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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

MODERNISING MEDICAL CAREERS

 

 

Thursday 24 January 2008

PROFESSOR PETER RUBIN, PROFESSOR NEIL DOUGLAS
and PROFESSOR SIR NICK WRIGHT

MS ANNE RAINSBERRY, DR MOIRA LIVINGSTON and MS SIAN THOMAS

Evidence heard in Public Questions 618 - 765

 

 

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Oral Evidence

Taken before the Health Committee

on Thursday 24 January 2008

Members present

Mr Kevin Barron, Chairman

Charlotte Atkins

Mr Peter Bone

Dr Doug Naysmith

Mr Lee Scott

Dr Howard Stoate

Dr Richard Taylor

________________

 

Witnesses: Professor Peter Rubin, Chair, Postgraduate Medical Education and Training Board, Professor Neil Douglas, Head, MTAS Review Group, and Professor Sir Nick Wright, Warden, Barts and the London School of Medicine and Dentistry, gave evidence.

Q618 Chairman: Could I first of all welcome you and then ask you to give us your names and the current positions that you hold.

Professor Rubin: Professor Peter Rubin and I am here as Chairman of PMETB.

Professor Douglas: Neil Douglas, President of the Royal College of Physicians of Edinburgh. Here, I believe, as past chairman of the Review Group.

Q619 Chairman: I have an interest to declare. I do know Peter Rubin. I am a lay member of the General Medical Council and Peter sits on the Medical Council as Chair of its Education Committee. Perhaps I could start by asking a couple of questions about the role of PMETB. It began work in 2005, the year the first MMC reforms were introduced. Was PMETB set up specifically to provide quality assurance for the MMC reforms or was the timing an absolute coincidence?

Professor Rubin: The timing was largely coincidence. I should qualify that by saying that I was not involved in the establishment of PMETB. I came on the scene somewhat later than the establishment process, which was earlier on. Inquiries and reviews going back to 1970 recommended that postgraduate medical education should be regulated, as undergraduate medical education has been since 1858. The most recent of those reviews was the Bristol heart inquiry and in that review Ian Kennedy very clearly recommended that postgraduate education should be regulated and PMETB was a consequence. MMC was developing in parallel with all that. One of the issues that has been all too apparent to us is that, because the MMC came on the scene at much the same time, there has been a lot of confusion about what the two organisations do.

Q620 Chairman: What are the extent of and limitations to PMETB's responsibilities for postgraduate medical training? It has been put to us that the creation of PMETB was a "direct attack" on the medical Royal Colleges. Do you agree with that?

Professor Rubin: Perhaps I could tell you what PMETB is intended to do and then I will comment on the Royal Colleges. The role of PMETB is to protect the public by determining the standards necessary for a doctor to go on the specialist or the GP registers. We do that in two ways. For doctors who undertake a regular UK training programme, PMETB determines the content of the outcomes of that training: we ensure that the exams are fit for purpose and we quality assure the standards of training. For doctors who train outside the EU or for doctors who undergo an unconventional training programme in the UK, we establish that those doctors have knowledge and skills equivalent to those who have done a regular training programme, and through the article 11/article 14 rules we establish whether they are fit to go on to the specialist and GP registers. That is what PMETB does. With regard to whether PMETB was established to undermine the medical Royal Colleges - and I should say that I was not involved in establishing PMETB - I think it best to respond in this way. Undergraduate medical education in medical schools in this country has been regulated since 1858. Their reputation is high; the reputation of medical education in the UK is very high. I do not think anyone would say that being regulated has damaged the medical schools in this country. I think it is therefore a rather flawed argument to say that, just because the colleges are being regulated, there is an attempt to undermine them or devalue what they do. I have certainly never taken that view.

Q621 Chairman: Why do you think PMETB's role seems to be so poorly understood by other stakeholders within medical education?

Professor Rubin: I really do not know. There has been a lot of genuine misunderstanding and, also, I think, some wilful misunderstanding about the role of PMETB. I think some of that goes back, as you have implied, to the unhappiness around the establishment of PMETB. We are very clear on what we do; Parliament is very clear on what we do. We are established by statute: what we can and cannot do is spelt out in the order. It should be very clear what we do but, I agree with you, there has been a lot of confusion and misunderstanding.

Q622 Chairman: Could I also welcome Professor Sir Nick Wright.

Professor Sir Nick Wright: I do apologise. My lateness was due to the vagaries of the District Line.

Q623 Chairman: Okay. I did ask for the names of our other two witnesses. Perhaps you could just tell us the position that you hold.

Professor Sir Nick Wright: I am the warden of Barts and the London School of Medicine and Dentistry in Whitechapel and Smithfields.

Q624 Chairman: Back to PMETB. You say that PMETB is not responsible for recruitment and selection to medical training posts. In evidence to us, the Chief Medical Officer told us that PMETB has "responsibilities for approving, not just the curricula of the new speciality training programmes, but also the applications procedure". Who is right?

Professor Rubin: The CMO is incorrect. Having looked at the transcript, I think Dr Marshall, who was at the time the DCMO, tried rather diplomatically to correct that rather quickly. That was my interpretation of the transcript. PMETB's role in the selection process is, again, prescribed in statute - so it is not a mystery, hidden anywhere - and our role is to determine the standards that a doctor must have reached in order to go into specialist training; in other words, to determine that the processes used can distinguish the eligible from those who are not eligible. It is not our job - nor, I think, should it properly be the job of a regulator - to get involved in telling those who are running training programmes how to pick the best candidate. That is for them. They know what their programme involves and it is for them to decide who is the most excellent of the applicants. Our job is simply to determine that the processes can distinguish the eligible from the ineligible, so it is a pretty minor role.

Q625 Chairman: The Department of Health included a letter in its evidence showing that PMETB received a presentation on plans for the MTAS system in September 2006 and was broadly happy with the proposals. Why did you inspect the MTAS system if you are not responsible for recruitment and selection?

Professor Rubin: The meeting was in August, the letter that we sent was in September. The background to the meeting was that the MTAS team asked to see us. We did not ask to see them. We had not intended to see them. As I have said, our role is pretty small, and we were going to pick up our limited role in the selection as part of our regular QA processes. They asked to see us, and we wished to be helpful - I mean, we realised everything was new and we did not want to be unhelpful - so they came along and gave a very high level presentation. It was not overflowing with any detail. For example, the application form, the electronic form that has been much criticised, was not ready and so we did not see it. They gave a very high level presentation in which they assured us that they would be consulting with interested parties (that is, the Junior Doctors Committee of the BMA and the medical Royal Colleges) on the form when it was ready. So they gave us a very high level presentation and we gave, as you will see, a very high level response, saying, "Broadly speaking, what you are proposing to do, in principle, seems to meet our requirements for the process." So it was all very high level and, I have to say, rather general stuff.

Q626 Chairman: You stated in September 2006 that the MTAS system "broadly meets the relevant section of PMETB Generic Standards for Training". What was this judgment based on? With hindsight, do you think you were correct in saying that?

Professor Rubin: We thought that, broadly, it would meet the requirement to distinguish the eligible from the ineligible. Despite all that has happened since, I believe that Professor Tooke's inquiry did not find that there was any evidence that it failed to distinguish the eligible from the ineligible. There were a lot of arguments over whether their best candidates were selected and so on, but that was not the regulator's role, to get into that particular aspect of the selection process.

Q627 Dr Naysmith: I do not think you answered the Chairman's previous question. He asked you why you took part in this procedure when it is not your responsibility and you said you were invited by them to see them. What was the purpose of this? You could have said, "It is really nothing to do with us. What are you telling us this for?" Presumably a number of highly paid individuals sat around a table and gave this great presentation which was, in your view, unnecessary. Why did you go through with it?

Professor Rubin: Because we wanted to be helpful. We were very conscious that a lot of new things were happening. A lot of new things were happening. MTAS was new, MMC was new, we were new, and we felt that to say, "No, we don't want to meet you" would be unhelpful, basically. It was as simple as that. We were clear to them - we were very clear and the letter was very carefully worded - that we were not approving anything. The word "approve" does not appear in that letter quite deliberately - quite deliberately. Equally, we thought it would have been gratuitously unhelpful to say, "We don't want to know."

Q628 Dr Taylor: I am rather struggling with the feeling that selecting the eligible from the ineligible is only a minor role. It would seem to me to be absolutely crucial.

Professor Rubin: The eligible, for example, going into the first year of specialist training, will be somebody who has completed the foundation programme or has experience overseas of the equivalent to the foundation programme. The arguments around MTAS and the selection process, the arguments that have raged since last spring, have been about whether the very best candidates were being short-listed and the very best were being appointed to the posts. When I use the term "minor" that is minor in comparison to our major responsibilities for delivering the content of 57 curricula, examinations in 57 specialities, and quality assuring postgraduate medical education throughout the UK. That is big stuff. In contrast to that, our responsibilities for selection are really quite small.

Q629 Dr Taylor: I understand that. Do you feel that the Department of Health and the Royal Colleges have tried to make PMETB a scapegoat for what happened?

Professor Rubin: The first thing to say is that people use the term "colleges" as if there is a homogeneous organisation called colleges. They are not homogeneous.

Q630 Dr Taylor: Although the Academy surely tries to speak for all of them.

Professor Rubin: The Academy tries very hard to speak for them but there have been some examples of wilful misunderstanding surrounding the MTAS process. Since you ask the question, Dr Taylor, let me give you one very striking example concerning the Royal College of Surgeons of England in their evidence to Professor Tooke. In their evidence, which was in the public domain on the website, they made the most extraordinary claim, which was that PMETB did not approve of having a clinical component to their flagship MRCS exam, their postgraduate exam. That was an extraordinary misrepresentation. The truth was that, as part of our regulatory functions, we had established that their flagship exam, the MRCS, had serious problems. We had established that the clinical and oral components of the exam were subject to deep uncertainty as to the level of the exam, uncertainty even as to what was being tested - and what was being tested seemed to be different in different parts of the UK - and uncertainty in the minds of examiners as to how to allocate grades for different levels of achievement. We, as regulator, said what you would expect us to say: "You've got to clean up your act. You must produce an exam that is fit for purpose and do it in a very short timeframe." That was misrepresented in their written evidence to you as saying: "PMETB does not agree with us having a clinical assessment," sending a completely different message. Clearly I wrote to Professor Tooke to put the record straight and so on, but that is an example of what I would regard as wilful misrepresentation to try to make PMETB look something that it is not.

Q631 Dr Taylor: You were obviously aware of the problems and the crisis emerging. Should you not have been the first to point this out?

Professor Rubin: From the very beginning, it was clear to me that, at the heart, the problem was one of a huge mismatch between the number of applicants and the number of places. That was clear very, very early on. Workforce is not something that PMETB does. We do not do workforce. That, at the heart, was the problem. Certainly there were issues around the application form and so on, but, had there been less of a mismatch between applicants and places, the problems that were there with the form would have been much more easily manageable at a local level. It was clear to us that the heart of the problem was a numbers problem. It is hard now, perhaps, to remember that there was a cacophony of conflicting anecdotes circling around - and, as a regulator, you need evidence, not anecdote. Everyone was claiming that the brightest in the generation were not being short-listed. There were counterclaims that the brightest in the generation had been so careless in completing the form that they had managed to conceal their brightness very effectively. There really was a maelstrom of conflicting anecdote. It was my judgment call. The board at PMETB was not united on this: there were many members of the board who wanted me to be up there campaigning. It was my call on this, and my call was that, as a regulator, it was not our job to get into the maelstrom of conflicting anecdotes.

Q632 Dr Taylor: You have really answered my next question. You do not feel as Chair of PMETB responsible for what happened in any way.

Professor Rubin: The answer is no. I do not feel responsible. I will draw your attention to Professor Tooke's report, in that PMETB is about the only organisation that is not criticised - and, of course, he took very extensive evidence. I should say, Dr Taylor, however, that, as with all regulators, what I did behind the scenes was often very different from what I was doing in the public arena. I gave various bits of advice to various officials at that time, to the Department of Health at various times, but there is a difference between what you will say privately to somebody and what you will say in public when you are a regulator.

Dr Taylor: Thank you.

Q633 Mr Bone: Basically you are saying that what you say in public is not what you are doing in private, then.

Professor Rubin: In the advice that you give to, say, a senior official in the Department of Health, when the timeframe is absolutely electric and when you realise that there are a lot of people who are having to make snap judgments, I think it is perfectly appropriate for the regulator, in my case as the Chairman of a regulatory board, to give advice to say, "I hear that you are planning to do A; I think you should do B". That is personal advice given by the Chairman of the regulatory body. I was not claim then to be acting for the board. I think, therefore, because I was not acting for the board, I did not have board approval for the advice I gave, it is quite wrong for me to go in the public domain with that kind of advice.

Q634 Dr Naysmith: You did say the system was broadly okay in 2006. At that time you broadly appeared to distinguish eligible from ineligible, but you had not seen the application form. How could you say that if you had not seen the application form?

Professor Rubin: The wording of the letter, as I said, was carefully chosen to say: "You have presented us with very high level principles and these high level principles seem to meet our requirements." But it was very high level stuff.

