into a GP programme went through a national assessment process which was the same throughout the UK, not just in England. There was piloting and validation of the GP process and it was delivered online. There has been agreement that as from August 2008 we should revert to that system and there is confidence in it. I highlight the number of years in development - it was not rushed - and also the corporacy within general practice certainly for that but also the assessment process that went on prior to entry to the specialty.

Mr Ribeiro: Perhaps I may clarify my earlier statement. This is a minute from our council meeting of March 2006: "Council received a copy of a letter to The Times which had been signed by 86 eminent doctors and outlined concerns about the electronic selection of foundation trainees. The process of F2 did appear to be problematic, and council strongly discouraged the electronic selection process in the short term." Therefore, we had concerns in March 2006 about the introduction of an electronic system.

Q497 Chairman: It would be fair to say that colleges had concern but accepted the decision of the department to go ahead with MTAS. Do you think the colleges should accept any responsibility for what happened last year in relation to recruitment? It was a bit of a disaster, to say the least.

Mr Ribeiro: It would be silly to say that we should not accept some responsibility as colleges because perhaps by not being as vociferous as we could have been it might be said we were complicit in allowing it to go ahead. We could have aborted the whole process. I gave an interview in June 2006 to Gateway which is referred in Alan Crockard's evidence. I was asked for my view on MMC and I said I believed that the curriculum which the surgical colleges had developed was up and running and would be ready in time for 2007 and for that reason alone I felt the process should continue. I however outlined concerns which I had about the numbers; I said that surgery as a specialty had a large number of SHOs which was unprecedented who would not be able to get through the system. At that stage we had no evidence that there would be a problem with the MTAS process, so again, separating out MMC from MTAS, I was prepared to give the go-ahead for MMC even though I had reservations about transition and selection. Nonetheless, we felt we had a curriculum which could cope with it.

Professor Black: Every college did its very best with MMC to meet its individual needs. What was missing was that they did not act together in unity as an academy. We would then have had a more powerful voice, so we could have helped each other much more and, therefore, would probably have been better co‑ordinated in our response. That is a very definite lesson to learn from this. I believe that everybody was doing their very best which on this occasion was not enough.

Q498 Chairman: You believe that you have some responsibility for what happened last year?

Professor Black: I think there is some responsibility in that perhaps we did not pool our resources in a united way that would have brought us together as a single voice.

Q499 Chairman: Dr Reith, do you agree with that?

Dr Reith: Yes, largely. As ever, hindsight is a wonderful tool. I think that in terms of responsibility there is no one body or organisation that is ultimately responsible for what happened, but many will share that responsibility, as I am sure you have heard. We are still of the view that MMC as a way of reforming postgraduate training had much merit. The MTAS system clearly had significant problems. I mentioned earlier that previously general practice had an online system. We and other specialties had concerns about MTAS at least in relation to the way the online system was set up and we sought to change it. As a doctor I tend always to look for solutions to things and move things forward. I am sure that is true of all of us. While at times we will challenge if we are given certain reassurances we will assume they will be delivered and sometimes they are and sometimes not. It seemed somewhat strange to us that in the midst of all of this the postgraduate deaneries were reformed and reviewed.
The fact that the Department of Health decided to reorganise the SHAs and deaneries - the very people who would be delivering it on the ground - must have had an impact. As far as concern the colleges, clearly we were doing a huge amount of work on this, but equally all the colleges were working to PMETB's timetable for the development of curricula and assessments. There was a huge amount of activity going on. Perhaps the colleges were looking to their own specialties rather than to others, but for PMETB - it is highly appropriate and I do not criticise it for one moment - we had to be specialty-minded because they were looking for a curriculum from each specialty, so perhaps at times we did take our eye off the ball.

Q500 Jim Dowd: Mr Ribeiro, you have already made reference to Mr Crockard. He put it to us that "initially all royal colleges 'signed up' to MMC. They only reverted when it became clear that MTAS would not deliver." Is that an accurate picture?

Mr Ribeiro: It is a question of how you interpret the MMC. We were all totally signed up to the underlying principles of MMC in Unfinished Business. The change over to Next Steps which moved to run-through training was not something to which we were all signed up. In the BMA diagram to which I referred earlier in terms of direct access to training the only specialty identified at that time was neurosurgery; that was the one that went through. I believe that in his evidence to you the CMO indicated, first, that in retrospect the introduction of MMC should have been staggered or phased and, second, the process of run-through training was expected to be done specialty by specialty, but in the end the department imposed it on all specialties to happen at the same time. Therefore, it is wrong to say that we were totally supportive of the concept of MMC because not all of us supported run-through training for every single specialty.

Q501 Jim Dowd: Does anybody else wish to add to that?

Professor Black: I believe that the word used by Professor Crockard was "withdrawal" which suggests a planned, organised action.

Q502 Jim Dowd: The word he used was "reverted".

Professor Black: It was not like that at all because MMC changed its educational direction, not with one big bang but somewhat more slowly.

Q503 Jim Dowd: Do you say that you were never signed up to it?

Professor Black: No. If I may continue, I believe that MMC met workforce need and constantly throughout those years and at the time I was President of the Royal College of Physicians I had numerous meetings with Professor Crockard. For physicians run-through training was not appropriate. I together with the educational team in the RCP spent two years trying to preserve core training and specialty training. As Mr Ribeiro indicated, in the end with numerous reassurances we managed to preserve core and then specialty training, but it was in the context of what was called run-through. I do not believe that we withdrew at all; we were trying all the time to influence a system that was losing its educational intent.

Q504 Jim Dowd: Therefore, it was not a question of being signed up to it in toto; you had reservations from the off, but you wound up in a position where perhaps you were resigned to it. Is that accurate?

Professor Black: We felt we had a greater opportunity if we were inside to collaborate and influence the process in the interests of our trainees.

Q505 Jim Dowd: Therefore, you do not agree that there has been a lack of consistent leadership on the part of the royal colleges during the MTAS process?

Professor Black: All of the royal colleges tried extremely hard to show leadership in the best way they could for their own particular trainees. It was an extremely difficult road along which to travel.

Dr Reith: I think it is clear from what I and my colleagues have said this morning that the colleges were signed up to the principles of MMC and I do not think we have withdrawn from that. Quite clearly, the colleges were not intimately involved in day-to-day implementation and could not be, and that may be where some withdrawal is perceived, but we did change things. Certainly, from our point of view run-through training had many advantages for us. Historically, one of the problems we have is that of all the specialties general practice has the most ludicrously shortly training programme for what is one of most complex specialties. That was originally cast in legislation and to some extent still is. Tooke suggests a five-year programme, which is what we have been suggesting as a college for 40 years.

Q506 Chairman: We may move into that area a bit later.

Dr Reith: It is important to remember that. Although MMC did a lot for us it has not delivered everything that we think patients deserve.

Mr Ribeiro: For clarification, as a college of surgeons we proposed that national training numbers should not be given at ST1 level but should be allocated and confirmed at ST3 level because as a craft specialty we wanted to be absolutely sure that those trainees had all the necessary skills to be able to practise safely for patients. That proposal was put forward to the deans and, through them, to the department. Again, it was rejected. Professor Shelley Heard is in the audience today. I know that a lot of the early work that surrounded the Gold Guide had that thinking in it within the concept of core training. Again, the decision was made, I believe through the offices of PMETB, that there would be selection into ST1 from foundation and it would guarantee run-through training all the way through. Therefore, all the objections that we had as colleges about having a second point of selection were completely removed. As a consequence of that we called for one-year transitional training until such time as this could be resolved, but again it was rejected.

Q507 Dr Taylor: I want to follow up the Postgraduate Medical Education and Training Board and the effect that it had on the colleges. I remember that as a practising physician one of the most important functions of the colleges was the inspection. We had to have everything absolutely correct, and even individual patients' notes would be looked at to see what the quality of care was like. What I should like you to do is to list the effects that PMETB had on the education role of the royal colleges. I do not know who wants to start.

Mr Ribeiro: The poisoned chalice! One of the significant matters was a document from PMETB in about July 2005 on standards for entry into specialist training. One of the first things it said, which even the deans objected to at the time, was that experience should not be a criterion for selection. Mindful of the fact that this is a process that involved two different groups of trainees, those coming through from foundation training, who clearly would not have had experience of the specialty into which they were going, and several thousand SHOs, many with five or six years' experience, a process of selection was being designed which would not take account of experience. We know how that factored in subsequently in terms of the forms. We sent a letter to Professor Rubin saying: "Surgery is an extremely popular specialty and the number of aspirants greatly exceeds the number of posts. The number of posts in ST1 would need significantly to exceed the number of posts in SAC‑defined surgical specialties. A means must therefore be found to reduce the number of trainees in ST1 through a robust selection process based on surgical aptitude and demonstrable skills." We put forward proposals to have selection centres that would look at manual skills, dexterity, aptitude and all those things and we said we did not feel we could provide a selection process that was robust until September 2007. That was why we asked for a delay, but the rules set out by PMETB created a rigidity in the process that made it difficult. The other matter that made it difficult for us with the PMETB criteria was the principle of open competition. Under 7.3 they said that, "Selection should be on the basis of open competition to meet current and accepted human resource practice." There was a procedure whereby up until 2006 or thereabouts we had two categories of trainees: type 1 trainees who were selected from a recognised pool of SHOs, many of whom were already in college-recognised posts, and type 2 trainees who were in non-training posts, many of those being overseas doctors in those posts. There was a clear distinction that the type 1 trainees would be the ones who would get full training and apply for consultant posts. If you then expand that to all categories it stands to reason we would have the problem that we encountered in 2007 because you have enlarged the pool of trainees who are applying for what is still a very limited number of higher surgical or medical training posts.

Q508 Dr Taylor: To go back to the educational role of the colleges, did they take over some of that?

Mr Ribeiro: The PMETB has always said it is there to establish standards for entry and exit and that the curriculum and what happens in the middle is for the colleges and specialist associations to define. As a principle that is correct, but we had repeatedly to go back to PMETB over lots of issues, many of them protracted in terms of educational principles. Of course, every discipline is different. What we were faced with were standards across all 57 specialists which were expected to be the same. I believe that was the inherent problem.