Q635 Dr Naysmith: You are admitting, basically, that, without seeing the application form, you just believed what they said, that they were going ----

Professor Rubin: We said that we were pleased to note that they were going to check the application form with the Junior Doctors Committee of the BMA, with the medical Royal Colleges, and we pointed out to them - although we did not use these words - that they had a mountain to climb because they were talking to us in August and they still did not have the application form ready. The background to the meeting, as I said, was for us trying to be helpful, to say, "Okay, you have told us how far you have got and, in principle, where you have got to seems to be okay but that is a long way from implementation, of course."

Q636 Dr Stoate: If everything is going so well at PMETB, then why do Professor Tooke and the CMO both call for it to be absorbed by the GMC?

Professor Rubin: I think the reason is an administrative reason that it makes sense. I should preface that by saying, as Kevin has already mentioned, that I Chair the Education Committee at the GMC and I am in a clear conflict of interest position. For that reason, I have stood back from the responses of both PMETB and GMC to the structural issue. But, if I can answer your question as to why they are saying that, I think it is the administrative and strategic argument that there is sense in having all medical education, undergraduate and postgraduate, CPD, regulated by one organisation. I would make the point, though - I am here as Chairman of PMETB - that, despite a dreadful start - I am sure you know the first chairman left and the first chief executive - PMETB is now a functional organisation that has major achievements.

Q637 Dr Stoate: What effect would it have on the arrangements, if it were, absorbed into the GMC?

Professor Rubin: If some or all of Professor Tooke's recommendations or recommendations that you make are implemented to postgraduate medical education, then an effective regulator will be very important, and so that would be the worst time to shut down the regulator that deals with postgraduate medical education because we are now functioning very well. Yesterday afternoon I had one of our regular meetings with college presidents and, notwithstanding all the history, there is now a very constructive relationship with the medical Royal Colleges and PMETB. We are very much functioning strongly with strong achievements under our belt.

Q638 Dr Stoate: In a nutshell, then, you are not happy about it being absorbed. At one stage you said it was an administrative process and therefore it did not seem to make much difference. Now you are saying it would have a disastrous effect.

Professor Rubin: I did not use the word "disastrous".

Q639 Dr Stoate: No, but it was what you were implying.

Professor Rubin: I repeat that I have stood back from the views of both organisations about the structural issue of a merger but I would like to make the point that PMETB has made significant improvements to the quality of postgraduate medical education in the UK.

Q640 Dr Stoate: But I still want to get to the point: Do you think it is a good idea for this to happen or are you opposed to it?

Professor Rubin: I really do not think I should answer that because of the conflict of interest position that I am in. The thing with conflicts of interest is, if you declare them, you must stand by them and I am in a conflict of interest position.

Q641 Dr Stoate: Do either of the other two witnesses have a view on this, because it is rather important?

Professor Douglas: I am a PMETB board member as of a year ago, so I cannot say anything.

Professor Sir Nick Wright: Speaking as someone who was head of a medical school when PMETB was set up, many of my colleagues and myself had grave reservations about the fact that you had a statutory body that was reporting to the secretary of state and yet was still responsible for setting the standards of postgraduate education, so the secretary of state was ultimately controlling everything. The one thing about the Royal Colleges, whatever their defects which Professor Rubin has pointed out, was that they were regarded as being independent. They inspected hospitals to see if there were appropriate training facilities and they were independent of the secretary of state; whereas the secretary of state now, theoretically, is in charge of both inspection and the provision of those facilities. We saw this as a retrograde step because the independence of inspection and the setting of standards was not being underpinned. It is rather ironic, when we are abandoning these visits by Royal Colleges, that in Scandinavia they are saying that they think it is a very good idea so they are setting this up to inspect training premises. It is really the question of the divorce of the facilities and the training from the regulation in which I would be very much in favour. Moving this to the General Medical Council would show that there is independence in regulation outwith the secretary of state's purview.

Q642 Dr Stoate: You are basically in favour, then.

Professor Sir Nick Wright: Yes.

Dr Stoate: That is the point I wanted to get to. That is fine. Thank you, Chairman

Q643 Dr Naysmith: Professor Wright, from a medical school perspective does it make sense to have a single cradle-to-grave regulator for the whole of the medical profession?

Professor Sir Nick Wright: Yes. The reason for that is, as Peter said, that the reputation of the General Medical Council in regulating and examining standards of undergraduate medical education is non parilis in the world generally. It has very, very high standards. Anybody who has undergone a GMC visit to either the dentist school (GDC) or dental school knows the stringency of the high standards which the General Medical Council sets in education. If that could be translated into their regulation of postgraduate education, as I suspect it would be because the General Medical Council has a tradition for excellence - notwithstanding the fact that it has been berated in other avenues, education standards are extremely high - I have every confidence the GMC could produce the goods.

Q644 Dr Naysmith: Do you think it has the skills and capacity to take on postgraduate ----

Professor Sir Nick Wright: Not currently. I think it would need certainly more staffing and more finance. It would be the question of organisation that they would have to approach, so, yes, I think they could do it, given the appropriate facilities.

Q645 Dr Naysmith: Is it not inevitable that they have been dragged into this current crisis that is going on in postgraduate education at the moment? GMC standards are good.

Professor Sir Nick Wright: I think it is rather unfortunate that bodies like PMETB, the MMC board and also the Tooke Review were not dragged into sorting out this current process. One of the criticisms I would have of the Tooke report is that they deliberately restricted their remit to not looking at the current problems in postgraduate education that we were facing last year and this year. They say similar things about the MMC board running through with the process and then post hoc the presidents of the colleges writing in the Times and saying it is not working. The fact that the Tooke report did not embrace the problem of MTAS last year and did not look for a solution to the recruitment problem this year is a real defect. I think the more people who get involved in trying to sort out current problems, the better.

Q646 Dr Naysmith: Who do you think should sort it out?

Professor Sir Nick Wright: I think the Tooke report should have taken this under its belt, to try to produce suggestions that could change the way in which we link training decisions, consultant decisions. As you probably heard before, it was a Fidelio suggestion that the link between junior staff numbers and consultant specialist numbers should be broken, and there should be a gradation of specialists, specialists and senior specialists, so the number of recruits into these jobs was not linked with the number of consultant vacancies. Add to that the fact that we are, I understand, 21st in the world in terms of doctor:patient per head of population ratio, and it argues for a big expansion of both grades. I would look askance at the Tooke report for not looking at that in some detail.

Q647 Dr Naysmith: Do you think you are talking on behalf of most medical schools is that just your personal view?

Professor Sir Nick Wright: I think quite a number of my colleagues would share my view.

Dr Naysmith: Thank you.

Chairman: We are going to move on to the question of the Tooke Review now.

Q648 Mr Bone: The first question is just a yes/no answer because of the way it is phrased but we will be moving on afterwards. In general terms, do you agree with the analysis and recommendations set out in the Tooke Review?

Professor Rubin: Strongly.

Professor Douglas: I agree.

Professor Sir Nick Wright: I would agree with that.

Q649 Mr Bone: In the consultation programme you have approval for the review in something like the terms you might get for a presidential election in one of the African democratic republics: 87% approval. Are you surprised at the medical profession, in that everybody thinks it is the best thing since sliced bread?

Professor Douglas: I was surprised that that particular analysis was used. The point has been made to you before that a group of people who are deeply involved in it, who have been designing or running part of the programme, were counted as one vote whereas an individual might be counted one vote, so I thought the analysis was a bit simplistic. But the overall messages put out, that the vast majority of the profession supported the vast majority of the recommendations, is absolutely correct and so not terribly surprising.

Professor Rubin: Would it be appropriate to mention what I consider to be the most important recommendation, about NHS Medical Education England, or do you want to keep it more general?

Q650 Mr Bone: We have sort of moved on and Professor Wright did that at the start. I was going to ask if you were surprised at the fact that it was not more critically scrutinised. Are there bits that need more debate and would that be helpful?

Professor Rubin: I think the MMC and MTAS events were a defining moment in the relationship between the medical profession and the Government. It was the moment when a lot of members of the profession said, "Enough" - rightly or wrong. It was the moment when a lot of members of the profession felt that the voice of reason, which they thought was their voice, had not been heard. Rightly or wrongly - I am not saying - that was the moment. In his report Professor Tooke has enunciated many of the feelings of the medical profession in this country and that is why I think those who respond to him were so positive in their response. When you get into the detail, of course, then a lot of things need a lot of careful consideration.

Professor Sir Nick Wright: The Tooke report took evidence from a large number of people. Most people in my position, for example, helped the Medical School Council in their report. I was part of the Academy of Medical Sciences consultations, through my own Royal College I was, through my own Medical School, and I also appeared before the Tooke Committee for Fidelio. Most people had multiple channels into the committee, and if you look at the response to the consultation they were uniform in their views on the consultation document. No, I am not surprised and, together with the things Peter has said, I would not be at all surprised if there is uniformity.

Q651 Mr Bone: Mr Chairman, this is the sort of evidence we are gathering. It surprises me that because this report seems to have done a very good job and seems to have represented people's opinion, the Government is doing very little, distancing itself, in effect, from it, and not implementing it. What are your views on that?

Professor Rubin: If the major recommendations in Professor's Tooke's report are adopted, they will have far reaching consequences. With the best will in the world, it would be unrealistic for any government to say by return post, "That's great. Let's do it." I just do not think that would be realistic. Some of the implications of the report are very far reaching - and quite rightly so. To put it into context, speaking now both for GMC and PMETB, we are UK-wide bodies and in that UK-wideness we have worked with NHS Education Scotland and have been very impressed by NHS Education Scotland. By its very existence it sends a message that education is important in the health arena. Just by existing it sends that message. It has the budget. The golden rule applies, does it not? It even has the golden rule and it really does have a big impact on health education in Scotland. Our view as regulators, speaking both for GMC and PMETB, is that the establishment of NHS Medical Education England, with a ring-fenced budget for medical education, with a sophisticated workforce machinery and workforce planning machinery, would by itself go a long way to ensure that we do not have a repeat in the future of the MTAS/MMC problems. That is a view that is shared not just by the regulators but by the Academy of Medical Sciences, by the Medical Schools Council, by the Academy of the Royal Colleges. It is a widely held view by all those who represent different aspects of the medical profession.

Professor Sir Nick Wright: I think the heads of the medical schools feel very strongly that the Department of Health has ridden roughshod over the ten key principles that link the Department of Health and the Department of Education and medical schools working together. There is a whole list within the Tooke report of reasons why the Department of Health is disengaging from the academic education agenda: the lack of Brightfield & Stellar(?), for example; the loss of workforce confederations with academic representation; the absolute refusal of Derek Nicholson to accept the representations from the Medical Schools Council that there should be a statutory academic representative on Special Health Authorities. I understand that only three of them have that. We lobbied very strongly to get that but got a very dark brown answer from him. It has always been the tradition in this country. The Special Health Authorities, the previous Strategic Health Authorities, the teaching hospital Trusts always had a non-executive director who is an academic. That has been lost.

Q652 Mr Bone: I think we are going to ask about that later.

Professor Sir Nick Wright: As Peter says, having a national body for medical education in England perhaps controlling the budget - the main budget and all the other budgets which the Department of Health or certainly SHAs have clawed back to prop up their own financial problems - would send a very strong signal that education within the National Health Service is a pivotal part of it - as, of course, it should be.

Professor Douglas: Speaking with a different hat on, that as Chair of the Academy of Medical Royal Colleges Education and Training Committee, I would entirely agree with Peter that recommendation 47 is the key one in the new version of Tooke. I work very closely with NHS Education Scotland in Edinburgh. They are an extremely effective organisation, controlling of the funds is critical to properly planning the training for the juniors. If anything gets enacted, it has to be recommendation 47. I am very concerned that I am not seeing evidence that this is necessarily going to go through very readily.

Q653 Mr Scott: Obviously you are all in favour of the NHS Medical Education England, but do you really think it is necessary for the new body to be set up? Could it not be devolved to postgraduate deaneries and Strategic Health Authorities?

Professor Douglas: My own view is that it is necessary to have a new body set up. The controlling of the funds by other bodies whose prime interest is not in training is a key issue and, also, because of the fact that there are numerous deaneries which work slightly disconnectedly sometimes, it would be very helpful. That is what has happened in Scotland: the deaneries are connected through NES. I think it would really make a very positive difference to training of the juniors in England.

Professor Sir Nick Wright: I would be very strongly against what you suggest. If you go around and talk to my colleagues in London, we have had reduction in the educational levies which have affected us somewhat but, for example, in Leicester they faced the removal, because of a problem with their SHA, of a minimum of £30 million of support for their academics. They were going to lose a significant number of staff in their school and it was only by intervention centrally that this was stopped. If the SHAs control the educational levy in the budget and they run into financial problems again - it is not ring-fenced; we thought it was - they could claw it back and use it for other purposes, and I have no confidence they would not do that.

Professor Rubin: I feel very strongly that there needs to be a national body. There are a number of reasons for that but perhaps I could give an example of one of the problems that led to the mismatch between applicants and places. As I am sure you have heard in other evidence, on the one hand we had the Home Office and the Treasury having an open door policy and trying to encourage doctors to come to this country, and then we had the Department of Health saying that we must be self-sufficient in doctors and produce all the doctors we need internally. Those were two mutually incompatible policies. It needs a national oversight to ensure that policies in different parts of government are genuinely joined up. Just staying on the subject of workforce planning: we can be sure that we will get workforce planning wrong because we always have, so that is something about which we can absolutely confident. But I think we will get it less wrong if we have some serous brains working on it at the national level, looking at all the issues involved. To try to duplicate really high quality workforce planning around each of the SHAs will be an unnecessary duplication of activity. As Neil and Nick have both said, there is the important issue that, with the best will in the world, I am sure if you sat down any SHA chief executive or Trust chief executive and said, "Is education and training important to the NHS?" of course they would say yes, but they are under pressure to deliver on short-term, here-and-now targets. I think it needs a body outside the heat and burden of the day to look ten or 15 years down the road and say: "This is what we think we need in the future."

Q654 Mr Scott: Do you not think that a new body could give the department a scapegoat when something goes wrong of saying, "It's not our fault. It's all down to them"?

Professor Rubin: Of course it could but that is not why we would want to see it established. We would want to see the body established as a very effective organisation.

Professor Sir Nick Wright: There has been this lack of engagement of both Trust chief executives in foundation and non-foundation Trusts and SHAs in the education agenda. All our attempts through the Medical Schools Council to get the Healthcare Commission to set some sort of targets for both Trusts and SHAs, both teaching and research, in the same way as they have targets in other things, have failed, so they will not have a target for education. I would far prefer to have a national body for medical education which will have those standards and targets, than the SHAs, and perhaps even Trust chief executives, who have lots of other things to think about and will not engage with the academic agenda.

Q655 Charlotte Atkins: Professor Wright, did MTAS cause any particular problems for academic trainees? Have these been addressed in the Tooke report?

Professor Sir Nick Wright: Yes, I think they have. It was our understanding before this all came out, that the academic applications would be processed before the general applications - and this would have been all right - but they were not. They were caught up within the maelstrom of general applications, so you had people who were high-flying academics not being interviewed and not being short-listed through the scandalous way in which this process was done. There would not necessarily be a repeat of the evidence that very good academics were not short-listed or even dropped because, as you probably know, Fidelio have kept quite a large database of the people who had these major problems. Bringing academic applications into the general thing was an absolute disaster, so they did suffer through that, yes. I think this has been addressed in the current round because they are being done before, which is a good thing. Also, if you look at Tooke report and go through it, a great deal of thought has been given to academic trainees, to the concept of the academic team: the fellows, for example, being managed by the deaneries of the medical schools jointly, which I would certainly approve of, and also, if in fact you do get the abolition of run-through training, to making sure that the academic FY2 positions are maintained because they have been a success. I think the Tooke report has given considerable thought to that and I would have no worries, as long as those were adhered to, about the academic recruitment in the future.

Q656 Charlotte Atkins: Should the foundation schemes be split to allow the Medical Schools to meet their legal obligations to guarantee students work until they achieve GMC registration?

Professor Sir Nick Wright: It is the view of the Medical Schools Council, which is why we agreed that it should be split. We have not referred to the MDAT problems of the year before, the Multi-Deanery Application Process, which was also an unmitigated disaster. We now have the situation where, when we admit students for medical school, there is a sort of contract that we get them medically qualified and we get them medically registered and, because of that, they have to get an FY1 position. In the old days, we used to have a matching scheme that made sure we could control to some extent where our students went, particularly locally, so that we matched our students to the jobs we had and that worked very well. With the advent of EC legislation and equality of opportunity, we cannot do that any more. My responsibility under the Medical Act is to make sure that my graduates are fit for purpose and, also, that their FY1 positions are suitable for them. If they are going up to Blackpool or Inverness, I have limited ability to make sure those jobs are appropriate. Also, we are responsible for the FY1 year within the medical school. Similarly, we know that there are individuals within medical school who do qualify but they may need special attention during their FY1 year. Again, we used to make sure these people got very good positions so that they could be looked after properly. Now, we cannot do that any more. I have to say that the foundation applications have worked better this year but, because of equality of applications, for example, from overseas and elsewhere, we would like to control the FY1 positions to make sure that our students who have got FY grade 1 and drop out are registered. That is the main reason behind that.

Q657 Charlotte Atkins: You agree with the splitting of the two-year foundation scheme.

Professor Sir Nick Wright: I do.

Q658 Charlotte Atkins: And the creating of a three-year core speciality training programme.

Professor Sir Nick Wright: As long as there is sufficient flexibility within that core specialty training, yes.

Q659 Mr Bone: Does anyone else want to come in on that?

Professor Douglas: I think foundation is a slightly difficult issue. In the original interim version of Tooke some of us were surprised that the recommendation to split F1 and F2 was not really compatible with recommendation 2, which is that everything should be evidence based, because the evidence is not in. We know that foundation has worked very, very well in some areas of the country and done very badly in others. I would agree entirely with the principles behind what John Tooke has recommended in his final report: namely, that people should be guaranteed F1 jobs; that we should select into foundation and to subsequent speciality training on merit, absolutely; and that we should not hinder the progress of people who are clearly committed to a specialty and have the ability to practise that speciality. How exactly you do that? It does not matter to my mind whether you split F1 and F2 or you have the same content on either side of a bit different divide. That is open to debate.

Q660 Dr Naysmith: Before I come on to the role of the medical schools, could I pick up on the F1 and F2 issue we have been discussing. Why do you think it is really successful in some places and not others? In my own area, in the Avon and Somerset Deanery, they have written to me saying, "Please do what you can to protect the foundation two-year course because it operates so well and is the best bit of the whole procedure. Why is it that it operates so well around Bristol and operates badly elsewhere?

Professor Rubin: PMETB and GMC are jointly responsible for quality assuring the foundation programme. Perhaps I might give you some evidence, but I should emphasise that this evidence is as a result of interim analysis. One of the things that PMETB has introduced - and we did it for the first time last year and we are now doing a second one this year - is a trainee survey. Last year we had a 64% response to our training survey, for example - which by survey standards is pretty mega. This year we are halfway through it and we have had just over 2,500 responses from those who did the foundation programme 2 last year. Of the 2,500 who did foundation programme 2 last year, 75% of them thought it was very good and that F2 added significantly in terms of value to what they had learned in F1. There is a significant majority of people out there saying F2 is rather good. Where it is not that good will be down to local issues, it will be down to local implementation - as is often the case here. I would agree with what Neil has just said. We are getting deep into structural issues here, but whatever happens to foundation there is clearly something of considerable value in F2 and we must be careful not to lose that value, whatever happens in any rearrangements that subsequently happen.

Q661 Dr Naysmith: The other thing Professor Douglas also said is that the evidence is not really in yet.

Professor Rubin: Exactly.

Professor Sir Nick Wright: From a medical school view, where foundation schools and medical schools have worked in close collaboration I think the foundation has been a success, but sometimes they have not. For example, under Tomorrow's Doctors medical schools are constrained to teach communication with patients to a high level. You do not want to see that replicated in the foundation programme. If you concentrate on the care of the acutely ill patient, a major thing in the MDAT curriculum, you do not want to see that replicated in the foundation years. If there is collaboration between the medical school and the foundation school, I think everybody is satisfied. But where there is a disjointed approach, I think there will be problems.

Q662 Dr Naysmith: I am going to go on to ask some questions on the role of medical schools. Some of matters may have been touched on, so excuse me if you sense we are going over old ground. The Tooke report commented on the growing divergence between the health and the education sectors and between medical schools and the deaneries. In your experience as the head of a London medical school, do you agree with this? What problems has it caused?

Professor Sir Nick Wright: I think we are very privileged in London because the London deanery is certainly not dysfunctional, it is very good. Apart from the way in which the London deanery is engaged in sort of nationally promoted activity like MSAT and MDAT, I have had no complaints at all. We have an associate dean, Professor Joe Herzberg, who attends my senior management team twice a term. We have very close relations with him. He reports to us on the inspections he is doing on the FY1, any problems he has, if it goes well with the foundation school - we often get him together with our foundation school head - and through Lis Paice and through the heads of the London medical schools committee, with which he works regularly, he has a very cordial and good relationship with the London Deanery. Speaking as a London medical school dean, I have had very little cause for complaint over our relationship with the deanery. I know this is not so in other parts of the country. I hear my colleagues complain continuously about the poor relations between themselves and the deanery in relation to many, many items: particularly for trying to arrange out of service time for people to do PhDs and things like that, and lack of flexibility and lack of co­‑operation with joint funding initiatives. I know that certain deaneries outside London are very dysfunctional and certainly need a great deal more work, but I would emphasise that in London it has worked extremely well - because I think we were determined to make it work well.

Q663 Dr Naysmith: You are saying there is nothing wrong with the system.

Professor Sir Nick Wright: Not at all.

Q664 Dr Naysmith: It is just that in certain places they do not operate the system well.

Professor Sir Nick Wright: We work very effectively with the system, because we have frequent contact with both our associate deans in the London medical schools and frequent contact with Lis Paice for the London Deanery. I probably see Lis Paice once every three weeks and if there is any problem we can sort it out because we have multiple venues at which we meet.

Professor Rubin: This is another example of what NHS Medical Education England would improve on.

Q665 Dr Naysmith: It is interesting that you mentioned Lis Paice because when she was here last week she was very much in favour of introducing a medical licensing examination, such as the one that goes on in the States, at the end of medical school training. Do you think it is a good idea?

Professor Sir Nick Wright: I think you find heads of medical schools would be very strongly against a national examination taken at the end of the undergraduate curriculum. We pride ourselves in this country on the diversity of the medical education we give. For example, in Imperial College, Cambridge, you would expect there to be a very, very academic education. We would look for those people, most of them, many of them, to go into academic medicine, to be high-flyers, to be very good. Then you look at a medical school like mine, where we like to think we do produce very, very good people. We are quintessentially a community-based medical school.

Q666 Dr Naysmith: Surely there must be a certain basic standard.

Professor Sir Nick Wright: Yes.

Q667 Dr Naysmith: Also, there are many academic excellence centres in the United States as well.

Professor Sir Nick Wright: The whole thing is competence based. We all have a competence-based curriculum. If we had that at the end of the undergraduate curriculum, it would not show us a great deal. Professor Rubin will back me up on this, when the General Medical Council, I think it was, did a survey of all FY1 positions a couple of years ago, only 19 FY1 doctors were found not to be fit for purpose and only three of those were UK graduates.

Q668 Dr Naysmith: If that is the case, what would be wrong with it?

Professor Sir Nick Wright: It would change behaviours. It would change the way we approach things. We have a very diverse medical education system.

Q669 Dr Naysmith: Is there any evidence that the American medical professional produces doctors who are significantly worse?

Professor Sir Nick Wright: No. The timing at the end of the undergraduate curriculum would not receive support from the Medical Schools Council and neither probably would a national examination at the end of the FY1 year. Certainly, in their evidence to the Tooke Committee, their view was that local selection into core training programmes, with a portfolio and a CV et cetera, was the way to do it, and then into specialist training would be part of a national examination, possibly replacing the college part 1 examination. Medical schools are not against national examinations: it is the timing of them. In their evidence to the Tooke Committee they suggested it might well be at the end of core specialist training, so we are certainly not against that. And if it did come into operation, then medical schools, I hope, would be invited to set part of that agenda. We are certainly not against a national examination.

Professor Douglas: I am strongly in favour of national examinations. We desperately need one to be fair to the trainees. There are very good trainees in bad medical schools and vice versa. The MRCP has published, this year, evidence showing differences in performance between medical schools. We need to have this as part of the selection process. I advocated it to MMC England in May 2005 and it was howled down by the postgraduate deans and the tutors at that stage as being undoable but I think it is an essential part of the selection process.

Q670 Mr Bone: Would that not lead to a dumbing down? If everybody is passing at the moment - and the medical colleges I think probably do a good job - if you have a national standard, and you are saying that some are not very good at the moment, to get the same numbers through you would have to dumb down a bit, would you not?

Professor Douglas: No. I am saying that the standard is good overall but some are absolutely excellent and some are just good. The people who are excellent deserve to be credited with being excellent.

Q671 Mr Bone: Is that not exactly the point I am making. Would a national exam not allow that to be clear?

Professor Douglas: It would allow that to be clear, provided it is a ranking exam - that is, not a pass/fail exam. It is one of the many signals we should be feeding into selection. Indeed, there is an argument for placing it in F2, if F2 existed, because you could then make everybody, whether they are from the UK or from outside, sit this test that is one component - not the critical component because clinical skills and communication skills are also vital - but one component for selection into specialty.

Q672 Dr Taylor: Perhaps we could turn now to the Douglas Review and, first of all, to MTAS. It is clear now that MTAS was a spectacular disaster. A lot of us think it was clear in March that it was going to be a spectacular disaster, certainly from the letters that we as MPs received. Why did the Douglas Review not call a halt right at the beginning of March, when really people were writing to us and saying, "There is time to go back to the old system just for this year"?