Professor Black: You are right that until PMETB was established the colleges took responsibility for standards, curricula, assessment and quality assurance, so it was quite a shock. I still remember that at the very beginning of PMETB the colleges argued as vigorously as they could to ensure that their views and experience were imbedded in the new statutory body. It is perhaps worth going back to what was reflected in the constitution of the board: "In exercising its functions the board shall co‑operate wherever reasonably practicable with any body that appears to it to be representative of the medical royal colleges in the United Kingdom." Therefore, there was a duty on PMETB to collaborate. It would be silly of me to sit here and tell you that has not been a challenging relationship; it has, but the colleges have provided curricula in all their specialties up to the standards of PMETB. I believe that we are now working much more constructively on quality assurance. Therefore, it has been a relationship that has sorted itself out. We have had some very challenging times, but I think it has improved particularly in the past six months.

Q509 Dr Taylor: Dr Reith, do you have anything to add?

Dr Reith: The gestation and birth of any organisation which has a complex range of activities or roles will always be difficult, and that was true of PMETB. It is perhaps worth remembering what the climate was like in the lead-up to PMETB when there had been a number of very significant medical scandals, if you like, and concerns about training and so on. General practice at the time, like other colleges, had some misgivings about PMETB but it thought that things were reasonable. Within general practice we had our own regulatory body in the form of the joint committee on postgraduate training for general practice which predated the specialist regulatory body by about 20 years. It had developed a way of working that we thought was improving all the time but at least assured certain standards of training and patient care. But the one great advantage to us of the order was that it brought general practice into the main stream. There had always been a question about whether general practice was a specialty. Legally as well as psychologically it now is, but that question has always arisen. In certain documents you will see a reference to "all specialties (including general practice)". We must get away from that. We are a specialty with all the other 55 or 56, or whatever it is. That was a big plus for us. It brought us into that. I believe that PMETB has done a huge amount of good. There is a requirement that each college produces a curriculum that is more explicit than it was before - clearly, there were curricula before but not subject to the same external scrutiny that PMETB has provided - and similarly for assessment. All of the colleges have found it a challenge to meet PMETB's principles, but ultimately it has been to the good. I believe that now the curricula are clearer and assessments will be much more robust, so they are benefits. Yes, there have been swings. Dame Carol has mentioned the requirement of PMETB to consult with the colleges. There was perhaps a feeling initially that they were not doing that as much as they might have done, but I think we are now back to where there is good discussion.

Q510 Dr Taylor: Therefore, you probably do not agree with the representative of Fidelio who told us that the establishment of PMETB was a direct attack upon the medical profession and in particular its royal colleges?

Mr Ribeiro: One needs to go one stage beyond that and look at what happened in 1995.

Q511 Chairman: With all respect, we are about a third of the way through our questions for this session but over half-way through the time allocated to it. I am sure it would be very interesting to know what happened in 1995, but I wonder whether you could be a little sharper in terms of the questions and answers relating to this inquiry.

Mr Ribeiro: I think the main threat, therefore, was that before PMETB was a specialty training authority which had major representation from the colleges. When PMETB was set up our main concern was that responsibility for PMETB was to the secretary of state, not Parliament. We felt that at a stroke we were creating a body that was directly responsible to the government of the day rather than an independent organisation as we would have wished it to be. That was where the conflict arose.

Q512 Dr Taylor: Tooke proposes that PMETB should be absorbed with the GMC. What are your comments on that?

Mr Ribeiro: I am entirely supportive of that. It does not make any sense to have the early part of the regulation of medical students and the latter half for consultants under one body, the GMC, and the bit in the middle under somebody else. I heartily support the Tooke recommendations that that be merged under the GMC.

Professor Black: I support the principle of seamless regulation and planning of undergraduate and postgraduate medical training, so there should be one body.

Dr Reith: In many ways it makes sense, but PMETB is due to be reviewed in 2011 anyway. It is not that long ago that the GMC was itself fairly heavily criticised for some of its inaction rather than action. It is interesting how fortunes turn. I can see a place for a joint body, but it may be a little bit early yet.

Q513 Dr Stoate: For the avoidance of any doubt, perhaps I should put on record that I am still a practising GP, a fellow of the Royal College of General Practitioners and I was previously a GP trainer and an examiner for the royal college. I have a very simple question for Dr Reith. You have already answered part of it by saying that the system for general practitioners seems to have been a lot more successful than it has for the other colleges. Can you briefly explain why you believe it has been so much more successful? Do you think the colleges could learn anything from what general practice has managed to achieve?

Dr Reith: I think that we are now talking about MTAS as opposed to MMC.

Q514 Dr Stoate: We are talking about both but it is mainly to do with MTAS.

Dr Reith: The benefit of MMC is that it gave us many of the things that we had been trying to achieve for many years, that is, an integrated programme of training over the course of the full period - the run-through - and also the opportunity for all those wanting to enter general practice to undergo that training, whereas before many had to make do and mend as it were with their own sort of scheme. As far as concerns MTAS it had been in evolution for a number of years, fortuitously as it happened. Obviously, when we started out with national selection we did not know that all of this would happen. There was the buy-in from all of those involved in the specialty - the directors, the college and so on - and also the opportunity, therefore, to pilot and validate it. Further, although successful clearly it was costly in terms of resources and the assessment one had to undergo to get into specialty training. Significant numbers of people did not get through; they were not found to be of a sufficient level of knowledge or competence to be ready for general practice training.

Q515 Dr Stoate: Are you saying that it is more a matter of luck than judgment that it happens to have worked in favour of GPs? What I am trying to get at is whether you took a slightly different approach to the whole process and perhaps other colleges could have learned from you?

Dr Reith: The other colleges are aware of what happened, as was MTAS. To an extent it was fortuitous. What we did hold out for - there was quite a lot of resistance to our doing so - was the assessment process. Pretty much everybody else said that we could not have an assessment process. To give the directors their due, they have stuck to their guns and I believe that was a major part of our success.

Q516 Dr Naysmith: Already in this inquiry we have heard a number of witnesses and the question of a crisis in the leadership of the medical profession has been raised with us. This morning various things have been said, for example that the application form was not seen before MTAS began, that you did not all work together in unity, you knew right from the start that run-through training was not appropriate and you should have preserved the core and objections were aired at the time, but still the disaster went ahead. Do you agree with the opinion of some that in the past year there has been a real crisis in the leadership of the medical profession? I am not talking about individuals but about a structure which provides an easily identifiable leadership for the profession. Perhaps Dame Carol would like to start.

Professor Black: This is a point that Sir John has also brought up very forcibly. I agree that effective medical leadership is absolutely essential. The challenge for us is: what is the most effective way to do it? Medicine is a very broad church and a widely differentiated profession, so whether it is possible to have one overarching body is a very challenging question.

Q517 Dr Naysmith: I shall ask about Sir John Tooke's recommendation in a minute. Before we get to that, why do you think we have got into this crisis? Why has it happened?

Professor Black: There are probably many reasons why we are where we are now. One of those reasons was the feeling in the medical profession long before the MMC and MTAS debacle of it being rather suppressed. There was a definite increased loss of empowerment and morale. That would have been noticeable to most of those who led professional bodies. I believe that background existed long before we arrived at this crisis.

Q518 Dr Naysmith: We will come to the solution in a minute. Mr Ribeiro, do you think there has been a crisis?

Mr Ribeiro: Yes, but I think you are wrong in your interpretation of why that crisis occurred.

Q519 Dr Naysmith: I did not say anything about why it occurred; I asked you to tell me.

Mr Ribeiro: You are asking me why it occurred. The problem in 2007 was the management of process. What happened in 2007 was that the department faced the problem of accommodating 5,000 trainees coming off the foundation programme. It had to find posts for them and educational principles were sidelined to deal with workforce problems.

Q520 Dr Naysmith: It is your job to protect these educational principles, is it not?

Mr Ribeiro: It is exactly our job to protect them, and that was why we asked for a staggered introduction. I have already explained to you why we did that. If you take your mind back to the introduction of Calman, surgery was a vanguard specialty that started the process in 1996. We were the first specialty to do it. The whole transition occurred over 18 months. This was a big bang which occurred at one stage.

Q521 Dr Naysmith: But my point is: why did you not stop this big bang? Your profession was the one that had the ability to do it.

Mr Ribeiro: The point is that the department was determined to do it. This was a departmental edict to get the thing through and to get these people employed. It has been very clear to me that the department has been obsessed with dealing with process. You have had it here before you to give evidence. In evidence it said that a selection process was initially commissioned for some 6,000 trainees, and that was because the initial process was to deal specifically with those coming out of foundation. When you add to it the whole cohort of SHOs it expands further and you then add in the IMGs.

Q522 Dr Naysmith: Why did you or somebody else - Dame Carol or others - not have the ability to say this must be stopped and there should be a return to the old system for a year until it was all sorted out?

Mr Ribeiro: This may be where the problem arises. My specialty of surgery which had the biggest competition ratios did that consistently. I have documented letters to the secretary of state here that go back to October 2005 putting forward my plans for a transition over three years and extra posts for trainees to get them through this process. It is on record and I will leave it for you today when I go. That is the position.

Q523 Dr Naysmith: Could you not have gone for the nuclear option, that is, that you would not recognise people trained under the new system unless it was done properly?

Mr Ribeiro: In retrospect, I think that would have been a very sensible thing to say.

Q524 Dr Naysmith: Why did it not happen?

Mr Ribeiro: But the power for recognition is with PMETB because it gives the final certificate which is the CCT. It is all very well to say that the colleges had the power to stop it. To give an example, on 1 March when the so-called Birmingham 12 surgeons decided to walk out of the interview I was rung up that weekend and asked whether I would support them in doing that. I told them to go ahead and do their interviews. They decided that they could not do it because it was wrong to interview a group of people whom they believed had come through a flawed process. It was that argument that we took to the secretary of state on the afternoon of 5 March. I made the point to her that if that was the situation with the surgeons in Birmingham it was likely to be the situation for all surgeons throughout the country unless something was done to revise the selection process. That was why we got the Douglas review and subsequently the Tooke review.