Professor Douglas: The Academy met on 5 March. At that stage we took information from all the colleges - this was, as you say, early in the process, a week into the interviews - and the messages we got from each of the colleges and faculties was that there were many excellent candidates who were coming forward and who had got themselves into a position to be appointed. The view of the colleges was that we should continue to go forward and not disadvantage those people who had got themselves into a position to be appointed and put in a huge amount of time to their applications, and also a huge amount of time had been put in by the HR staff of the deaneries and by consultants - that should not be underestimated: the amount of time that consultants and GPs put into the appointments process - provided that some of the most obvious faults were fixed immediately. We asked for a meeting with Patricia Hewitt that night and got it, and she agreed to fix some of the obvious faults: CVs had to be available from then on; full, probing questioning would be allowed and not just formulaic interviews; and only very appointable candidates were appointed to try to leave some jobs for later on. And the review was set up. Once the review was in place, we had several heated debates as to whether we should keep going forward. The consensus from the colleges and from the BMA and from the postgraduate deans - those being the members of the medical profession on the team - was always, at the end of the meeting - not always at the beginning - that we should continue to go forward but it was a very close call on several occasions.

Q673 Dr Taylor: We have certainly had the feelings from the colleges that they were pressurised, and certainly Liam Donaldson, when he came to see us, said it was absolutely clear that the colleges agreed to go ahead. We got the impression that colleges had rather been steamrollered by the department. Is that fair or not?

Professor Douglas: It is entirely unfair. There is no doubt that the department would have liked it to go forward but we were independent and we debated it independently. Indeed, I took the medical members of the committee out of the room to debate it without the department around and the consensus, always at the end of the day, was to go forward.

Q674 Dr Taylor: Thank you. That has cleared that up. To clear up one other point, last week Professor Black said, "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." Is that your recollection?

Professor Douglas: I absolutely suggested that the two individuals concerned wrote a letter to the media because I did not feel I could do that in my independent role as Chair. They had offered to support if they could. I was keen that they established the difference between MTAS, which, as you say, was in very deep problems, and MMC, the principles of which many of us supported then and still do now. That is what I asked them to do. She is right that I requested them to write a letter.

Q675 Dr Taylor: Right. It did not actually help, did it?

Professor Douglas: I did not write the letter.

Dr Taylor: Okay. Thank you.

Q676 Dr Stoate: Let us stick with the Douglas Review and the competition ratios. You wrote to the Times last week to complain at competition ratios of up to 20:1, and yet the MMC board has currently endorsed the 2008 arrangements and NHS Employers have gone so far as to welcome high competition ratios. Is it not true, therefore, that the profession's leaders are in fact being taken for granted around this issue and, in fact, it is trainees who are receiving the lowest priority if it is acceptable to have ratios of that level?

Professor Douglas: I joined in writing to the media, having made considerable thought as to whether I should do that. I had not contacted the media at all over the last year about MTAS or MMC. Peter was at the meeting of the English Programme Board in December when we were first shown the figures for next year for England. You will recall that one of the big problems, as Peter said earlier on, for the 2007 process, was that the numbers were too low and were not known until post hoc basically. When we were shown the numbers it became immediately apparent to me that there were too many jobs at the lower levels. There were 1,200 excess jobs at ST1 compared to the feed-in from foundation. 1,300 too many jobs in ST3 compared to the feed-in from ST1 and FT/STA1. That was going to result in sucking in international graduates - with the moral issues that gives rise to - with the expectation that they will have that they might train further and the problems for the 2009 process as they compete again. Even more concerning to me was the fact that there were going to be many hundred too few jobs at ST3 - exactly the same issues we had last year. I took this to ministers that day. We wrote to all the appropriate channels and made full recommendations as to what I suggested they could do to try to rebalance the situation just a little bit to try to help the situation, and, despite others taking the papers that I had written to ministers, I was getting the impression that there was just no room for movement on this. It was out of a feeling of intense frustration for these senior trainees, many of whom had been in medicine training towards their career for the last ten years and the only thing they had done wrong was to graduate at the wrong time, that I wrote a letter to the Times.

Q677 Dr Stoate: That is fair enough, I can see exactly what you mean by that, but postgraduate deans last week told us "so far, so good" with the 2008 process, and yet obviously the colleges took a rather different view that they were very worried indeed about these very high competition levels - particularly in surgery, where it did go up as high as 20. Why do you think the deans are so much at odds with the colleges over this issue?

Professor Douglas: I think I have made the colleges' view quite plain. You would have to ask the deans why they have their position.

Q678 Dr Stoate: Fair enough. If three applicants for every training post appears to be too many but competition is desirable, what level of competition do you think there ought to be? What do you think would be a reasonable level? What should we be aiming for in terms of numbers of applicants for each post?

Professor Douglas: I do not think you can say anything from this year's competition ratios because people are allowed an infinite number of applications. We just do not know.

Q679 Dr Stoate: I am asking you what would be desirable.

Professor Douglas: There is no way of knowing what desirable is.

Q680 Dr Stoate: I am asking you for your opinion of what you think is a reasonable level of over-demand for posts compared with supply.

Professor Douglas: My basic stance would be that people who have trained in the UK, who are highly competent, should have a reasonable chance of getting a job. That does not translate into a competition ratio.

Q681 Dr Stoate: Your position is there ought to be a job for every applicant.

Professor Douglas: Not necessarily in the area in which they wish to work.

Q682 Dr Stoate: No, but a job.

Professor Douglas: A job. I do believe we need more doctors in the country and I do believe that we have a lot of very, very talented people who have been grossly disadvantaged by MTAS.

Professor Rubin: Your question shows why we need effective management workforce planning. I do not know what the right competition ratio should be. I do know that 75% of medical graduates now are female. I know that medical graduates male or female want a life of the sort that we did not have when we were young doctors. We do not know what the impact of these changes will be and we need to get a handle on this. I do not want to be misinterpreted as saying that every doctor is guaranteed a job for life - I am not saying that at all - but I think we have to be sensible about workforce planning in this country and we have to decide whether we really do want to be self-sufficient in doctors or not. If we do, that has implications well beyond the Department of Health. We really have to get our head around the changing patterns of the workforce in the future. That is not being done at the moment.

Professor Sir Nick Wright: Speaking as a medical school head, I think Dr Marshall said to this Committee, "T'was thus ever so". There has always been stringent competition but never at this level. If you think about the aspirations of my students and the aspirations of people coming towards medicine in the next five years, they want a reasonable chance of fulfilling their career ambitions. That is where I am coming from. We certainly do not want to disenfranchise a whole generation of medical students and prospective medical students by 'gold medallists', for example, who want to do cardiology, having to do psychiatry because they cannot get a job in cardiology. By all means, let us have competition, but let us have a reasonable level of competition and let us try to solve this current level by increasing the number of junior training positions. You could argue very cogently for a longer training because of the European Working Time Directive, certainly in the craft specialities, and that would help solve this problem, and, also, de-linking the number of junior staff with the number of consultant positions.

Q683 Dr Stoate: The GPs are calling for a five-year training programme. Would you broadly think that is a good idea?

Professor Sir Nick Wright: Yes, I do.

Q684 Dr Naysmith: Why is it always that people end up talking about psychiatry when they want to indicate that if you want to be a brain surgeon ----

Professor Sir Nick Wright: That was just an example.

Q685 Dr Naysmith: I know it was just an example but it is amazing how often it comes up, and yet, if one third of the population need treatment for mental disorders, should we not be providing more doctors in this area and better training?

Professor Sir Nick Wright: Let me give you two examples from the last round of MTAS where there were two candidates for psychiatry positions who both had MB PhD degrees from the University of Cambridge who were not short-listed for any psychiatry jobs in the country.

Q686 Dr Naysmith: That in itself is a bad thing. I am just pointing out that it could well be that the country needs more psychiatrists, highly qualified, well trained ones, than brain surgeons at the moment.

Professor Sir Nick Wright: Absolutely; as I would want try to make sure that the people who want to do psychiatry are able to do psychiatry.

Professor Douglas: It is one of the findings of our review group that there were very few UK graduates who wanted to go into psychiatry, obs and gynae and paeds, and we need to rectify that.

Q687 Mr Bone: This is not a party political point because I am well out of tune with my own party on this issue, but is it not strange that this unique state-run health system that we have cannot match the number of people it puts in with the number of people it wants? If you are like me and think there should be a great expansion in the number of doctors, et cetera, are we not being held back by the state plan. Presumably in other countries they do not get these imbalances, or do they?

Professor Rubin: It varies from country to country. In the USA, for example, they take a very pragmatic approach, in that they under-produce doctors and then buy them in. You can argue about the ethics of that very seriously, but that is how they do it. It comes back to having to have a serious, mature debate at the national level of what sort of health service we are looking for and how many doctors do we need in this country and, having decided that, are we going to produce them all ourselves or are we going to have a mixture of home-produced and abroad. We need absolutely clarity and honesty about that.

Dr Stoate: Could I just say that there is a massive imbalance across Europe. For example, Spain, Italy and Germany produce quite a lot more doctors than they need, who often have to come to this country for further training because they cannot get posts abroad. It is not an issue that just is facing us.

Q688 Chairman: From the evidence session of the postgraduate deans last week, I am going to leave you with a couple of quotes I would like you to comment on. David Sowden said, "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 ..." Professor Thomas, from my area of the UK, said, "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." Would you agree with those comments or do you have any knowledge of that?

Professor Douglas: I think those are perfectly reasonable comments. Some places have benefited from people looking beyond their normal horizons as to where they should be applying. My understanding for this current year is that there are going to be areas where there are relatively few applicants, still, in areas where there will be a vast surplus, so we have not solved the balance but I am sure there are others that will benefit.

Professor Rubin: I am not surprised to hear this. A personal view with regard to MTAS is that just because it was implemented badly this time does not mean that MTAS is bad in principle. UCAS works well and has been respected for many years. UCAS results in good applicants, through clearing or whatever, going to universities they may not otherwise have gone to, but if MTAS is properly implemented then there is no reason why it could not work as well as MTAS with the benefits to which you are alluding, which is that very able doctors go where they might not want to go.

Professor Sir Nick Wright: I would agree with that. UCAS, as far as medical school admissions goes, is extremely well implemented. Most medical schools will, after short-listing from UCAS, form interviews for themselves. We know a structured interview is just about the only thing that does correlate with success in medicine, so it is a well‑trodden path. If MTAS was implemented correctly, with CVs and appropriate interviews, then we would have much more confidence in it.

Q689 Chairman: The picture we have painted about what happened last year is one of complete disaster. I am saying that my constituents are benefiting by what happened last year, in so far as, when they go to Rotherham District General Hospital, the doctors they have there now are a better cohort of doctors than they have had in years gone by.

Professor Sir Nick Wright: That may well be true. At the same time, if you have individuals who are going into specialities they did not want to get into and they are having to do a speciality which they had no plans to do ... Of course they will do it to the best of their ability but then we have stories of people stuck in specialist training without the ability to change because of lack of flexibility. I am sure that this is a success story so far as DGHs in the provinces are saying but, if you think about the personal aspirations of those doctors, then we have to consider this, because of successive generations of students who may find that their ambitions are not going to be realised.

Q690 Chairman: My personal aspirations are a bit clouded with the needs of my constituents in relation to healthcare, Professor Wright.

Professor Sir Nick Wright: I am speaking as head of a medical school.

Chairman: Could I thank you all very much indeed for coming along here this morning and giving us evidence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witnesses: Ms Anne Rainsberry, Director of Workforce, NHS, London, Dr Moira Livingston, Strategic Head of Workforce and Deputy Medical Director, NHS Northeast. and Ms Sian Thomas, Deputy Director, NHS Employers, gave evidence.

Q691 Chairman: Good morning. Could I welcome you to what is our fifth evidence session in relation to our inquiry into MMC. I wonder if, for the record, I could ask you to introduce yourselves and give the position that you hold. Can I start with you, Anne?

Ms Rainsberry: Anne Rainsberry, Director of People Organisation and Development, NHS and I am a Member of the new MMC England Programme Board.

Dr Livingston: Moira Livingston, Head of Workforce, NHS North-east and Deputy Medical Director; previously a Member of the Modernising Medical Careers team on the staff grade area of work.

Ms Thomas: I am Sian Thomas and I am here representing NHS employers. We are the employers organisation for the NHS supporting and helping employers implement best practice around employment.

Q692 Chairman: Thank you and welcome. A question to all of you. Do you accept that the 2007 MTAS process was a disastrous experiment in workforce planning?

Ms Rainsberry: I do not think it was absolutely disastrous in workforce planning, no. I would agree, actually, with the evidence that the CMO gave to the Committee. I think there was one particular variable, which was the late decision on IMGs, which changed the projections quite substantially. If that had not been the case, in effect, the projections, in terms of demand and supply, would have been pretty much aligned.

Dr Livingston: I would agree with Anne. I think the issue was the difficulty in predicting the number of doctors who would apply for the posts available. In terms of workforce planning, looking at the number of training posts and how that fits with future service delivery, that was well in place. I think the increased number in specialty training posts, there was effort to target those in terms of workforce planning needs according to locality and capacity to train. I think, where possible, attempts were made to align the developments that were needed, but it is very difficult to predict the number of applicants at that point.

Ms Thomas: We believe that evidence from employers shows there were many good things about MMC, and we welcome the opportunity in this session to tell the panel about that. There are two issues that we think did affect the failures around MMC. One was the high volume of applicants, which has already been commented on, and the second was the failure to take into account a transition period and a big bang approach to, effectively, a large cohort of doctors, and that led to a sense for them of a last chance attempt to get into specialty training. So, it was those two factors: the high volume of applicants and no transition.

Q693 Chairman: You were a member of the Douglas Review.

Ms Thomas: I was.

Q694 Chairman: Which recommended a single interview for English candidates last year. Did the NHS Employers put pressure on the professional members to ensure the jobs were filled by the 1 August deadline and do you accept some responsibility for the way that many of your employees were treated during the subsequent months?

Ms Thomas: I endorse many of the things that you have heard Professor Douglas say this morning. In fact, his transcript would pretty much reflect our view. The review group, at the beginning, was in a very difficult situation, but all partners agreed that to carry on was the best thing. The 1 August date was critical because we only had weeks to go to ensure the service had these doctors in place to deliver Save Patient Care, which the service was relying on, so employers fully supported those decisions; and behind every representative's evidence that I gave, we had over 150 employer views backing that. Increasingly, we based our decisions on evidence. It is always easy in hindsight to go over those decisions, but I think, on the whole, the review group did the right thing and tried to base its proportionate decisions to make a good outcome for the August service delivery pressure.

Q695 Chairman: Could I ask Anne and the Moira: by how much were medical education budgets cut in your areas in the lead up to the implementation in 2007. Do you accept that budget cuts were a major cause of the failure of the MTAS system?

Dr Livingston: I think in the north-east there were, in fact, no budget cuts to the deanery. We receive a deanery investment plan every year and we met the requirements of the deanery. If we look at the increase in training numbers, since 2005, 2006, when the deaneries became the responsibility of the SHA in the north-east, there has been an increase in training numbers, overall 58%, and if we look at the specialty training, training numbers, they went up by 71%, with general practice being less, at 22%. So that commitment to training, in terms of the number of trainees in the system, I think, is evident. At no point have we had any sense from the deanery that they were under-resourced. If we look at this year and our commitment to delivering the MTAS process as efficiently and effectively as we could, then I think that we can demonstrate from the SHAs perspective that we invested a further £1.6 million in the delivery of the MTAS process, which included additional posts as part of transition as well as meeting the Secretary of State's commitment to on-going employment from 1 August and the transition arrangements for doctors to help them become more competitive for next year.

Q696 Chairman: So no cuts as far as you are concerned?

Dr Livingston: No.

Q697 Chairman: Anne?

Ms Rainsberry: It is a similar picture to the north-east. There were cuts in 2006/2007, and I gave evidence to this Committee last time we talked about workforce planning. The majority of those cuts came from non-medical education. Because of the nature of the way the contracts are set up with medical education, it makes it very difficult to do that. In London, since 2005, the numbers of specialty training posts have increased by 65% and, therefore, we have had to invest in the infrastructure to support that. I think it needs more investment, and we have just gone through a process with our own deanery of looking at their three-year strategy to look at how we would tailor that investment, but certainly, in relation to your question, I do not think there was a relationship between the problems that were experienced in the recruitment to specialty training in the last year and the degree of investment, and, indeed, as Moira has alluded to, SHAs used their flexibility quite substantially in order to smooth the bulge of trainees in their unit of application to help transition. That was funded by SHAs.

Q698 Dr Naysmith: Before I go on to ask the question I was going to ask, can I ask Anne and Moira: you have both said there were no cuts in postgraduate training, but are you not just talking about the salaries, paying the salaries? Is there not a separate little budget that is supposed to be used for courses and that sort of thing? Lots of people tell us that the budget was cut.

Ms Rainsberry: Let me clarify my answer. I said the majority that came from non-medical education. The financial position in London last year was really quite serious, and as an SHA we had to create the right platform in order to take the service forward, like other parts of the country, and therefore there were some reductions, temporary reductions.

Q699 Dr Naysmith: For that year?

Ms Rainsberry: For that year, which have been restored.

Q700 Dr Naysmith: Which impinged on some people who were training that year?

Ms Rainsberry: That is correct, but it was not to training numbers, it was around the infrastructure, and that has now been restored.

Q701 Dr Naysmith: Let me get this absolutely right. It was not to do with reducing training numbers?

Ms Rainsberry: No.

Q702 Dr Naysmith: But it may well have influenced the quality of the training process that took place that year.

Ms Rainsberry: Yes.

Q703 Dr Naysmith: By spending training money on something else.

Ms Rainsberry: Things like CPD were affected, so study leave budgets would have been affected, but not the core infrastructure.

Q704 Dr Naysmith: I will go on to the question I was going to ask you. During our workforce planning inquiry you told us that the strategic health authorities had little influence on the development of MMC. Do you think that is the reason why the disastrous transition took place in the new system in 2006? If you had had more influence, would it have gone better?

Ms Rainsberry: Yes. I think hindsight is a wonderful thing, but in terms of development of policy, as you get nearer and nearer to implementation, it is extremely important to gauge those people who are interacting on a daily basis with the service, because one of the complexities (and that played out last summer) is when you get into difficulties you have got difficulties around doctors' careers, their aspirations and training, but also very real service risks around that and, therefore, all of those competing risks and priorities need to be properly looked at and balanced, and I think that going forward it is important to have that service view. I, together with an SHA chief executive, sit now on the MMC England Programme Board that has been planning a round for 2008, and I think that that view has been heard and has been balanced against the medical profession, and we have certainly, I think, as a board produced a framework that, to date, is working well for 2008.

Q705 Dr Naysmith: Is that the same in your area, Dr Livingston?

Dr Livingston: Yes. If I can address your previous question in terms of cuts to training, just to clarify for the north-east that no such cuts were made in terms of access to training and study leave and that the way in which we managed the reduction in the allocation was through working very closely with the service through a bundling of funding approach and a quality monitoring of delivery to ensure that no such cuts were made. I would also add that, at times when phrases such as "raided the budget" are used and "cuts were made to training", it is important to understand that, as part of effective workforce planning, there will be changes made to the commissions that we make with higher education and we have a GOS contract which allows flexibilities within that. When we did reduce the contract for the number of diploma nurses, for example, in the north-east, that was done through full consultation and also was done as a result of effective workforce planning. I think sometimes that is misunderstood and is taken as evidence that budgets were raided. In fact, it was exactly what we think we should be doing, which is effective workforce planning and collaboration with higher education and the service.

Q706 Dr Naysmith: Thank you for clarifying that. In the north-east we had some evidence, clearly in my own area, where cuts were made by the Strategic Health Authority which had really disastrous effects on the local university which was training nurses, and it happened virtually overnight. Not everywhere is the same. Thank you for that clarification. What do you think about the involvement of strategic health authorities in this whole area going forward, given that you commission the trainees?

Dr Livingston: Going back in time, and certainly my knowledge is within the north-east and particularly within the area of MMC that I worked in, I would say that there were attempts made at engagement, and I think when you look back it could always have been improved. There was a responsibility on us - at that time I was working in the deanery - to engage with strategic health authorities, so early on in the process of MMC development we were involved in the Workforce Planning Committee set up by the Strategic Health Authority so they could fully understand the implications of MMC at a local level. At a national level the SHA Chief Executive representative was on the MMC Programme Board throughout the process. For me, where I like to get to is, I think, full integration of education, training and service delivery. I do not think that they can be separated out. I think it is a core function of the NHS. I think it is essential that we see it as the core purpose of all our service delivery organisations, and in that sense understanding the needs of employers as we move forward is essential to get to the structure right for training. I do think that the structures now in place are going to be very effective. The evidence that we have seen so far, in terms of the signing up to agreements and the workforce planning embedded within the training thinking, is a really positive step.

Q707 Mr Scott: This is a question for Mrs Rainsberry and Dr Livingston. Is it correct that only three of the ten strategic health authorities have non-executive directors from a higher education background and, if so, is this not short-sighted, given your responsibilities for commissioning education?

Ms Rainsberry: I cannot comment. I have not done a survey of strategic health authorities.

Q708 Mr Scott: I am told it is correct.

Ms Rainsberry: Okay. Certainly in London we then would be one of the ones that does have an academic representative as a non-executive director on our Board. We also have a Workforce Strategy Board, which is a formal sub-committee of our Board, so I think you can take from that that we would obviously take the view that it is important to have that reflected on your book, but, there again, it is important to understand that of the 4.4 billion that is spent on training and education in England over a billion of that is spent in London. So, clearly, we have a very large responsibility in that regard.

Dr Livingston: Within the north-east we have two non-exec directors who are both from higher education and a third who is a non-exec director on the Higher Education Organisation Board. We do see it as very important, and I think it reflects the priority that we give to workforce development. It is important that we do not see that as a solution to the engagement of higher education, which I think needs to be there throughout the system. I think, as Anne was mentioning in terms of her workforce board and engagement with higher education, we need to ensure that a proper debate happens at all levels within the decision-making process at a regional level with higher education, and the board membership signifies that interest in commitment, but the work has to be done throughout the system within the region.

Q709 Mr Scott: Do you think one answer to it in areas which do not have people is if postgraduate deans were co-opted onto local strategic health authority boards?

Dr Livingston: I think the structure at the moment is that the postgraduate dean is accountable to me and, in that sense, therefore, the deanery is fully represented through to the board. I think that the postgraduate dean needs to sit on the decision-making committees about workforce development and workforce planning, but their presence on the board I am not sure would be the right way forward.

Ms Rainsberry: I would agree with that. What is the problem we are trying to fix? If the problem we are trying to fix is to make sure that there is proper advocacy of education training issues, then I think it is legitimate to say: where on the board is somebody who has that in their brief and to ensure that there is a proper alignment with the dean. I suppose a strategic health authority could appoint their dean director as their director of workforce in some areas, but I think the principle is a good one, that you should have somebody on the board who is advocating, particularly when a large part---. Normally, in most strategic health authorities, the largest part of their budget is their education training budget.

Mr Scott: Thank you.

Q710 Charlotte Atkins: Sian, do you feel that your organisation and employers in general had too little influence during the development of the MMC, and, if that is the case, what sort of problems did that cause?

Ms Thomas: I think we gave written evidence to you and in that evidence made it very clear that our views were that we had very little influence at the beginning. We were a fairly new organisation when MMC commenced, and it is very difficult to cohere the view of 500 separate employers, but increasingly we are, and were, doing that. I would see our role in three phases. Before February 2007 we had a very peripheral role. We were probably regarded as a peripheral stakeholder in the process and, therefore, our influence was limited. We had no role on governance and had very limited engagement in implementation and design. In fact, I would say a great majority of the design decisions were made without employer input. One of the lessons learnt, I think, is that a great deal of expertise across the NHS in medical staffing departments and HR department was not, in fact, taken into account by the people designing the process, so we would agree with you. The second phase, which was during the latter part of 2006, we began to have engagement with the department because we were anxious about the lack of communication to the service and, indeed, became aware that the potential of mismatch between applicants and posts was greater than we had probably anticipated. We never knew what the numbers were, those numbers were not shared with us until the spring 2007, so we began road shows with employers and tried to engage with employers more during that time. Then, as has been alluded to today, at the beginning of March we realised there were grave problems, and that was when our active and full participation began through membership of the review group, and I would have to say since that date we are more engaged. I still do believe actually that employers need to be more centrally involved in this policy area and more employer views need to be taken into account in the design especially of the recruitment processes, because at the end of the day these are our employees who we will be employing for 30, 40 years and the end product of this process is important to employers on the ground.

Q711 Charlotte Atkins: The new MMC Programme Board has got two large employers on it, I think. Is that adequate?

Ms Thomas: It is adequate at the moment. We are giving a balanced view, and both of the people who attend the Programme Board are backed up by a system which means that over 100 employers' views are fed into that debate, but that is the only engagement we have on MMC at the moment.

Q712 Charlotte Atkins: In parallel with that, do you think that the department recognises the need for more employer input into medical education.

Ms Thomas: I think it has been acknowledged by the department and also by the Tooke Report that that is needed to be developed further.

Q713 Charlotte Atkins: Do you think at the moment things are improving?

Ms Thomas: They are improving.

Q714 Dr Taylor: We are moving on to NHS Medical Education England. If you were here for the first part, you would have heard all our three witnesses give a ringing endorsement to this. One of them actually said that he thought that recommendation 47 was the most important in the whole of Tooke. Would you agree with this or do you see alternatives or disadvantages?

Ms Rainsberry: I agree it is the most important recommendation, but I do not agree with it.

Q715 Dr Taylor: Let us have the counter view then.

Ms Rainsberry: I was here for that evidence, and you were talking to those witnesses about the 87% level of support and, just as a point of clarification, that was a new recommendation that has not actually been consulted on, so there is no benchmark, if you like, as to whether 87% of people who responded agreed.

Q716 Dr Taylor: Let me be absolutely clear. To those last two recommendations that were added, there was no comment, so the 87% support did not apply to those?

Ms Rainsberry: That is my understanding.

Q717 Dr Taylor: What you were saying is you would have been one of the large per cent who disagreed?

Ms Rainsberry: Yes, that is right.

Q718 Dr Taylor: Why do you disagree?