Q525 Dr Naysmith: Dame Carol, do you think you could have done anything to stop it?

Professor Black: I think that each individual college was trying very hard. I come back to the point I tried to make at the beginning. I think you have much more power to influence if you have a united voice. That is the matter on which we should now concentrate if we wish to influence government and the department.

Q526 Dr Naysmith: We come to Sir John Tooke's proposal that there should be a body set up to do that, but in some respects that is what should already happen with the body which you chair?

Professor Black: Indeed, but it is important to understand that although since 1976 there has been an academy of medical royal colleges it was in a rather rudimentary form to do the things that you would require it to do. I hope and believe that we are now putting in place a more effective mechanism and we have better infrastructure. I believe that it was there but not in a form which enabled it to do the very necessary things about which you are asking us.

Q527 Dr Naysmith: Therefore, do you believe that the Tooke proposal is desirable and we should move?

Mr Ribeiro: I support Tooke. I think there is a real problem in that there is a vacuum of medical input at the Department of Health. I do not refer to what has been brought in by Lord Darzi and Sir Bruce Keogh but in the educational sense there is a vacuum. Why is that? The deputy medical officer has now left. Within the department in terms of the new MMC board on which I sit there is no medical leadership in terms of departmental responsibility. What the Tooke proposal will do is appoint a senior officer with responsibility for education who is not influenced by the need to deal with the workforce. He would be able to protect the educational principles that we need to produce the excellent doctors that this country desires. That is the reason for creating this.

Q528 Dr Naysmith: Dr Reith, do you have anything to add to that?

Dr Reith: Medicine like politics is a complex profession and has many leaders. It is difficult to see how one person or, some might suggest, one body would deal with all of that. We disagree with Tooke's suggestion that there should be a new body. We think there is already a body in existence, namely the academy, which brings together leaders of the different specialties. I can say that; Dame Carol cannot. I do not know her view but it may be similar. I believe that the academy needs to do some work to review its process and so on, but it is already doing it. For me, that would be the starter anyway. I should like to emphasise the way in which the department has changed. The Department of Health used to have a very effective medical education section containing a number of professionals. I believe that all departments in the UK, not just the Department of Health, have seen a decline in the number of medical professionals occupying significant positions. In addition, Dame Carol has already suggested that many within medicine feel that the views of doctors in senior management have been dumbed down in recent years and there is a general view within the profession that that is to the detriment of everyone.

Q529 Dr Naysmith: What do you think of that, Dame Carol? Further, the Chief Medical Officer has been widely criticised in all this for failing to provide leadership and oversight during the implementation of MMC and for denying the scale of the problems which arose in 2007, and yet in May of last year you expressed confidence in the CMO. Do you still have that confidence in the Chief Medical Officer? Perhaps you would answer both points together.

Professor Black: I believe that the academy is a body that can bring together effectively 15 colleges and five faculties but it also requires that that body has very close relationships and works closely with the many other bodies that believe they too have a right to a voice. Perhaps on certain issues one needs several bodies to join together to provide a united voice.

Q530 Dr Naysmith: Therefore, do you agree with Mr Ribeiro's suggestion?

Professor Black: I do not think that the academy alone should deal with every issue. If it was a matter of terms and conditions we certainly would not be the appropriate body. There would be issues where the Academy of Medical Science might be the appropriate body to take the lead, but each of these bodies wants to be strong in itself and then learn how to work constructively with one another. I am not sure there can be one absolute body, but we certainly could work much more effectively together.

Q531 Dr Naysmith: Do you still have confidence in the Chief Medical Officer?

Professor Black: I believe that you are referring to a certain letter which appeared in The Times last year. It may be worthwhile putting on record how that letter came about. It was simply an attempt at unity which obviously did not work well. When the Douglas review was doing its work the chairman of that body asked the academy and BMA together to produce a letter which would be supportive of that review and would also correct some of the inaccuracies already in the press about it. It was a genuine attempt to see whether two bodies which perhaps are quite separate could come together to support the CMO. We were supporting the principles as expounded by MMC and Unfinished Business. As you have heard from witnesses here, those principles have never lost the support of the colleges. Therefore, that statement was support for the principles of MMC through the CMO.

Q532 Dr Naysmith: Is it fair to say that you still have confidence in the Chief Medical Officer to the extent you have outlined this morning, that is, the principles of MMC?

Professor Black: I think the colleges have continued to support the principles of MMC.

Q533 Mr Bone: I apologise in advance to the witnesses that I shall go after I have asked my questions. It is not intended as a discourtesy or reflection on anything you might say. My first question requires just a yes or no. Do you generally agree with the analysis and recommendations set out in the Tooke review?

Mr Ribeiro: Yes.

Professor Black: Yes.

Dr Reith: Yes.

Q534 Mr Bone: That is very interesting because through consultation there appears to be 87% approval of the Tooke review. Are you surprised that the Chief Medical Officer is not implementing this and is still going for wider consultation, because everybody seems to think that these recommendations are a good idea?

Mr Ribeiro: I heard and read what he said in his summation here. I personally expressed concerns to the secretary of state that the 87% support for this recommendation demonstrated the strength of feeling of the profession that something needed to be done. I indicated that if we did not get a speedy response from the department there would be a reaction from the profession. He told me yesterday that there would be an announcement by the Department of Health about the Tooke report by the end of February. I hope that that indicates a determination on his part, if not necessarily the department's part, to come up with some answers to that recommendation.

Professor Black: There is unease in the profession that there has been no Department of Health response. I would like to think that it is in part because this Committee is still in session and Darzi has not reported, but there is an urgent need for the department to make a response to Tooke.

Dr Reith: If you allowed me two words, I would say "yes but". There are some significant elements of Tooke with which we disagree, for example the dismantling of the foundation programme. Within general practice that seems to have been a success and there is not yet evidence upon it. We come back again to the lack of evidence. As yet there is not a lot of evidence one way or the other about foundation, but the early evidence we have seen suggests there is benefit in the two-year programme. We also have some concerns about the potential impact of everybody undertaking core training on general practice training because we have just now achieved integrated training which may well go by the board. We have to make sure that it does not go by the board as we move through to core training. There are therefore some significant qualifications. The way in which the profession has responded is in part to do with morale. People see so many things happening to them and not being able to influence them. Clearly, there is great disquiet among the profession that junior doctors and the next generation of GPs and consultants have had the most appalling experience. We hear that numbers have emigrated and are doing things that they would prefer not to be doing. I think their confidence has been shattered. All of these things come into play.

Q535 Mr Scott: The department has played down the problems experienced in 2007 and is non‑committal about the Tooke recommendations. Meanwhile, the 2008 recruitment round has begun with three applicants for every training post. Is not the medical education system sleepwalking into another disaster?

Mr Ribeiro: In a word, yes. I hope that you saw my letter in The Times on Tuesday because that was intended to raise the question which has not been asked. I have written again to the secretary of state and others making the point that certainly in surgery those competition ratios are considerably greater than that. I give you some figures. I sit on the MMC programme board. Although this may be privileged information I shall give it to you. In surgery I refer to the second year of training and the fixed term training posts for trainees who do not have a training number. If they do not get a number next year effectively they will not get into specialist training and will have to do something else. There are 555 of those trainees currently in FTSTA2 posts. We estimate that there are 1,661 college members who have their MRCS and who are eligible for appointment to this grade. The figures that I have been given by the department indicate that there is a potential in surgery of a minimum of 90 and a maximum of 130 posts in 2008 in ST3. If you take the maximum that represents a ratio of 13:1; if you take the minimum it is a ratio of 19:1. For surgery a lot of trainees will not get training numbers. It is too easy to say to these people that they can go and do psychiatry. Yesterday at the diploma ceremony at the college I spoke to one of the doctors who had just passed his MRCS exam. I asked him what he would do if he did not get a training number. He said that he would leave medicine. I said that surely he could find something in medicine to do and he said that he was passionate about and dedicated to surgery and if he could not do it he would not continue in the profession. It is very glib to say these doctors can do something else. Many of them have invested four, five or six years in progressing. We know that 50% of them in the past did not get through and therefore they will have to make some painful choices, but in the past the difference was that next month and the month after and so on there would be another job for which they could apply. This time we do not have that luxury.

Professor Black: There is a huge problem with numbers not just this year but ongoing. We could discuss that in greater detail if we have the time, but we have a particular problem in the transition period with young people trying to get in at ST3 and ST4 level, which is really what Mr Ribeiro has been emphasising. I should like to emphasise the importance of returning researchers. The quality of the medicine today is dependent on making sure that you have a steady stream of very good clinical academics. I think we have about 350 - maybe more - returning this year who will come into that transition group. Will we be able to accommodate them? We have a major problem with numbers.

Dr Reith: We are certainly in a time of considerable uncertainty and 2008 is probably less certain than 2007. I have already hinted at the impact of that particularly on young doctors who are embarking on a career in medicine but also on the service and patients. We have people who are already in specialty training and who are doing something different from those who are a bit further on in the specialty training. We will now have a third cohort doing something else. It will be very difficult to work out which doctors have which competencies. That is potentially quite risky for the service. It is however not an easy thing to sort out and we have to proceed as best we can. Tooke is a good pointer. For example, we very much support the five-year programme of training for general practice that is suggested. My two colleagues have mentioned numbers. We have a huge numbers problem in Scotland. In August 2008 there are more entries into general practice training at ST1 than all the other specialties put together. That is the scale of it. We are heading for a shortfall of GPs in the UK particularly in England because of the way the system has worked, and we need access to more hospital placements so we can expand the number of GP training programmes. That will go some of the way to help things, bearing in mind what Mr Ribeiro said about it.

Q536 Mr Scott: Officials have hinted that the Tooke recommendations will be considered as part of the NHS Next Stage Review. Is this appropriate? Is it not Lord Darzi's remit to look at the provision of clinical services rather than medical education?

Professor Black: I think it is inappropriate that the Tooke review should be subsumed into the Darzi review. I can see that there are interlinking parts where service requirements and education meet and obviously they must be considered, but I believe it would be wrong for this excellent review to be dealt with in the context of the Darzi review.

Mr Ribeiro: I would say the same. Once again, one is trying to merge education with workforce and we must bear in mind that the recommendation that has been made deals specifically with education.

Q537 Chairman: Do you agree with that, Dr Reith?

Dr Reith: Yes. It is clear that there is a significant interplay between education and service, but you can imagine the response when an independent review is commissioned and that is then subsumed by a departmental review.

Chairman: We get the message.

Q538 Charlotte Atkins: We have already heard about the Department of Health wanting to create the arm's length body NHS Medical Education England. Why cannot responsibility for postgraduate education be devolved directly to the postgraduate deaneries and strategic health authorities? Why does there have to be a separate body?

Mr Ribeiro: Independence would be one thought on that. Do not forget that the deaneries are subsumed currently within the SHAs and therefore are answerable to the department. I believe that when I gave evidence to the workforce group I made the case that last year there was a significant raiding of deanery budgets from the SHAs to pay off the Department of Health's deficit which was heading for 1 billion. That has a significant effect on training. One of the effects is that our college put forward proposals to the deans to have a five-station selection centre to select trainees. We said that this could not happen until September 2007. We were told that, first, the process had to start in February with everybody else and, second, there was not the money to allow the development of the selection. That is one of the problems you have when there is a body directly answerable to the department whose funding may be withdrawn. Therefore, one recommendation in Tooke is that this funding should be ring-fenced for education.

Q539 Charlotte Atkins: Are you saying that the separate body would create some sort of independence, but would not the department automatically interfere? Is it not perhaps over‑optimistic to suggest such a separate body would be independent of Department of Health interference?

Mr Ribeiro: Of course, where money is concerned ultimately no organisation can be independent of government and the department, but what is important is to have the focus on education with a senior responsible officer with whom we can interact acting in an advisory capacity on workforce in the department but not being subsumed by it. At the moment the danger is that within the current structure whereby there is a vacuum in the department - there is currently no deputy chief medical officer and we are in a transitional process for trainees for 2008 - there is a lack of cohesion within the department to come up with those decisions. I think that it would help us as colleges to have an identified senior responsible officer for education with whom we could interact on those particular issues and also to know that the funding to deliver the training was protected.

Q540 Charlotte Atkins: What impact do you think that body would have on the role of the royal colleges in medical education? Would it be entirely beneficial?

Mr Ribeiro: I think it would be beneficial and I shall explain why. Before the present government came in in 1997 there used to be an organisation called the Standing Medical Advisory Committee. That body consisted of college representatives who advised the CMO on matters of education and to some degree, through the workforce element of it, on matters of workforce. There was also another sub-group. These advisory committees provided the CMO directly with the views of the colleges. That mechanism has now disappeared. I have to make an appointment to see the CMO to discuss workforce issues, so I see this as a return to a structure that will allow us to meet with the person responsible for education and put our points of view corporately.

Dr Reith: Within Scotland we have such a body, NHS Education for Scotland. That was set up following a review of postgraduate education in Scotland. I believe that that has done a huge amount of work and has helped in the way some of the things have gone in Scotland, which seems to have fared fairly well in relation to some other parts of the UK. I agree with Mr Ribeiro that the main difference is that the focus is on medical education. I think that particularly within general practice, although clearly within other specialties, we have seen some strategic health authorities raid GP budgets; they have cut training places for GP registrars. It is very easy to chop a year's salary times whatever the number to save money. We are now in the ridiculous situation where we are not producing enough. There is a national policy to produce x GPs. The SHAs should be buying into that. We are told that they are performance managed to do it, but we do not see any evidence of performance review going on. There are so many things for SHAs to be doing that, frankly, it seems that for some education does not have the priority that it merits, so we certainly support an independent special health authority of some kind.

Professor Black: If you look at a number of recommendations in the Tooke review many are intertwined and interdependent and I believe their successful implementation requires a new coherent approach to medical education. That is one very good reason for his body. Experience shows that the Department of Health has not been able, given its resources and design, to provide such coherence. In the interests of time I shall give just those two reasons.

Q541 Dr Stoate: Dr Reith, from what you said earlier it appears that you are very much in favour of extending GP education from three to five years. That is something for which I have been calling for many years and I am pleased to hear you say that. Do you have any estimate of how much that might cost the NHS?

Dr Reith: At the moment I do not because it depends on how it is configured, but the question I put to you is: what would be the cost of not doing it given all the government's policies of shifting more care into the community, the complexity of the curriculum and the degree of experience that doctors going into general practice need to acquire? From our point of view, moving to five years is a priority. We anticipate working closely with all the bodies and the department to bring that about. Part of it is that we have to be open about the cost. At the moment the costs of general practice training are identified differently from the costs of hospital specialty training. There is an element that comes through for the GP part of training which is very open and that is the bit that can be easily picked off. The hospital placement side tends to be hidden more in deanery budgets and is not within our control. If we had budgeting for the whole of the integrated programme we would be able to facilitate shifting around different hospital placements and improve on them from our experience.

Q542 Dr Stoate: You think that is a good idea and it can be done?

Dr Reith: Yes.

Q543 Dr Taylor: Mr Ribeiro, we are a bit confused about the college's position on the sub‑consultant or junior consultant grade. What is it currently?

Mr Ribeiro: Currently, all trainees once they reach the end of training with CCT are eligible to apply for a consultant appointment. We in surgery would require them also to have passed their intercollegiate examination in surgery. The combination of those two things makes them eligible for consultant appointment. Over the past year there has been a freeze on consultant appointments which has led to quite a few trainees findings themselves with CCTs and no jobs to go to. There were discussions with the department early last year and the year before, with Andrew Foster and later Nick Greenfield, about how to deal with the consultant level. It was agreed that the concept of sub-consultant grade should not be encouraged and that within the consultant grade we should look for ways to determine the progression of consultants throughout their careers; in other words, to put forward a portfolio of attainment to allow progression. As one can imagine, the BMA had views on that and those talks collapsed. One of the things I said at the time was that it was unfortunate we had not come to a decision about this because I felt that by default those people who had not gone through the training programme would be appointed by trusts, mainly foundation trusts, if they were thought to be competent to become the new specialists, if you like, and that by default the term "specialist" would occur and we might well find people who were not able to get jobs being pushed into those posts. Therefore, my concern is that there is likely to be such a category anyway. The original report of Tooke demonstrated two distinct groups, specialists and those moving on to consultant posts. In the early diagrams in MMC that was also shown. We are more inclined - this was what Dr Wilson alluded to when he said I might be changing my view - to look at how we can take the established consultant body and look at means of progression, not take the view that a consultant appointed at 35 will practise in the same way throughout the whole of his career. He will have to demonstrate why that progression should occur. That might well give some structure to the consultant level. That is our position. Having said that, somebody coming from Europe who has not gone through our training programme may still be employed by a trust and given the title of trust specialist.

Q544 Dr Taylor: Dame Carol, do you agree with progression as a consultant?

Professor Black: I think there is already the possibility within the consultant contract to do the progression to which Mr Ribeiro refers. We have it in academic medicine. One becomes a lecturer, senior lecturer, reader and then professor. That progression is absolutely acceptable. There is the machinery for us to think about an equivalent progression in the consultant grade.

Q545 Dr Naysmith: One matter associated with the business we have been discussing this morning - MMC and MTAS - is the failure to manage properly the number of international medical graduates who apply for UK training posts. Dame Carol, you have described it as a calamitous situation. Why do you think this calamity came about, and what can we do about it now?

Professor Black: I think it is a calamitous situation which came about because in 1997 the government decided we should become more self-sufficient in the production of doctors. That was the time when they should have been in discussion with the Home Office and other relevant departments of government to ensure there was a transition, if one could just do the numbers, such that the international medical graduates on whom we have relied so much and who have given so much good service to us would not be disadvantaged in the way we find them disadvantaged today. I think it is a failure of two policies to come together. I have read very carefully what other witnesses have told you. It is quite obvious from reading that evidence that none of us has a good answer to the morality and practicality of the situation. How do we solve what I believe to be a calamitous situation which is a failure of policies which should have been developed several years ago? We are now trying to deal with an immediate situation for which there is no easy answer.

Q546 Dr Naysmith: Referring to the decision of the Court of Appeal, there was evidence of confusion among the Home Office, Treasury and the Department of Health. Is it that to which you refer?

Professor Black: I am referring to the fact that once a high-level policy decision had been made for us to become self-sufficient, or close to it, that had obvious implications for those who had come from overseas.

Q547 Dr Naysmith: In this Committee it has already been suggested that the immigration rules should be changed in order to limit the number of overseas doctors. Do you believe that is possible or desirable?

Professor Black: I have not given this a great deal of thought. It is of interest that many of our international medical graduates now come in through the highly skilled migrant route, but somehow the numbers do not add up. Would we have so many highly skilled migrants coming into medicine? If they are coming into a training programme how highly skilled are they? Obviously, it needs a great deal of thought, but in the meantime we need to give due care and concern for those people who have served our country very well.