Ms Rainsberry: First of all, I think that it fractures the relationship between service and education. At the end of the day, we are in the business of training doctors to deliver care to patients and at the moment strategic health authorities are the only part in the system where the balancing of service, long-term strategic planning and education align, and I think, by taking medical education off-line in that way, it would fracture that relationship. I think it adds another layer of bureaucracy by setting up an independent body and I think it would make SHAs in how they discharge their accountabilities in terms of the strategic development of health services and maintaining the integrity of the system, the health system, particularly as we move more towards foundation trusts, more challenging: because you have to have some body that has an oversight of a particular health system that is looking at where the service is developing and whether there are proper workforce plans in place to deliver that. So, I would be quite strongly against it.

Q719 Dr Taylor: You may remember that our workforce planning inquiry actually recommended that planning functions should be given to SHAs?

Ms Rainsberry: Yes; so I see it as being contrary to that recommendation.

Q720 Dr Taylor: Your views, Moira?

Dr Livingston: I fully support everything that Anne has said. I do want to note a point about the 87% response rate to the Tooke Inquiry, because it is my understanding that where an organisation responded, such as an SHA, it was given the same weighting as a single trainee, and it would be very interesting to see that in some way managed, through perhaps a further request for some data on the actual pattern of responses, once we look at organisations with an appropriate weighting. Moving on to NHS Medical Education England, if you think about the policy direction, we have Our NHS Our Future, which is all about developing local services for local people: how do we develop local services for local people. That is running through the commissioners at the moment in PCTs. In developing local services, we then train people in order to be able to deliver those services. In training people we need to therefore understand what those local services are going to be and, if we genuinely want to deliver care closer to home, deliver care which is exactly what the local public have asked for, we need to be able to flex and develop training according to local needs. Thinking about separating the medical profession off, I think there are certain elements which we need to consider. In the Terms of Reference for the Tooke Inquiry, it was very important that engagement of the medical profession was achieved, and I think there is evidence that engagement was sought and has been achieved, but the devil is in the detail and I think the challenge now is how do you maintain that. I think that much of MMC has been challenged because of the difficulty in getting a consensus view from the medical profession and a consistent view from different bodies within the medical profession. I think that understanding how we can achieve that is an essential part of us moving forward and having a fully integrated and effective workforce development plan locally and nationally. If we then think about the Warwick Report, which was an evidence-based consultation which the Workforce Review Team carried out, the evidence is that workforce planning actually is not done very well anywhere inside health and outside of health, it is an extremely challenging area, but the thing that is much more likely to lead to success is when you integrate service planning with funding and with education and training, and that is very difficult to do from a distance. The other element is around quality assurance. I think that it is essential that we have a system of continuous improvement and driving forward the quality of education. At present within SHAs we are all required, through a service-level agreement with the Department of Health, to have a learning development agreement and that has provided us with a tremendous lever. In the north-east we have all bar one trust as a foundation trust in terms of acute secondary care providers, and having a lever such as that allows to us to go in and discuss funding, directing the funding and driving up the quality of training. I have concerns that if we no longer have that lever that we cannot work through a dialogue with organisations delivering training to ensure across the board that the quality of training is continuously improving to benefit patient care.

Q721 Dr Taylor: One of the things you said was that it was difficult to take a consensus view from the medical profession, which we all realise. Was not the point of NHS:MEE, or one of them, to have a medical director in charge of that who would speak for the whole of the profession on training issues?

Dr Livingston: My question back, I think, is: is that the solution? If we go back a few years, deans were accountable to universities. Did we see an improvement in medical training at that point? We have royal colleges, we have an academy, we have specialist societies, we have the GMC, we now have the PMETB, and I think that, despite august bodies doing an extremely good job and working hard and delivering what is required of them individually, we cannot seem to get a consistent consensus view. If we then think about the proposal of NHS Medical Education England, there is not enough detail in the Tooke Report that would enable us to analyse: "What exactly is this? Who is around the table? Why would it be different?", and when we think about the engagement that we have had, which has been extensive throughout the consultation period of "unfinished business" and through Modernising Medical Careers, of all those bodies that I have described, despite that engagement, we have what we have, why would it be different? I think I would like to understand that more, and I have not seen anything in Tooke that helps me understand that more at the moment.

Q722 Dr Taylor: Sian, do you want to add anything?

Ms Thomas: Yes, one of the things I would say is that you are quite right, this was a new recommendation and we have only seen it for two weeks and we have not had a chance to discuss this recommendation with employers, but we are doing so on 6 February and I should think we will spend the majority of the meeting talking about this point, and so we are very happy to give you a note after the sixth on the views of the employers we talk to. I would say three things about it. First of all, there is definitely a need for strategic oversight - we cannot have a situation where there is not a strategic view about medical education, so we do need that - and, as has been alluded to today, there are wider government issues to consider, not just Department of Health issues, wider policy issues. You can only do that at a strategic level. The second is that that needs to be balanced against a demand-led, employer-led service focus, and so the challenge is how do you bring those things together? Finally, just about clarity of roles, we have already had major structural change in the NHS and we would always say further structural change needs to be very carefully considered before we go ahead and implement.

Ms Rainsberry: Can I make one further comment. I am not sure that just getting consensus is a good objective, because it is a very important area we are talking about. Actually, my experience over the last few months sitting on the MMC England Programme Board is that, whilst we have come up with what, I think, is working for the service, it has not always been through a process of consensus, and we have had some very frank, robust and important discussions through the different perspectives, and so I think if that board can continue it is a very valuable contribution. The other thing I think the Tooke Report is saying is that there is a need for greater co-ordination and, you touched on it with the previous witnesses, I think the model that the SHAs have around the Foundation Programme Office, which is commissioned by the SHAs and works on behalf of it but is a co-ordinating body, could be something that you could look at for specialty training which could provide that co-ordination across England. The last point, I would say, is one of size. It does work well in Scotland, I would agree with that, but the number of their trainees is similar to one of our medium-size deaneries and so I think it is a massive job.

Dr Livingston: I think the last point is very important. We have embarked on a consultation in the north-east and, again, we would be very happy to submit the outcome of that consultation to this Committee, if you would like to receive it, on NHS education in the north-east. We are looking how we can integrate the whole work force, the employee-driven, and look at the whole quality issue and process as well as an understanding of the learning environment in which education needs to take place within NHS delivery organisations. I think the interim report is due at the end of this month and we are quite interested in some of the models that the consultancy organisation is coming up with for the future.

Q723 Dr Taylor: I am sure we would be very grateful for any further thoughts. Can I go briefly back to education budgets. I think it is right to say that Tooke recommends that the funding for NHS:MEE would be ring fenced, but what you have implied is that really there have not been cuts in actual medical education training budgets, the cuts have been borne largely by continuous professional development for nurses and people like that. Is that right across the country or is that just you? I think you said you had not had to make any cuts at all.

Dr Livingston: I think we reduced the numbers of some of the nursing and physios as a result of Effective Workforce Planning. If we look at the overall number of trainees within the system, across England there was a massive increase in training opportunities this year, and that was supported by the SHAs and managed through the budgets that are allocated.

Q724 Dr Taylor: What about last year when there were the reductions?

Dr Livingston: Last year we had a 15% increase, and it was a much higher increase this year.

Q725 Dr Taylor: Not coming from the north-east and being very envious of the north-east, is it not fairly true that you are reasonably well-off up there compared with some of us elsewhere in the country? I think Doug implied that there were drastic cuts, particularly in budgets for continuous professional development for nurses particularly.

Ms Rainsberry: I think the reality of the situation is I am sure that SHAs would have made reductions in budget where it could be retrieved relatively quickly through the subsequent years. For example, in London we had a lot of discussion. You have contracts with HEIs, so you cannot just slash and burn, and you only have a 10% variation in that in any event. You do not want to destabilise an HEI to the extent that they have to make a faculty redundant, and then you want to increase commissions, and, therefore, the things that tend to be reduced would be things like NVQ training, continuous professional development, things that have a much shorter lead time which you can then put money into the system the following year. It is damaged limitation.

Q726 Dr Taylor: So there could not have been reductions in junior doctors' salaries and the numbers of those?

Ms Rainsberry: No.

Q727 Mr Bone: Can I direct my question, first of all, to Ms Thomas. Supply and demand. Am I right in thinking you said it is good that there is plenty of competition for training posts. We are told that, on average, there are three people applying for every training post and that is good for patients. Is that your view?

Ms Thomas: Yes, we said to this Committee, I think 18 months ago, on the question of supply generally, that one might expect most employers in any sector to say that a modest over supply is a good thing because it improves quality. One expects that competition leads to improved choice for employers around candidates, so, as a general point, that is what we would say. I think it is a good thing that we have grown the supply of UK graduates, because it certainly is not a sustainable labour market strategy to rely on overseas recruits, and it is certainly true that in some parts of the country people have recruited doctors they would never previously have been able to recruit. In fact, as a result of some of the media attention on 1 August, I had an email from a chief executive at Ipswich - this is another little case study for your geography, and I do not get many emails from chief execs - directly to say for the first time Ipswich General Hospital has filled all of its junior doctor training posts with good doctors, and that is exactly, as a patient, what you want to hear if you are in Ipswich. Similarly, in Barnstaple, they recruited all of their orthopaedic training posts, a very high competitive specialty but they had not traditionally been able to fill all their surgical posts. Even in the high competition specialties, not every location in the country was able to find doctors, so, yes, on the one hand employers would always say in any sector (and it is particularly true in health care where safety is an issue) one wants more in the pool for better quality. However, we are different in health.

Q728 Mr Bone: Can I stop you there. That is very refreshing, Chairman, and that really is encouraging, because you are putting, effectively, the patients first, but we are not in a normal organisation, we are into this state planning, state-controlled unique organisation, and it is difficult for me to get into that organisation and I am not in favour of it, but having got there, you would think the one advantage you would have in state planning is that because you ration the amount of health care you are not subject to market forces for demand, you actually set it - you say, "This is how many doctors and nurses we are going to have" - and the one advantage of that system is that, if you know that, surely you can work out what number of people you need to put in at the beginning to supply those places, you can build in for competition a service, say 10%, but we seem to be hopeless at it. It is really unfair for the student, is it not, who wants to go into the medical profession, who goes into university, does years of work and then does not get a job at the end of it. Are we just hopeless at it?

Ms Thomas: I completely agree with everything you have said. We have not been very good at it. I think I agree with some of the comments earlier on at the Committee's first session, that we are never going to get this right and the world changes so quickly in medicine and it takes so long to train health care professionals that, actually, we do need a broad, flexible lens when we look at this issue. It is never going to be possible to work it all out exactly right. Two things have changed, and one is the EU market that is affecting the pool of people, and the second issue is, as I say, the huge expansion, 60% expansion, in medical under-graduate trainees. So, we have this balance: on the one hand we want this pool to be bigger - you quoted 10%, some employers might quote 5% - we do need to analyse exactly what the over supply picture would be, but we cannot have the situation we now have, which is not a modest over supply, it is, in fact, a huge over supply of very expensive trainees, and I think that is why this question, which is really a question for wider government policy-makers, needs to be resolved. Employers have not been in agreement all year on one side of that question or another. We have found it very difficult, actually, to get a consensus with employers, and only since these figures have become more known and the really grievous situation for these trainees has become known have employers finally given a view. The employer view at the moment, but we think it should be under review, is that UK and EU graduates need to be prioritised. It does need to be kept under review, and I should say, there is still not an insignificant number of employers that would not agree with the statement I have just made.

Q729 Mr Bone: On that point, Chairman, if the employer is sitting there and has all these different applicants to choose from, some home-grown, some from the EU and some from outside the EU, and we are sort of saying the problem arises because people are flooding in from the EU and outside, why are employers choosing people from outside the UK? You do not need to prioritise; the employer can make the selection. So, if I am interviewing people I can choose who I want. Is it a bit of a red herring?

Ms Thomas: There are two points. The first is that there is a general point to be reflected on, which is at what point do you want over supply and competition? Do you want it very early on in the training programme or do you want it much later? If you talk to foundation trusts who are employing CCT holders, they want the international market, they want to be able to say they have international expertise in their hospitals at consultant and CCT level. So there is a first decision, which is at what point do you want the pinch point of over supply? Do you want it at the beginning or more towards the end? The second point is just an issue about the dilemma around the cost; so I completely agree that a large pool of people is adequate. The final point is about legislation and recruitment. It would be something I would bring to the Committee's attention, because a lot has been said about entry to foundation. We have a legal framework in the Medical Act which requires medical schools to guarantee employment. That could be inconsistent with employment law, where guaranteeing employment to anybody might actually be unlawful. At the moment we have a situation in the foundation programme that needs urgent review around the recruitment processes for those individuals, because at the end of the day it may be called a foundation programme of training, but it is employment those people have, and, therefore, the route to those posts needs to be through fairly robust employment law processes.

Q730 Mr Bone: Finally, I think you touched on it in your answer there, very briefly, cost. There is a suggestion that if you flood the market with supply you keep costs down. It is a sort of cheap and cheerful model, if you like. Do you think there is any credence in that?

Ms Thomas: I think what I would say - it goes back to the first point I made - certainly one would expect in any sector, if you do flood the market and leave it to the market, then you do potentially apply some pressure around cost, but it is at what point in the career pathway you do that, and, arguably, you can achieve far more doing that at the end of the process when people have completed their training. Certainly the cost to the UK taxpayer of displaced trainees is significant, so that has to be a factor in making the decision about where the competition should be early on.

Q731 Dr Stoate: Can I clarify one point? I think you just said that you would like to see priority given to UK and EEA graduates in the selection process. Is that right?