Mr Ribeiro: As I am the only member of this panel who was born overseas you may say that I have a different view on this. Coming from a third-world country where you see resources being removed in the way of doctors - I come from Ghana where most doctors leave the country and the health service in a poorer state - I am not keen on IMGs coming to the UK to support first world services, thank you very much. You should produce your own doctors to do it. My position is very firm on that. I believe that what caused the problem was the open door policy that everybody could apply. I have already alluded to type 1 and type 2 training which restricted the number of overseas doctors who could get into training programmes. Just like D‑Day when the weather caused Eisenhower to delay the landing, the Department of Health had the opportunity in February 2007 to delay the implementation of the whole process by waiting for the result of the judicial review. It would have had to wait only about three days, but it chose not to do so. Because the "go" button had been pressed it felt unable to do so. That was where there was lack of leadership. If you are looking for a lack of leadership amongst the colleges you must ask the question: why was there no leadership shown to make a decision which brought 10,500 people into a process which clearly was going to fail? They were told by Alan Crockard and Shelley Heard that the whole process would not work if the IMGs were included. I wrote to the secretary of state about it and, if you will give me a few minutes, I shall read it out to you. My solution was: "The position with regard to overseas doctors, particularly those who have qualified in developing countries, is different from those in the EU [for whom there are no restrictions]. I believe that we have an obligation to help them meet the health needs of their countries and any training opportunities that are provided here should be in the short term with a requirement for those trainees to return home." My view is that we should encourage and make arrangements for overseas doctors, who are already half-way through their training, to come over here for enhanced training for two years as specialists and then go home. What we should not be doing is bringing them here at a junior level to shore up the NHS.

Q548 Dr Naysmith: That is a very straightforward view. Dr Reith, you come from a country whose doctors have traditionally populated half the Commonwealth and the rest of the world. What are your views on that?

Dr Reith: I would agree with my colleagues that sadly there seems to be a lack of joined‑up thinking within some government departments, unfortunately not for the first time. Dame Carol mentioned morality. I think that as a wealthy country we need to look to how we support or do not support third-world countries. To offer training here to shore up our service seems to be morally questionable. By all means, if doctors from third-world countries can receive training here which will then be of benefit at home that is worthwhile.
The impact of IMGs on the whole system is probably a significant factor in the debacle that we have since seen.

Q549 Dr Naysmith: Dame Carol, do you want the last word?

Professor Black: No. I believe I have said all I have to say.

Q550 Chairman: Dame Carol, if you have any thoughts on this matter that you would like to share with us on paper in the next few weeks we would be more than happy to see it. Mr Ribeiro, would you also share that letter with us?

Mr Ribeiro: I have a dossier of all those letters for you here because I thought you might ask me that question.

Dr Naysmith: It would be better if you read the whole lot out.

Q551 Chairman: I do not want you to read it all out at this stage. I thank all three witnesses very much for coming along to help us with this inquiry. I know we have run a few minutes over, but I think your evidence will be invaluable to the outcome of this inquiry.

Mr Ribeiro: Perhaps I may take the opportunity to thank you and the Committee for dealing with this in a courteous manner. We have solutions and want them listened to, and we shall continue to interact with the department in the hope that we can make this happen.


Witnesses: Professor Elisabeth Paice, Dean Director, London Deanery, and Chair, Conference of Postgraduate Medical Deans, Professor David Sowden, Dean, East Midlands Healthcare Workforce Deanery and Senior Responsible Officer for MMC, Department of Health (from January 2008), and Professor Sarah Thomas, Dean, South Yorkshire and South Humber Postgraduate Deanery, gave evidence.

Q552 Chairman: I welcome you to the second part of the fourth evidence session of our inquiry into the MMC. I apologise for the late start. Perhaps for the sake of the record you would introduce yourselves and the positions you currently hold.

Professor Paice: I am Elisabeth Paice, dean director of the London Deanery and I am chair of COPMeD.

Professor Thomas: I am Sarah Thomas, postgraduate dean for South Yorkshire and South Humber.

Professor Sowden: I am David Sowden, dean director of East Midlands Healthcare Workforce Deanery and since the beginning of January I have been seconded to the Department of Health as senior responsible officer for MMC.

Q553 Chairman: I should like to start with a question to you, Professor Paice. What is the remit of the Conference of Postgraduate Medical Deans, and what powers does it have? How does COPMeD co-ordinate the deaneries when each individual dean is responsible to his or her local strategic health authorities?

Professor Paice: In England?

Q554 Chairman: Yes.

Professor Paice: COPMeD is a UK body, as opposed to the body for English deans which has to deal with the issue of the SHAs. COPMeD UK is a conference or forum in which the deans gather to share good practice, to discuss educational initiatives and to work in a co‑ordinated, corporate way. For example, COPMeD was the body with which Ken Calman dealt in order to implement his reforms and the body which introduced the reforms relating to the pre-registration house officer year, implemented the foundation programme and so on. There is therefore a good deal of co‑ordinated activity. As with any body of that sort, if there are strong disagreements relating to the relationship that each dean has with the employing body obviously one cannot move forward; there must be a consensus.

Q555 Chairman: Professor Sowden, can you tell us how English Deans is different from COPMeD and why you think these two separate organisations are necessary, if that is your view?

Professor Sowden: I certainly think they are necessary. English Deans as a corporate body has existed for only a relatively short period and it is related more to the creation of devolved administrations in Scotland, Wales and Northern Ireland. It became increasingly apparent to us that previously COPMeD had dealt not just with strategic discussions and common business, best practice and so on but also with operational issues across the United Kingdom in terms of the delivery of postgraduate medical education. With the creation of the devolved administrations that became increasingly difficult because we found that English operational business began to dominate proceedings to the frustration and annoyance of our colleagues from the Celtic countries. As a result, we decided that English Deans needed to be established in a more formal sense to deal with many of the common operational issues that we faced in England working in the postgraduate medical education arena but also with regard to our interface with the strategic health authorities both before the recent changes and subsequent to them. I think it has worked very well in that particular environment, but I agree with Professor Paice that we are not in a position where English Deans, any more than COPMeD, can tell its members what to do. That is very much about the personal relationship between the deans and their managers who are the strategic health authorities. Despite that, we manage to achieve a remarkable degree of unanimity. Whilst we have differences they are usually handled with good spirit and in the best interests of patients and seldom to the detriment of postgraduate medical education.

Q556 Dr Naysmith: Do you agree that the transition to the new specialty training arrangements which began in 2007 was a disaster for many specialties? If so, what caused that crisis?

Professor Thomas: It is said that if you started again you would not start from here. Largely the problems were to do with timing and resourcing and therefore there was a lack of piloting. There was an unexpectedly high volume of applications. The design of the initial process was always supposed to exclude IMGs. It was well recognised that that was an unquantifiable part of the system and you would never be able to calculate exactly how many applicants you would have if there was global recruitment and it was open to the whole world.

Q557 Dr Naysmith: To what extent do you think that the deaneries themselves either corporately or individually have some responsibility to bear for this?

Professor Thomas: The deaneries which did the recruitment for doctors in training signed up to a national system but the agreement was that the volume would be controlled. When they signed up they were told that that would be sorted out and the number of posts recruited would largely match the number of applicants. Therefore, it would be more of an allocation than a high volume competition as it became.

Q558 Dr Naysmith: But has it not always been the case that in some specialities there are a lot more applicants than places?

Professor Thomas: That is absolutely right.

Q559 Dr Naysmith: Therefore, it cannot have come as a total surprise?

Professor Thomas: No, but if a system was to be designed with a fixed number of training opportunities in a whole variety of specialties there would be some very popular specialties with high competition ratios; others would be much less popular, and some parts of the country are much less popular. There is less than one applicant per post in some specialties in some parts of the country, but the quantifiable part is how many applicants you will have and how many posts you will need to fill. If you make that recruitment global you just do not know how high the volume of applications will be. That was a significant factor.

Q560 Dr Naysmith: Professor Paice, do you have anything to add? No one will deny that it was a pretty awful situation.

Professor Paice: Absolutely. What Professor Thomas said about the IMGs is very important. It was designed so there would be phasing, that is, first there would be an accommodation of those people with the right of residence within the UK - one can call them "UK graduates" for short - and, following that, because there would be more posts than people, there would be a second phase for the IMGs. It was not an attempt to exclude IMGs but to do it in phases. The first phase was designed very much along the lines of the successful matching scheme that had been applied in foundation which was where this was being piloted, if you like. The outcome - that everybody was in the first round - came as a shock and it was not going to work without a metric of some sort which would provide some way to sift the applicants electronically before consultants had to do this short-listing exercise.

Q561 Dr Naysmith: That did not happen?

Professor Paice: It did not happen. It was one of the things originally planned to happen. In the academy's statement of 2006 it was said there would be a knowledge test, but that was one of the things that became lost by the wayside. The GPs maintained that machine-markable test but without that there was no way to manage huge volumes and it became an undoable task.

Q562 Dr Naysmith: Professor Sowden, the Tooke review showed that project management for the MTAS process was extremely weak. Clearly, COPMeD has a key role in the project arrangements, so what went wrong? What lessons has COPMeD learned from the debacle of 2007? Perhaps you would also answer the other question I put?

Professor Sowden: The second question is slightly more tricky. To follow on from what my colleagues have said, we also need to emphasise that there were very substantial geographic differences in the experience of the selection and recruitment process.

Q563 Dr Naysmith: It worked quite well in some areas?

Professor Sowden: Yes. For reasons that are not entirely apparent, my area of East Midlands is a relatively unpopular place to come to. As a consequence of that the numbers with which we were faced were manageable, but because of the IMG issue two areas of the country in particular, West Midlands and London, were absolutely swamped. I do not believe that was predictable in terms of scale, particularly on the basis we had been told that the IMG situation would be sorted out prior to the process starting. To turn to the issue of project management, in the evidence I presented on behalf of English Deans I said I believed that the MTAS process and other aspects of MCC were exceptionally poor. The point is that that was not in the gift or control of COPMeD to any great extent. We and many other parties, including the colleges, were involved in some of the decisions reached, but the process of project management should have rested with the department and it was there where many of the deficiencies became manifest as this began to unfold. You may think "He would say that, wouldn't he?" because of the role I have now but, to be fair, I believe that the project management systems that have now been put in place as a result of the problems of last year are considerably more robust. Time will tell whether they are absolutely ideal, but to me they appear to be considerably stronger and have learnt from that experience.

Q564 Dr Naysmith: Professor Thomas, you were closely involved in the design of the MTAS system, as I understand it. Do you accept that the project management and governance arrangements were not adequate?

Professor Thomas: The governance arrangements were wholly inadequate.

Q565 Dr Naysmith: Who is to blame for that?

Professor Thomas: MTAS is described as covering everything. There were two parts to this system: one was the electronic portal, the procurement, design and delivery of which were wholly the concern of the Department of Health; they had nothing to do with COPMeD. The other part, which was COPMeD's bit, was the selection and how to short-list and interview all selected people face to face.

Q566 Dr Naysmith: Was that the bit in which you were involved?

Professor Thomas: Yes, but they could never be separate in the way they were managed separately because in order to design an appropriate electronic system and for it to work properly they needed to have all the information from the other part. Unfortunately, there was not very good communication between MTAS and the electronic portal end of it and the MMC team; they were very much separated. There was better communication between the COPMeD recruitment and selection steering group which had members representing everybody on it. Even so, the governance of all those areas was confusing, to say the least. I think it was poor and severely under-resourced; there just were not enough people working on it full time or the money to pay them. This was at a time when the resources put through to the deaneries by SHAs were being severely restricted.

Q567 Charlotte Atkins: Professor Thomas, do you accept that the part of the process in which you were involved relating to short-listing was inadequate? As a result, was the selection system fundamental unfair?

Professor Thomas: I do not think it was unfair as a result. We need data to support that. Some evaluation was made of the system and outcomes of the selection process, but, to put it into context, the procurement happened in May 2006 and the professional team contracted by the Department of Health to design the selection process started in June and they had to have it finished by December of that year. The specification for that work was materially different from what they ended up having to do. They had to expand enormously the amount of work that they needed to do and were required to do by the Department of Health. The design of the IT system did not start until half-way through September 2006. Despite asking for the IT system for foundation and specialty to be designed in parallel so that it would go together the decision was made that for specialty the IT system would happen after the one for foundation had been done. It left very little time to get it all finished. Having said that, they did finish it.

Q568 Charlotte Atkins: Given that you predicted all these problems, why did you not say it should be scrapped?

Professor Thomas: I together with my colleagues attended all of the high-level decision-making committees. This was certainly discussed because the BMA had great reservations and wrote in and asked for a delay of a year. Its letter was given serious consideration at the highest level at the UK MMC strategy group with all the stakeholders present and the decision was made that it would continue. The MTAS representative Mark Johnston was asked to come to a meeting of that committee in early October 2006 when anxieties had been expressed by many. He presented an update on the MTAS system and reassured the committee that it would work all right and the decision was made to carry on.

Q569 Charlotte Atkins: It must have been a pretty good presentation if he managed to convince all these people that everything was fine and hunky-dory?

Professor Thomas: He did, but anxieties were certainly expressed about the level of resources, not just money. There was concern about people on the ground to project manage. The risk registers show that; they are red on the human resourcing end of things.

Q570 Charlotte Atkins: Why do you believe there was no proper piloting of this process?

Professor Thomas: Piloting was asked for by COPMeD two years earlier. It was clear that MMC was about changing all of medical training, not just foundation. Many of us had done pilots for foundation and some had done pilots for specialty selection. We did so in my deanery. My deanery had pioneered the GP selection process. We made proposals two years earlier to do more extensive piloting and no resources were made available; they were not supported.

Q571 Charlotte Atkins: You were involved in the GP recruitment system, so why were lessons not learned from that more successful process?

Professor Thomas: We wanted to do a knowledge test for specialty selection. That was very unpopular among some members of the COPMeD steering, selection and recruitment group.

Q572 Charlotte Atkins: Why?

Professor Thomas: The BMA and trainees in particular were vehemently opposed to it. They sent in a three-page official letter, not just an email, and it was minuted at the meetings that they absolutely would not support any kind of knowledge test. They then wrote in to confirm that. Therefore, we had no support from the trainees at all.

Q573 Charlotte Atkins: Why were they so adamantly against a knowledge test?

Professor Thomas: They felt they had been tested at medical school and the way they were to be assessed should not include further knowledge tests to get over a first hurdle.

Q574 Charlotte Atkins: "We know best; we are above all this"?

Professor Thomas: Yes. Having said that, we had GP membership on that steering group and it was accepted that because the GP process had piloted the knowledge test first hurdle extensively and rolled it out nationally that would continue, but they would not agree to doing that for specialty; they were very much opposed to it.

Professor Sowden: I believe the argument they made - there is an issue about it - was to do with the extent to which the knowledge test was predictive of people's subsequent performance in training. The big advantage of the GP piloting and evaluation work was that we had direct knowledge that their performance prior to training in the knowledge test and subsequently the situational judgment test linked both to their performance in training and to some extent their performance at the end of training. The juniors' objection was problematic because it was fundamental, but I believe they did have a legitimate argument when they said it had not been proven for other specialty areas; in other words, what element of knowledge do you test which is predictive of future performance? All three of us would have liked to see those pilots and the evaluations conducted, but they are very expensive and that issue was continually put back to us as a reason not to proceed immediately down that line.

Q575 Dr Naysmith: Surely, there is evidence from other parts of the world for predicting performance. The States is a perfect example; it uses it regularly. Why not use it here?

Professor Sowden: The argument put forward by the juniors was, if I remember correctly, that there might be something different about the United Kingdom.

Q576 Charlotte Atkins: Professor Paice, do you want to come in?

Professor Paice: Only to support that point very strongly. Past performance predicts future performance usually very adequately and this kind of test does not just test knowledge but rewards commitment and conscientiousness and provides a level playing field, which we otherwise would not have, between people who apply out of EGF2 and those who have EG and 10 years' experience obtained abroad. It was not a level playing field and a good part of the application form was designed to try to bring some levelling to it, but it would have been much better had it been done on something as concrete as knowledge as opposed to what was felt to be very waffly competency questions.

Q577 Charlotte Atkins: Professor Sowden, you said earlier that the MTAS system worked better in less popular areas. You referred to the East Midlands as being unaccountably less popular than other areas. Do you think that overall the MTAS problems were exaggerated in 2007, or do you think you were just a lucky region?

Professor Sowden: It is very difficult to say that the concerns were exaggerated. I do not believe that any of us sitting here, or perhaps those who spoke before, would want to underestimate the distress caused to a significant proportion of junior doctors. Much of what has been said about MTAS, however, has been anecdotal. Obviously, bad news travels incredibly fast and good news is quite difficult to obtain. If you speak to the junior doctors who had a positive experience - in my patch there are a lot of them - they are reluctant to speak out because of the opprobrium heaped upon them by their junior colleagues. It is very difficult to be positive about something that everybody else says is absolutely hopeless. I do not believe that even with the review of Professor Douglas and subsequently by Professor Tooke we have quantified the scale of badness and goodness. We are still very reliant on anecdote. I do not believe that is a reason to say that MTAS was a success. There are elements of success in the sense that DGHs, which historically outside the South East in particular have had real difficulty in recruiting good quality staff, are singing the praises of the people they have recently appointed. Speaking to my specialty training committees, many say that this is the best cohort of trainees they have ever had in postgraduate training, not that they did not have stars before but the spread has been narrowed. These people are almost universally very good whereas before you had the excellent through to the relatively poor.

Q578 Charlotte Atkins: Therefore, the East Midlands was the beneficiary of this. Can you quote other areas as having had a good experience?

Professor Thomas: There are hospitals in Yorkshire and the Humber that run on international medical graduates because usually UK graduates just do not apply to them. In particular, Hull has said it has the best doctors that it has ever seen and many others have said the same, particularly DGHs across Yorkshire and the Humber which have had difficulties in recruiting doctors. This year they have had much better recruits.

Professor Sowden: North West and Northern, that is, Mersey and Manchester and over towards Newcastle, have also reported.

Q579 Charlotte Atkins: But did West Midlands have a problem because of the IMGs?

Professor Sowden: They were just swamped by numbers. It is very difficult to judge in that environment the extent to which the outcomes have been good. I suspect there are areas such as Burton and Stoke which may well have benefited from this, but because of its size - it is an extremely large deanery - West Midlands was just swamped. Therefore, the experience of MTAS there as a process was not a positive one. It was not uniformly negative, but there were areas in particular specialties where competition had always been high and they really struggled for understandable reasons.

Q580 Charlotte Atkins: One would expect places like Stoke perhaps to benefit given the experience of East Midlands, Yorkshire and Humberside. Professor Paice, is there anything that you want to say?

Professor Paice: Obviously, the experience in London would be different. Good processes had been in place for some time previously and they had been developed with the profession. Consultants and trainees understood it. They formed the basis of some of the work done nationally. The timescales were not appropriate for the volume; 23,000 applications is a lot to process. We prepared for that kind of volume, but at the last minute things had to be changed and timescales got shorter and things that we thought would be delivered and their functionality did not happen. The consequence was that we ended up trying to move things along too quickly, which in turn caused a crisis of confidence in the performance of the short-listers. That in turn delayed some things. We ended up with the intolerable situation where we had appointable people left on the list and vacancies to fill and the bell went. We were unable to put those together. Obviously, those people turned up elsewhere and are doing extremely well. It is good for patients that good people are all over the country, but it is very sad for individual doctors who perhaps have set their heart on particular placements. One of the outcomes is that people have applied for jobs and have got them but feel very distressed at the outcome. That is a weird situation in which to find oneself.

Q581 Dr Stoate: It is funny that you never read the good news in newspapers; you just read the bad bits. I am very pleased you have all put on record that there were some significant wins, albeit with significant problems as well. I want to talk about the IMGs, in particular the highly skilled migrant programme. What sort of numbers do you expect this year given that there is now no restriction imposed that has actually worked?

Professor Paice: I have contacted the postgraduate deans to see how things are going. In general practice it looks as though the numbers are pretty much like what they were last year and the year before. The prediction is 7,000 or 8,000. In the deaneries that have closed the numbers are what you might call manageable. Because there is no restriction either on the IMGs or the number of applications that an individual can make one might have feared a tidal wave of applications, but that has not happened. Obviously, people are targeting the post they want and not applying for things they do not want, but they are spreading their applications so that across the country people are getting applications in the thousands, though not tens of thousands. Therefore, so far so good. It is hard work for the applicants because they have to make a separate application for each deanery and specialty. On the other hand, obviously they are putting a lot of thought into it and spreading their applications. As far as one can see at this early stage there is a spread.