Ms Thomas: We support the general recommendations in the Tooke Inquiry. We generally do support the first four-year broad-based concept of core training. As Neil Douglas pointed out, we can debate the finer points of where the cut-off point between F1 and core are and this issue of basing the decision of entry to core on evidence, which, after only five months training in F1 as employers, we are not quite sure how we are going to do that, but on the point about exactly how people are selected, I think we need more discussion, certainly.

Q732 Dr Stoate: How would you suggest doing it?

Ms Thomas: If legally there is a way in which entry to foundation programme and core should initially close off recruitment for EU and UK graduates and you set the bar at the appropriate level, then that might be a way, if you could then say this is the first four-year programme, that you, if you like, give as much chance. What we want to do is give opportunity to those graduates to show excellence at the right point and to be competitive at the right point, which might be at the end of core.

Q733 Dr Stoate: We heard earlier on, though, that there did not seem to be a problem with the junior levels. If anything there was an over supply of posts. It was when you got up to the higher specialist training grades that there was massive over application with competition ratios of 20 to one. So your idea of sorting it out after core training, I do not think, would address it.

Ms Thomas: One way that could address it is better career advice during core. There is a world of difference between choosing four themed specialties and being asked to choose from 57 specialties, so taking that decision a bit later on for the trainee might actually give people better information about where the competition ratios were and potentially ease that problem.

Q734 Dr Stoate: But it would not stop a huge number of graduates coming in from outside the EEA, which the Court of Appeal ruled we could not do anything about.

Ms Thomas: It certainly would not unless the immigration rules change.

Q735 Dr Stoate: Our understanding is that the guidance given to the NHS, which was ruled unlawful, was in fact drafted by NHS Employers. Is that right?

Ms Thomas: It was certainly not drafted by us, no.

Q736 Dr Stoate: Certainly our information is that it was, but you are saying otherwise.

Ms Thomas: Our role is to implement the policy decisions of the Department of Health, and that is what we do.

Q737 Dr Stoate: What would you do then to restrict immigration rules? How would you see that happening?

Ms Thomas: It is not for me to comment. I am not an expert on the immigration arrangements. I think I have just said, the position employers are telling us at the moment, and it is not a consensus, is that we probably ought to try and priorities EU and UK graduates, and we should do that legally, through, if possible, a change to the immigration rules.

Q738 Dr Stoate: What do you think?

Dr Livingston: I think it is a really important issue that needs resolution. Sitting in SHAs with responsibility for delivering an effective recruitment process this year, we would like to know what success is going to look like for us. I think that if we have similar competition ratios, there will be a not lot of noise, but that will not necessarily mean that the process has not been well implemented. I think it is essential at a national level that a decision is made. I think there are two other issues in terms of competition. I think the first is: do we have the eligibility criteria right for specialty training? Do we believe in an excellence model? In which case, is the barrier high enough in terms of eligibility. The second question is: are we confident that if we are producing a home-grown cohort, our future medical workforce, that that will be a highly competitive workforce in an open market if we cannot influence that? So what do we need to do to ensure that future medical graduates from the UK are highly competitive, and we should be in a very good position to influence that through working closely with higher education to ensure the curricular is mapped into the service changes. We should not forget that, as we move forward and look forward, Lord Darzi's NHS next stage review is going to really help us understand the future picture of services, and that in turn should then greatly influence the content of curricular and the commissioning of education, and that may play some part, but working with higher education to ensure that we are confident that the money that we have invested in training medical students puts them in a very good position to be competitive.

Ms Rainsberry: I just wanted to say, I do not think it was hopeless. If you look at the high level numbers, and this is with no disrespect to IMGs because they have actually produced and given a lot of service to the NHS, but the ongoing hypothesis at the beginning of this whole process was that they would not be included, and that was the basis on which the additional medical school commissions came through. If you take that as a hypothesis and you look at that running through, broadly, the numbers were right. I think that is an important point. The other point is that there is a real challenge for us around the managing doctors' training expectations - it is the point you were talking about earlier - in terms of which specialties they wish to train in, because a lot of the mismatch we are talking about that occurs and a lot of the noise, quite frankly, is about people who cannot get into surgical specialties or cannot continue to pursue their career in surgical specialties. There is a lot of evidence this year that SHAs funded transition packages, creating new training posts in specialties where we needed more doctors, provided career supports, counselling to doctors who did not get posts in round two to help them think about moving from, say, a general surgical specialty to maybe obstetrics and gynaecology.

Q739 Dr Stoate: That is all true, but that is not going to solve the problem of a very large number of non EEA graduates applying for posts. That is the issue I am trying to get to. What would you do to address that specific issue?

Ms Rainsberry: I am not an expert on this, but going back to when I was an HR director in a trust, I think the work permit rules we had there, both in terms of the work and the study, seemed to work very well. Where you had specialties that you found it hard to recruit and you had evidence that you could not get trainees, and that worked for Europe as well as it did for the UK, then you would make an application and someone would either come through on a training permit or a work permit. I wonder whether we have got the system to manage it, because in the short-term (and this was the link I was trying to make) we do have a mismatch between what people want to train in and what we need for the service, and, therefore, we are reliant on doctors from overseas for some specialties.

Q740 Dr Naysmith: Even if we managed to restrict the entry of non EU applicants, there is still an increasing number of EU applicants coming in. Do you think that is going to increase in the future?

Ms Rainsberry: The evidence is that it is. You heard evidence last week from our Dean, Liz Pace, in London, and I would agree with her that some kind of examination would be a way of starting to manage that, thinking very carefully about what the bar should be in that. I think that would be one way of trying to manage that issue.

Q741 Dr Naysmith: We are going to have the first graduates from the new the British Medical Schools coming out in the next two or three years. They are going to be adding to the competition, so we really have to do something about that as well, do not we, fairly soon?

Ms Rainsberry: Yes.

Q742 Dr Naysmith: Even if we did restrict non EU applicants, we are still going to have a problem in a few years time.

Ms Rainsberry: Yes, and I think, as Sir John Tooke identifies, key in that will be the debate about what is the role of a doctor and are we having a consultant-delivered or a consultant-led service, because if you are sitting in an SHA the answer to that question makes an awful lot of difference to what you then commission.

Dr Livingston: I think the other aspect of Tooke, it is a question that remains answered but it is highlighted as an area, is this issue of excellence and understanding what excellence might be. If excellence is that a doctor who is in the country will train to become a specialist, then, of course, that means we continue to have a very broad programme, but it will be highly competitive and will be of interest to Europe because the salary is good and the training is paid for. If we then think that excellence is a different model and excellence is about ensuring those who have the ability to move swiftly through a training programme achieve the competences, then you need a different type of structure to support that to ensure you have your workforce output at the end. I do not think we have a clear view on what excellence is, but if we knew what that was, then we would get the eligibility right. We would then be able to understand just how high is this bar and then actually consider, through proper modelling, what the competition ratios may well be in truth, not in terms of number of applications but in terms of eligibility to the post.

Q743 Dr Naysmith: Anne, you talked about managing expectations amongst those who wanted to get into the really competitive areas finding that they did not get a job. Actually, medical training is a very general training which trains you for all sorts of different specialties, so it is not unreasonable to say that we should be helping people who do not get their first jobs to do other things. Is that something that is happening fairly widely? Is it coming from recommendations from the department, or is it just some areas where there was a lot of expectations that were unmanaged coming up with ideas how to do it?

Ms Rainsberry: Yes. There is certainly evidence from the royal colleges in terms of the curricular and looking at core medical training and themed training in surgery. It is starting to look at that and, obviously, one of the issues that have been raised with run-through training was this issue that you were just nailing your colours to the mast. If you did not get in, it was seen that all was lost.

Q744 Dr Naysmith: Do you know of any good schemes that we might recommend?

Ms Rainsberry: Certainly in the London Deanery there are a number of programmes that are looking at generalising, if we can use that phrase, before you actually give people a broad base. There are challenges in that in terms of the design. The issue for us (and Sian mentioned transition) is just managing through people who have been training in a specialty for a large number of years who suddenly find that they cannot get into the higher levels. That is a particular challenge we are having to deal with.

Q745 Dr Naysmith: The other thing was something which Sian said, about controlling entry to the hospitals from the overseas doctors. Should not hospitals have the right to choose whether they want overseas doctors or not?

Ms Thomas: Some hospitals are saying that to us, and I think that just signifies the dilemma. Going back to the point about competition, it is where you want to put the pinch point of competition. Where do you want to have, as Moira said, the analysis of high skill? If we have got hard to recruit posts, it is absolutely entirely appropriate that we recruit from overseas but we must try and drive over supply into previously unpopular specialties by giving better advice to doctors and channelling good doctors into parts of the country that previously they may not have gone to.

Q746 Chairman: What level of competition is desirable? If we have got three people eyeing one post, what percentage of competition should there be?

Ms Thomas: When we were giving advice at the department last summer around the recruitment process, one of the first questions I asked as an HR professional, which is characterised in all high volume recruitment situations which are apparent in lots of different sectors - the IT sector has huge high volume recruitment processes - you need better hard measures to shortlist, but I asked a question about the ratio of interviews to posts. Because in the profession for high skill that is generally between a two-to-one or a three-to-one ratio, you generally expect to have a face-to-face assessment process with three people for every one post. You certainly would not put all your backing on a two-to-one ratio, it may not give you the best applicant, so, actually, three-to-one may sound a huge over supply, but in terms of recruitment process a three-to-one interview process is good. In terms of the comment before about over supply, I ask employers this question, and have asked it for a year now, in terms of their own thinking of good applicants, eligible applicants, to the posts available, and anything between 5% and 10% in any sector is considered reasonable. The question I think for health is, when you are funding people's training at huge cost, what is a reasonable level of over supply? Maybe I would say 10% is probably too much, but we do need some for the people to go and work in those parts of the country that could not get good doctors.

Q747 Mr Bone: I am trying to get this pinch point argument. I have been thinking about it. I am not entirely sure I understand it. Are we saying that it is okay or desirable to bring overseas people in at the beginning and give them training posts, and then, when it comes to the end and they become qualified, that is where the pinch comes and you do not want them then and you have paid for their training costs?

Ms Thomas: I think an employer perspective would be that if we have grown the UK graduate workforce to enable UK graduates to have the best opportunity they possibly can to be competitive and you have a system where you have to give them practical training for their first year of training to get them on the register, we have to have a situation which somehow gives them maximised opportunity, and that means, for the first few years of their training, we should give as much priority as possible to the EU and UK graduates. The EU graduates have that right through law. Then there is a situation around at what point actually employers would want competition. I talk to foundation trusts that want competition internationally for their consultant vacancies. So, actually, the reality of the situation is we are in a global healthcare market that is very competitive and employers will always want, potentially, the widest pool as possible.

Q748 Mr Bone: I think I have got it right now. You are saying the pinch point should be when they are qualified.

Ms Thomas: Further up the training programme. At what point it is debatable, but further up the training programme.

Mr Bone: That makes sense.

Q749 Chairman: The European Working Time Directive. It clearly shows a significant reduction in training doctors' hours in relation to that. The logic then tells me that we should have an increase in training posts on that basis. Why has this not happened?

Dr Livingston: I think the reduction in training hours across Modernising Medical Careers was driven to address that to ensure there was a competent structure and an assessment process in place and that we could then demonstrate that the curriculum had been delivered and that the doctor was fit for purpose as a specialist. I think all of that is an issue. I think that MMC is part of the solution to the original Working Time Directive issue. If we then think about how service reconfigures, certainly if we go back a couple of years, the service reconfigured by increasing the number of very junior doctors in order to cope with the Working Time Directive and they have subsequently been amalgamated into some of the new training posts and also the FTSTA, because there is concern that doctors at that level providing a service to patients are not as experienced as patients deserve their doctors to be. If we look forward, and the discussions that we are having with the service are actually about new and different ways of delivering the service, I think that when we compare the UK NHS to other models of healthcare, we need to bear in mind that employers have a very different view on how they wish their service to be delivered and that they may choose multi-professional approaches, that they may have different team structures, and so I think the priority for services, certainly in the north-east, is to actually look at the workforce in a different way, and they are not necessarily looking to increase the number of doctors. I think there are some striking examples where that will need to be the case, such as looking at obs and gynae, paediatrics and, I think, anaesthetics may well be another critical area, but I think in general the plans seem to relate to a change in the make up of the workforce rather than necessarily having more junior doctors in the system or more senior doctors delivering.

Q750 Chairman: Do you agree with that?

Ms Thomas: Yes, I think I agree broadly with that. One of the big risks, of course, of increasing numbers of people to cope with shift patterns where there were gaps for the European Working Time Directive results is the situation we have got around the SHAs bulge, which is that we have got lots of people who have done training programmes who now cannot find posts in their specialty. We have to be responsible when we do that and not lead people to believing that there may be posts for them in the future; so we are back to we need to be clear about what it is that the service wants in terms of the doctor for the future.

Q751 Chairman: If consultants and trainees are working fewer hours, when do they train or when do they have the opportunity to train people? The logic is that there are less opportunities in that sense.