Q582 Dr Stoate: But you are not expecting a huge meltdown in terms of vast numbers?

Professor Paice: Not so far, but do remember that what is on offer this year is not what was on offer last year. Last year what was on offer was the best possible thing to get. If you got run-through training to take you through to CCT in the specialty you wanted that was a terrific offer. That is not what is on offer this year.

Q583 Dr Stoate: You are saying that last year was genuinely unique. What you are trying to tease out is not that this is something that will happen year on year but that last year was a very special year?

Professor Paice: It was a very special offer that was attractive internationally.

Q584 Dr Stoate: As far as you can tell, it is not likely to be repeated?

Professor Paice: Not if the recommendations in the Tooke report are implemented because it recommends uncoupling. It is the run-through training that is such a good offer.

Q585 Dr Stoate: One of the things we were told by Shelley Heard, the former clinical adviser to MMC, was that the deaneries would not implement the Department of Health's guidance anyway because you knew it was illegal. Is that right?

Professor Paice: We were told by the Department of Health that this guidance was that the HMSPs should not be in the first round of applications if they did not have enough time on their passports to complete the whole programme. We then got a message in an email from the Home Office, which you have probably seen, to say we could not do that because it would not be legal. Next, we got a message to ignore that because the department's advice was more important. Then we were told it was really up to local decision. We decided that we had to have very clear instructions about what was the right thing to do and in the meantime we would include the HMSPs in the first round of application and we would tell them, as we did, that their appointment was subject to continuing eligibility under immigration rules. What we did not want to do was to find ourselves acting some kind of quasi-immigration department. We could not do that.

Q586 Dr Stoate: If everybody seemed to know that it would fall foul of the court how come the Department of Health was the last one to find out?

Professor Paice: I do not think we or the department knew that. We wanted a much firmer lead than we were getting.

Q587 Dr Stoate: So, it is unfair to say that you should have warned the Department of Health that there were problems with it?

Professor Paice: We certainly did; we were in communication with the department, but we are not immigration experts. How could we know it was illegal? We just did not accept the situation in which we were told, "Here is some guidance; it is your choice locally." That did not seem right.

Q588 Chairman: Professor Paice, you told us about the interaction you had in correspondence. Can you let the Committee have that correspondence?

Professor Paice: I have email correspondence and I can give that to the Committee.

Q589 Dr Stoate: Looking to the future, do you agree that something needs to be done to restrict the number of IMGs, particularly under the highly skilled migrants programme?

Professor Paice: In my view it is appropriate. Either you have a policy of self-sufficiency or an open-door policy but you cannot have both. We have already invested pretty heavily in the self-sufficiency policy, but it is not sufficient just to do that because we are in Europe. We need a level playing field and I feel passionately that we need something along the lines of what the Americans do. Therefore, there should be some kind of test that provides a baseline; otherwise, we cannot cope with volume applications, and we are likely to get them from within Europe if we make our training as good as we would like it to be.

Q590 Dr Stoate: Effectively, you want to raise the bar for non-EEA graduates?

Professor Paice: It might not even be a matter of raising the bar. I would just like there to be a bar so we know what the situation is and we can sift. The Americans recommend that students apply widely from the things they really want to do to the things that they are just about prepared to do; they do not worry about the volume because it does not impinge on any senior doctor's time. You just sift electronically and you can start to do short-listing in the assessment and selection centres with skilled staff, but you cannot manage that if you have unsiftable volumes of applicants.

Q591 Dr Taylor: Professor Sowden, I want to look to the future. First, did you volunteer for this poisoned chalice, or is it not a poisoned chalice?

Professor Sowden: I think the degree of toxicity will be determined over time and it is difficult to judge at the moment. For my sins, I said I would be prepared to do it as a secondment for a short period. I believed that the job was worth doing. My predecessor had left to take up another post. There are some particular issues within the department which would have made it difficult for them to make a permanent appointment over the next six to nine months. It seemed important that there was somebody in place who could take forward the 2008 process and lead on the development for 2009.

Q592 Dr Taylor: So, you are safe in post until after the 2008 process has been completed?

Professor Sowden: Pretty much so, yes; I am certainly in post until August/September.

Q593 Dr Taylor: Is it true that, according to the figures we have been given, there are three applicants for every post?

Professor Sowden: It is difficult to tell. That is the prediction in terms of the number of UK graduates who are in the system and those we expect in terms of IMGs. We have not had back any information to suggest that is wrong, but it is an average which means that, for example, at entry to ST1, the first stage of training, that ratio is less than three to one, whereas at ST3 in some specialties it is considerably more, perhaps as much as 20 to one. There is a danger that people think that strange; in other words, that it is a function of this process. It is not. Many specialties have always been intensely competitive. I suspect from your experience and mine over the past 20 or 30 years there have been some careers which have been immensely difficult and the majority of people fail to get into them.

Q594 Dr Taylor: Therefore, competition quite rightly has always been a part of the job. Do you think that inevitably competition will be greater? Mr Ribeiro talked of a ratio of 19 to one as an example. It will be pretty tough in those specialties.

Professor Sowden: Yes. Surgery is a particular case. Historically, it has had a very large population of intermediate grade junior doctors, the traditional SHO grade, who provide an important patient service, but only a small number ever leave the sump of SHO training to get into SBR training, as it were. They were the ones who often trained in the SHO grade for very long periods, say, six or seven years. The worst example we found was someone who had been in post for 14 years. One would query the validity of training somebody at that level for that long. How much more can you learn in that grade? Many of them realise during that process of attrition that they will not make progress. The difference between then and now is that they are confronted with their failure as a stark reality and they cannot make progress. There is nowhere else to go; they have to find somewhere else. That is very difficult for a group of young people who up until now have had only the experience of success, that is, success at A-levels, at university and so on. It is very difficult for them to adjust to that.

Q595 Dr Taylor: Can you give us a thumbnail sketch of your plans to make it work this year?

Professor Sowden: In terms of how it will work, the big thing is the process of allowing the deaneries to manage the selection and recruitment process at a local level. The reason for it is that you then have some control over the process you put in place. You are managing the consultant staff situation with trusts with which you are familiar and you do not have the added complexity of an IT system that in the event does not work particularly well for the reasons you have already heard. It does not necessarily mean that the final outcomes for a certain group of junior doctors will be better, but their experience of the process may be and should be considerably improved and up until now it feels better.

Q596 Dr Taylor: So, short-listing will be left to deaneries?

Professor Sowden: Yes; it is all done at a local level. The long-listing, short-listing and interview are done locally with the exception of a small number of specialties where we have had agreement to go national, but they have already piloted or they are small and it is possible to do it.

Q597 Dr Taylor: One of the main reasons for MTAS was to try to make the short-listing process a little less time-consuming for everybody. How will you cope with short-listing this time?

Professor Paice: It did not make the short-listing any easier for anyone. Every application form had to be looked at by at least eight consultants. What we are doing this time to make things easier is to ensure we have a great deal more time for people to go through the forms and to recruit a large number of consultants, making sure that each does not have an excessive number of application forms to score. We are really working on the timescales and numbers of people involved rather than what we talked about before, which is some way of taking the work away from consultants.

Q598 Dr Taylor: How do you give consultants more time to do it?

Professor Paice: For example, in London where volumes are big we are stretching out the whole process over a prolonged period of time. We knew that we had no hope of trying to do things so we could get in first. We are just making sure that we have got three weeks for short-listing wherever we possibly can to allow people to pace their work. Different people take different times, but we know approximately what sort of time it takes to short-list and we can make sure people are not overloaded.

Q599 Dr Taylor: Therefore, they will have old-fashioned application forms to go through?

Professor Paice: That is correct. They are not cv's; they are cv-based application forms that we have been using for 10 years in London. Everybody is used to them. Obviously, they are modified to make sure they fit in the latest person specs, but it is a familiar exercise.

Q600 Dr Taylor: Therefore, the stories we heard about people being faced with a huge pile on a Friday and having to go through it by the end of the weekend will be avoided?

Professor Paice: I refer in particular to the 650 forms. It is worth remembering that that was one question and there were 150 words on each form. It was not 650 cv's. If you like, because it is one-tenth of the form it is the equivalent of 65 cv's to mark. That is the kind of number that we would be looking at, and not over a weekend but over three weeks. Anything from 50 to 100 will probably be the burden. It is not a trivial burden, but it is the sort of number that people would be expecting.

Q601 Dr Taylor: We shall be watching with interest how you get on this year.

Professor Sowden: You can tell me afterwards whether or not it was a poisoned chalice.

Q602 Chairman: I want to ask about the Tooke review. What is your overall response to the findings and recommendations of that review?

Professor Sowden: Obviously, we respect it as an excellent piece of work. The vast majority of the recommendations are ones that we wish to support in full. Certainly, there is very little difficulty with the eight principles he has established with the interim report and has added to very slightly in the final report, but they are largely unchanged. Obviously, there are some recommendations that require very careful consideration, not the least of which are the two new recommendations added to the final report. From a deanery perspective, there are also particular issues around the proposals on foundation programme training and its linkage to the guarantee of employment for UK graduates. There is some doubt about the legality of that particular statement and therefore we are concerned about it. Most of it is wholly supportable, and the bottom line of the Tooke review is that for some recommendations the devil is in the detail which need to be worked through both in terms of the departmental response which will come out by the end of February but also in terms of how the profession as a whole - the colleges and deaneries - respond to some of the details. Some of this requires fundamental reworking, for example the specialty curricula, which should not be underestimated. It will take not an inconsiderable time to implement.

Professor Thomas: I would reflect the same view.