Ms Thomas: One of the really welcome points in John Tooke's report is bringing in the aspect of the Working Time Directive. I am not sure his recommendation - we have only just seen it, the new recommendation, in the last two weeks, and we are carefully analysing it - is necessarily the solution, but he has raised again this issue of the tension between reducing hours, because it is certainly true that many doctors do not have exposure to procedures in the hours available, and if that is the case, then you either increase the number of years that people are doing their training or you change the role that they do when they finish their training, because they will not have had that experience. I think the fact that he has written it in his report means that we now need to go back to that, because certainly that was something that had become lost in the MMC debate.

Ms Rainsberry: I think that was one of the reasons why MMC was competency based, in the sense of trying to get away from this idea of time served, and is basically saying, "You will move on to the next stage when you are deemed to be competent." So, I think that is an important principle that needs to be taken into account. I would also like to agree two points really. One is that there is a challenge about allowing employers to create additional training posts just to support rotas, and certainly in surgical specialties that is a big contribution to the bulge that we talk about. Equally, there is an awful lot of work going on which is looking at alternative solutions to meeting the European Working Time Directive which does not rely on doctors and training to do that, because they are a very expensive resource, and a lot of the evidence is that the way the old House Officer grade used to get used in hospitals really did not add a lot to patients and a lot to the training and, actually, by providing different models, certainly at night, you can get more training done during the day, more concentrated training, and provide different service models at night; so I do not think it necessarily follows you need more training posts because we have got to reduce hours.

Q752 Dr Taylor: We are nearly at the last lap. Moira, starting off with you, because as a committee we probably have not looked into the position of doctors in staff grade jobs and things like this and as you were responsible, we believe, for implementing the policies of Choice and Opportunity, we would like to know how you have got on. We know that the department estimated, because they did not know how many there were, that there were 12,500, no career structure, variation in the type of work and the stigma and the fact that it is a professional cul de sac. How do you think you see the career of these people going and how can you implement the suggestions?

Dr Livingston: I think that if we go back to unfinished business, where it was highlighted that there was an urgent need to review the staff doctor grade, which is a non-consultant career grade, and the associate specialist, then choice and opportunity was consulted upon, and in January 2004 Choice and Opportunity was launched and was seen as a key part of Modernising Medical Careers. It is fair to say that lot of the energy and focus of the work went into modernising medical training, and I think that that emphasis on training was very necessary and within the limited resources available at the time. I was asked to look at the implementation of Choice and Opportunity and the recommendations within that and work very closely with NHS employers who were tasked with implementing the recommendations around the new contract, so the work that we did, which involved a very wide consultation with the service as a key focus because of the importance of the employer role in supporting this grade of doctor, did progress and the work was completed by December 2006. What then happened is that the work, which is a best practise guide for employers, is sitting with NHS employers and NHS employers will be responsible for publishing that guide and it is to be published at the time that the new contract goes out to vote and has been accepted. So there has been a delay in that we felt that the new contact was an essential component of Choice and Opportunity, and whilst waiting for that to be agreed there has been a hold on the publication of the work that we did within the MMC team. As we move forward, there was some work to be completed on a best practice guide for the doctors themselves who are currently in the post but, more importantly, for doctors who then enter the new career post, as it was called under MMC, and that has been on hold because we were unable to find an organisation that would actually take responsibility for that. I think that that is a piece of the jigsaw that was missed. In terms of what we achieved, I think there are some things that we did manage to achieve. One was to bring together a body of evidence for the employer to understand how to ensure that doctors in these roles could fully reach their potential, how they could be supported in achieving their aspirations and how employers could view them differently in terms of their contribution as clinical leaders within organisations, so their role as managers, teachers, their role in research. Where we were unable to again any momentum was around the issue of credentialing. The origin aspiration had been that doctors in the new career post would be able to the get credentialing as they progressed within their job learning as they go for new competences that they have gained, and there just is not a regulatory structure in place to support that. Because the doctors in the career posts are not part of the training structure and there was a lot of tension about using the term "training" with respect to these doctors who were in employment, they fell out with the remit of PMETB and, although we did work with skills for health to look at a structured framework for their development, again it was something that could not sit with the GMC in its remit and could not sit with PMETB. Whereas all the organisations were interested in this, and I know that PMETB were concerned that their framework did not allow them to do work on this grade - it is something that they would have in their sites for the future should the situation arise that they were able to address it, and their priority was going to address a kind of credentialing system called CCT Initialling for Consultants - I think that remains one of the recommendations that we were able to successfully move forward. When we talk about MMC, I think there are three elements that are confused. I think Modernising Medical Careers was about modernising medical training, it was about choice and opportunity, and then there was MTAS, and I think sometimes that is confused and lost. I do feel concerned because I think you need to champion this area of development and, looking at the new MMC website, I think the non-consultant career grade work does not feature and I think the reaffirmation of the principles of the MMC Programme Board, which were deemed MMC principles, actually are MMT principles and actually modernising medical training principles because they do not take account of Choice and Opportunity, which was a key part of the whole programme.

Q753 Dr Taylor: Because these doctors provide the backbone of a tremendous amount of service.

Dr Livingston: Absolutely.

Q754 Dr Taylor: Am I right to take encouragement from Tooke's diagram, because his diagram of the inquiry recommendations puts the staff grade in the same sort of block as the specialist registrars and there is an arrow, if you follow it very carefully, that allows them to go towards CCT?

Dr Livingston: This is part of Choice and Opportunity. It allows them to enter the specialist register through PMETB, through something called the CESR route, through article 14 or article 11 in primary care. I think that certainly the ambition is there to support these doctors to progress, and I think that as a new doctor entering that career structure, if we sign-up from employers, then gathering evidence of their performance will result in them having an effective portfolio, which will give them a better chance. For doctors who are currently in the system, actually going back five years and looking for evidence of achievement of competences that demonstrate their equivalent to a specialist is quite a challenge. I think that Tooke does ask for an urgent review, an urgent need to implement the new contract. I think that this debate sits within the overall debate of what is an excellence model. We have talked a lot about the difficulty in workforce planning and how do you look at a ten-year programme with all the changes in technology, the change in service. How do you know that what comes out at the end from the start is what we are going to need? I do think we should take another look at a potential model which is slightly different to the model that we might be running with, whereby we can see doctors working in the service learning and developing all the right skills but actually they provide a drip-feed into the senior end and, because they are more senior and more experienced, actually provide us with a shorter run-through to delivering a fully trained workforce, if we mean by "fully trained" a specialist. I think at the moment everybody goes on the very long path. We do not have a fast-track path and, looking at other professional groups, the model we have in medicine is quite unusual in terms of other professions outside of medicine. The expectation that everybody is automatically on the excellence path is very high, and I think, as part of the debate, I am not sure that we are questioning that and I am not sure that we are looking at other models that would provide us with a workforce planning model that offers us a drip-feed from the service with doctors who have been fully supported, allowed to develop appropriately, with competence akin to what will be required in terms of service, but, therefore, better prepared to enter specialty training at a higher level.

Q755 Dr Taylor: You have mentioned the best practice guide and the new contract. Can Sian tell us when the contract is coming and why it has been delayed?

Ms Thomas: NHS Employers have been negotiating the new contract for SAS doctors, as you know, for some time and we concluded those negotiations in November 2006 and agreed with the Department of Health and the BMA the overall framework of that contract, and we are ready, through the BMA, to ballot SAS doctors. Before we could do that, or the BMA could do that, this needed to be sent to the Government for ratification, and that has taken a year, and in December 2007 we received the decision from the Government that we could implement the contract and the BMA are now balloting their members. So, we will know by the end of March if their members have supported the contract recommendations and then it will be implemented by employers from 1 April.

Q756 Dr Taylor: So the delay was not your fault.

Ms Thomas: It is not for me to say.

Q757 Dr Taylor: You have said it very clearly. Finally, do you have any suggestions about what they should be called, because staff grades, trust grades, associate specialist, non-consultant career grade - it is absolutely ridiculous, is it not? What is a complementary title for them that implies it is not a cul de sac?

Ms Thomas: There are two pieces of work in NHS Employers we are doing with employers. The first is to determine what we want doctors to do in the future: what is their role in the healthcare team and what will the career structure look like? Employers will determine that, and they may actually not all determine the same thing and may want to do different things, which is obviously, in an autonomous employer situation, what they are entirely able to do. What we will try to do is determine what the overall structure will look like. The second piece of work is on looking at what the individual career pathways for doctors look like to make them attractive in a world where 70% of students at the moment are women and their potential medical pathway might look very different for a workforce that might look very different in the future from what it does now.

Q758 Dr Taylor: It has got up to 70% now, has it?

Ms Thomas: 70% of undergraduates are female.

Q759 Dr Taylor: Very good.

Dr Livingston: If I can just add to that. Creating an alternative to specialty training is essential to improve the morale of the medical workforce, a real alternative which is valued. It has been one of the issues for doctors in the system, the importance of them getting on specialty training, because the choice was not there for an alternative route. Even where there is a work/life balance issue it is a very difficult decision for the doctor to make because we have not made it attractive enough. This work is essential to reduce some of the heat within the system around that.

Q760 Dr Taylor: These sorts of posts could be a long-term worthwhile alternative if they are organised correctly?

Dr Livingston: They need to be.

Q761 Chairman: Earlier I quoted from what was said to us in our session last week from a post-grad dean. He said that in some parts of the country outside of the Southeast these were the best cohorts of trainees they had ever had in post-grad trainee. Could I ask you, Moira, do you have a view about that?

Dr Livingston: Yes. We have had regular meetings with employers across the patch throughout Round 1A, Round 1B and Round 2. After Round 1A the employers were absolutely certain that they were very positive about the recruitment they had made from Round 1A. Round 1B, for them, was felt to be an add-on which was not necessary to assure them of getting the highest calibre, but we understand nationally the need for it and support the decision that the Programme Board made. We have also seen improved recruitment in areas where that has been a challenge in the past and general satisfaction with the quality of the doctors who have been appointed.

Q762 Chairman: A marked difference from years gone by?

Dr Livingston: I do not think I am able to say a marked difference but I would definitely say satisfaction with the quality of recruitment.

Ms Thomas: I have already given some examples of the real case studies we have had. I will just make two points. I do agree broadly with that statement but we have also heard of very excellent doctors who have not got into their specialty. The recruitment process did generally give us high calibre people and generally some employers who have not been able to recruit are recruiting, but the real question is did we discriminate between good doctors and excellent doctors. We did get reports from consultants that they were unable to do that through some of the recruitment process. I think the general answer to that is "yes", but it is a "yes, but we may not actually have the right doctors". One example of that I would give where there is real concern is on the clinical academic recruitment. We were unable to recruit posts to the clinical academic structure in some parts of the country and we are not quite sure if we have got the really excellent clinical academic doctors we need for the furthering of scientific research. In a year where new money was injected into that programme, where we really need to give emphasis on encouraging doctors not only into clinical medicine but academic medicine and research, that is absolutely critical to get right. Broadly, yes is the answer but I do not think that fits for every single situation. A final point I would want to make about recruitment issues is you have heard a lot of evidence as a Committee about the redesign needed of this huge change programme and time is getting on. We have a process for 2008 which we think will run smoothly but is a one year local fix, if you like. We have got increasing concern from employers that we should not repeat the mistakes we have made before, if you like. Huge change needs time, it needs testing and it needs stakeholder engagement. I really do not know if we are going to have all of those things in place for 2009. We talked to John Tooke and his team about this. We may even be talking about 2010 or 2011 before we have the actual solution for the longer term and we must be courageous and stick to our guns if we think that is the right thing to do and not rush headlong into something for even 2009 which is not the right solution.

Q763 Chairman: I was just going to give the last word on the question I asked to the Southeast.

Ms Rainsberry: We bear out what has been said in that our fill rate in London was the lowest we have known it, so there obviously was a redistribution that was going on. The question of whether gold standard doctors, the stars, were not getting into training is probably right, but the reason for that was because they persisted in going for being a cardiothoracic surgeon and the reality is you have lots and lots of stars going for that. Despite giving lots of advice and lots of support, it is very difficult to dissuade people when they have set their heart on it. On 2009, the MMC England Programme Board has just started to consider that and will be considering it in more detail at the next meeting. Just to offer some reassurance, there are a lot of stakeholders around the table saying exactly that. We need to look at what is the change that is required and then how long it will take to implement that change properly, not to say we must do this by 2009. That is certainly the tenor of the discussion at the moment.

Q764 Dr Naysmith: I wanted to pick up what on what Sian said. Obviously we do not want discrimination, we need to eliminate discrimination, but I have been around medical schools most of my working life and there have always been some people who were disappointed at not getting into their preferred speciality. It seems to have been highly focused this year but it is something that has always happened. The other thing is, it has always been relatively difficult to recruit into academic medicine, particularly with GPs getting the salaries they are getting now, and some of the consultants. Being an academic and spending a lot of your time doing research as well as seeing patients is not as attractive and never was as attractive to some people, unless you are obsessed with becoming a medical scientist. Both of these problems have been in the system for a long time.

Ms Thomas: They have, absolutely.

Q765 Dr Naysmith: It is not true to blame them, despite ---

Ms Thomas: No, but we should expect a change through MMC to deliver improvement, that would be the point to make.

Dr Naysmith: Yes, we can always make things better.

Chairman: Thank you for coming along and helping us with our inquiry.