Professor Paice: In general postgraduate deans are very sad about the proposals to break up the foundation year and I would not like anyone to think otherwise. We are all united on that. We believe that the foundation has been good and we are sorry to see it uncoupled. One must not lose sight of the problem that MMC was trying to fix. It was not just a bright idea that people had. I should like to make sure that when the Tooke recommendations are implemented those things are fixed, for example the issues around whether or not too much of the service is being provided by people in training and whether the people you are training have what it takes to provide a modern health service with safe patient care and they are reliable and competent. We need excellence absolutely but they must be reliably competent. We should like to make sure that we do not develop another process of milling and queuing between core and higher specialty training. That is the detail, if you like. I would also be very unhappy if there was any distancing between medical workforce planning, financial planning and service planning because that would be a retrograde step. I am sure that is not the intent, but there are ways to read the recommendations that might give rise to that. That is the anxiety I have.

Q603 Chairman: Professor Sowden, you said the devil was in the detail. Sir John told us that the medical profession supported his recommendations. He said that he received 87% per cent support during consultations and it appears that he has united the medical profession. Are you surprised by such comments?

Professor Sowden: There are different interpretations of statistics. What we do not have is what the 87% of respondents mean. We know, for example, that the directors who represent all the foundation programme schools responded as a group. If they are treated as one negative responder against a single person's response obviously the 87% is not a meaningful representation of feeling out there. One needs to have access to the core data to be absolutely certain that the 87% looks as it is presented. I do not suggest there is a misrepresentation here, but we all know sitting here that there were a lot of responses to suggest that the foundation programme recommendation was premature in advance of formal evaluation of that programme. We would be concerned that that 87% response rate was not reviewed in the light of the possibility that it did not reflect a total professional view of what is going on.

Q604 Chairman: Do you think that a more open debate about the proposals would have been a healthier outcome? It does not appear to be the case at this stage; it will be subsumed by the department and handed out at some stage.

Professor Paice: The postgraduate deans have been debating this so vigorously that they do not feel they have failed to consider this one. Perhaps that is a feeling that others have.

Q605 Chairman: Professor Paice, you mentioned the issue of splitting up the two-year foundation scheme and introducing a three-year core specialty training programme, and that is on top of the changes that have taken place in the provision of training, foundation and specialty training established recently. What effect will this have in terms of these two areas?

Professor Paice: Every time you restructure a lot of energy goes into it, as we have seen, because a lot of what we have been talking about has been the impact of the restructured training and then recruiting into it. There is so much else that needs attention, for example the content of training, implementing new curricula and keeping them up to date with a continuing dialogue with the service about whether the curricula are fit for purpose. Another matter is the way we deliver training. With the European working time directive and so many changes in the health service the way we deliver training has to change; and we have to change the way in which we assess people so be more reliable and robust. A lot of this change is being driven, rightly, by PMETB and the standards set by it. My anxiety is that in restructuring some momentum that has been gained will be lost. I would be sorry to see that happen. I am sure it can happen without losing momentum, but it is a worry.

Q606 Chairman: Do the other witness want to add to that?

Professor Thomas: The problem is that it may prove a distraction.

Professor Sowden: It is clear from the Tooke recommendations that the foundation programme training split is there to provide a first year of secure employment. If that is not forthcoming as a legal option - it may well not be - there is much to be said for looking at how we can allow the foundation programme to evolve. There was already a plan to have a fundamental curricula rethink before 2010. There are issues to deal with the first couple of years' training in specialties to see how we can create more flexibility, but those are all about evolutionary change, not revolutionary structural change. We need to be very careful about structural change because we have all experienced it ad nauseam in the NHS over the past 20 years and often it distracts you from what really matters. What matters in postgraduate training is the outcome for patients and trainees.

Q607 Dr Taylor: I want to turn to recommendation 47 and the suggestion as to NHS Medical Education England. What are your feelings about it?

Professor Paice: It cannot be a bad thing to have medicine speaking with one voice. Whether it is the academy or this body, to have an arena that brings together the medics to discuss and agree things has huge appeal. There are however a number of details within that concept with which I would struggle. It comes back to what I said before. Given the descriptions of what that body would do, there is a risk that you would separate the financing of medical education. Ring-fencing has been referred to. I would hate to see medical isolationism as the outcome of this and a step backwards from the integration of service strategy and financial planning, using medical education, if you like, as an enabler for service change and reform. The tension is always between education and service but that is really tension between service today and service tomorrow. I should like to see the postgraduate deans of training helping to drive the way the service should look tomorrow. Therefore, I would worry about too much separation of workforce and education.

Q608 Dr Taylor: Do you think that the academy could take on this role?

Professor Paice: It depends what the role is. If the role is to speak with one voice then the academy is ideally placed to do it; if the role is to hold a very large budget obviously that would not be the sort of structure you would put in place to manage sums of money.

Q609 Dr Taylor: What do you see as the role of the SRO for medical education? Sir John thinks there would be an SRO responsible for this. Would that SRO be, as you are, a member of the Department of Health or would he or she be completely independent?

Professor Sowden: That depends very much on how you deliver the concept of the MEE.
Certainly, the SRO is designed to be a director of medical education sitting within the Department of Health potentially but not confirmed as a deputy CMO position. That gives considerable authority within the profession. Whilst I acknowledge there are issues about perceived independence, those can be dealt with within an appropriate framework of accountability for the establishment of the body. I think the points Professor Paice has made are critical and without them being sorted out it is a little difficult to be explicit about what the role of the director of medical education or SRO ought to be or could be. I hope that does not sound too vague, but it is very difficult to see a way through the fog at the moment.

Q610 Dr Taylor: If I may go back to Professor Paice, workforce, finance and service must all be kept together?

Professor Paice: I would have thought it made sense if you were planning to improve and reform the service to make it more patient-centred, safe and of high quality. You would want to bring into that every aspect of what care is about. The trainees are absolutely central and critical to delivering care as well as being trained and educated today, but they are the trained workforce of the future. It makes sense to ensure that all of that is considered and taken into account and is integrated and joined up rather than that education is seen as being slightly out on the side. I am sure Sir John never had any intention of anything like that happening. I am just saying that it raises a concern that that might be a possible danger to be avoided.

Q611 Dr Taylor: Therefore, you do not believe that the Department of Health can be stripped of all its responsibilities for medical training?

Professor Paice: I do not see how it could be.

Q612 Charlotte Atkins: Given the different size of the deaneries, do you think all of them have the capacity to plan for and implement such complex reforms as the MMC? It seems to me that the events of 2007 indicate that such capacity does not exist right across the board.

Professor Paice: I would draw a different conclusion from that. It can get too big to manage. One of the successes in Scotland and Wales as a result of this is that they were able to make decisions that worked locally. I believe that the events of round two and what is happening this time round show that some things are better managed on a smaller scale than a huge scale.

Q613 Charlotte Atkins: Why do you think that Tooke recommended a new co‑ordinating body?

Professor Paice: The idea of getting a joined-up agreed medical voice is an extremely appealing one. When educational initiatives are taken or changes made everyone is absolutely signed up and if there are dissenting voices they are listened to carefully because there may well be something very important being said by the dissenter. A corporate view in itself is no good unless what comes out of it is definitely the right way forward. It is often that voice from the side to which people need to listen.

Q614 Charlotte Atkins: You refer to a co-ordinated voice, but do you think the fact there are two organisations, COPMeD and the deaneries, mean they cannot speak with one voice? Do you believe that is a problem?

Professor Paice: I think we have been speaking absolutely with one voice through what has been an extremely difficult time. It is correct that the experience has been different. If one asked whether this had been smooth one would get two answers, yes and no, but that is not the same as not being together in what we are trying to achieve. We had a shared goal and understanding of what we were trying to do and why we were trying to do it. We all worked together to do our very best, so this did not fail because we could not agree with each other.

Q615 Charlotte Atkins: Is that a common view?

Professor Sowden: Yes; I agree. To go back to your earlier point about the size of deaneries, I agree with Professor Paice. We have gone through a process of rationalisation of the deaneries and two of us sitting here are the bi-products of that. I was originally in a smaller deanery; I am now in a much bigger one that is coterminous with an SHA. Professor Thomas has literally just gone through that experience. But there is a size beyond which you begin to get too big. Having moved from a relatively small deanery to one twice its size, it is about as big as I would like it to get. It is very difficult to maintain those key personal relationships with clinicians and trusts as one way of levering change behind the scenes without having to get out the big guns and so on. I do not want that to sound as if it is Machiavellian or underhand, but those personal relationships are important. The bigger you get the more difficult they are to maintain.

Q616 Charlotte Atkins: At the moment there are some quite small deaneries, like the size of Oxford, and others that cover the whole area of a strategic health authority. Is it time for all the deaneries to be coterminous with SHA boundaries?

Professor Sowden: You could aspire to that but I think it would be very difficult. I have one particular example in mind: the South West. The reason it was split into two deaneries was that the geography did not work. It was so huge that you could not meaningfully run Cornwall from Bristol, which was what happened. We have to recognise that there are patches in England where that is different or difficult. You can aspire to one model but you have to accept that that model must not be the only one because there are exceptions to it. I recognise however that there are oddities in the system that might warrant review in due course.

Professor Paice: The experience of London Deanery working with five SHAs and working with one, NHS London, has been a revelation. It has been infinitely better to work to the same agenda and with the same span, concept and goals. I would not wish to turn back that clock.

Q617 Charlotte Atkins: The fact that you have the same geographical area does not mean that you have the same agenda.

Professor Paice: No, but, interestingly enough, it has not felt like that; it has felt like having one agenda.

Professor Thomas: Patients throughout England and the UK need consistency of delivery of healthcare and therefore we ought to be doing things in a consistent manner across the SHAs and deaneries. This is supposed to be about common national standards and consistency of delivery and I would not want to lose that.

Chairman: I thank all of you for coming along to help us this morning. This has been a comprehensive and wide debate. Some of us represent areas of the country and do not recognise the national debate. It is nice to know that we do not represent other planets but actually do represent parts of the UK.