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The Tooke report makes 47 recommendations. Time does not allow me to comment on them all, so I shall concentrate on a few. Recommendation 6 relates to policy development, implementation and governance for the key areas of medical education, training and work force issues. The recommendation that the Chief Medical Officer should be the senior responsible officer for medical education seems logical, but it is important that the SRO should have a clear understanding of the role of doctors—the key area that was missing—and the authority, responsibility and time commitment to do the task effectively. We must not underestimate the scale of the task and the responsibility, which is for the whole of England. Understanding of and interest in medical education is also essential. The Government’s response requires greater clarity. It is not surprising that the profession would have greater confidence if the SRO had an understanding of medical education and the role of doctors.

Recommendations 24, 25 and 26 refer to the functions of postgraduate deans; that is, their relationship with strategic health authorities, and the postgraduate deans and the strategic health authorities’ relationship with universities. The recommendation relating to a review of postgraduate deaneries is key to the future of medical education in England. The need for greater involvement of universities in postgraduate medical training is crucial and long overdue. Universities already have responsibility for and experience of undergraduate and foundation year 1 training. Universities also work well with regulators.

The performance of postgraduate deaneries in managing postgraduate education and training is variable. Their close link with SHAs is not only an anomaly but a possible hindrance. As evidenced, SHAs have neither been closely involved in nor demonstrated a responsibility

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for medical education and training. There is some evidence that some SHAs raided education budgets to meet financial problems in service delivery to the detriment of the training of all professions.

Postgraduate deans should be a part of the university structure and be responsible on behalf of the universities for the delivery of postgraduate medical training. Universities would then have responsibility for the training of doctors from undergraduate level to the completion of specialist training. That would in no way diminish the role of professional organisations; it would enhance it. The proposal sits well with the recommendation in the Tooke report related to core and specialist training.

The GMC and the education committee would, as now, be responsible for curricular development, for the monitoring of undergraduate training and for foundation year 1. PMETB, as part of the GMC, would be responsible for the curricular development of core training, working with colleges and specialist societies, which would also, as now, have a strong role in developing the curriculum and assessment of specialist training. The colleges would be rather like specialist boards in the USA and, with PMETB, would monitor delivery of training by universities. That would help to strengthen academic departments and help with academic recruitment. Importantly, it would reduce the plethora of bodies vying for roles in postgraduate training. It would also strengthen the relationship between strategic health authorities and universities. The initial responses of some of the organisations and individuals that I have spoken to have been positive. I hope that the Minister finds it so too.

Assessment could also be made more uniform and structured. Why do we not have a national exam at, let us say, some stage in foundation year 1? The model of the PLAB exam for the GMC may well be developed to satisfy this and will replace the exam at the end of medical school. At the end of core training, all trainees, prior to entering specialist training, should undergo assessment at national assessment centres, as suggested by Tooke, and these will be monitored by the colleges.

The last and new recommendation is about establishing a new body, NHS MEE, with a co-ordinating role and wide-ranging responsibilities. As proposed, it will only be for medical education and not for other health professionals. That might be a drawback. The Government, in their response, have reservations. For such a body to be effective, it has to be relatively small. It did not surprise me that, when I had this discussion, everyone who had supported the recommendation also expected to be on it, which would mean a body of between 25 and 30 people. In the past, we have had such large bodies that became ineffective. Some noble Lords may well remember that. The proposal in the Tooke report of an effective body with a co-ordinating role should not be lost, but we should have further discussions about it.

It is clear that we should start sorting out the mess that MMC and MTAS have created, to regain the confidence of young doctors so that patient care does not suffer for years to come. I look forward to the Minister’s response.



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4.46 pm

Lord Turnberg: My Lords, I congratulate my friend, the noble Lord, Lord Patel, for introducing this very timely debate. It is always a pleasure to listen to him although, as usual, he has pre-empted much of what I was going to say. I too welcome the Tooke report, which is a very brave attempt to start again and put behind us much of the chaos which surrounded last year’s arrangements for doctor training. I do not want to go back to see where the blame for the problems lay; let us say that no one comes up smelling of roses. As someone who has spent much of his life in medical education, as a dean of a medical school and as president of a medical Royal College, I spent many happy hours on education and manpower planning committees. I know how difficult it is to get it right.

The Government’s response to the report is very positive and helpful. Inevitably, there are a number of problems on which I would like to focus. First, there are the immediate and urgent difficulties facing young doctors this year. I will not go on about this, because the noble Lord, Lord Patel, dealt with much of it. The fact is that many young trainees feel very insecure and uncertain about their job prospects now. The Government are leaning over backwards to offer solutions, with increased numbers of posts. Do the Government have any idea of the numbers that will be needed and where? Will they ensure that the application process, which caused so much resentment last year, will be revised? There is much that needs to be not only done, but widely publicised if we are to regain the confidence of trainees.

There is much in the Tooke report about the need to define the role of doctors in a modern health service, and much emphasis on the need to strive for excellence. It is suggested that we should wait until we have defined the roles of all other healthcare workers before we suggest what doctors should contribute. Noble Lords may not be surprised if I say that I do not see it that way at all. I see the doctor’s role as central, because I believe that patients and the public expect nothing less. I am not trying to deny the role of nurses and other healthcare workers, pace the noble Baroness, Lady Emerton. Far from it—they make enormous contributions. I am saying that we should already know what we want from doctors. Ask any patient.

Medical students know, or are soon made aware of, what is required of them to be a good doctor. It is a combination of attributes, which include a full knowledge of the scientific and biological basis of health and disease; an ability to communicate, empathise and deal sympathetically with patients and relatives; and practising in the safest and most effective way. They are taught how to deal with uncertainty in an open and flexible way, and of the need to keep up with the latest developments as they occur. For all that, they need five or six years of undergraduate education and a further five years for general practice, or seven to eight for specialist practice, so it is not surprising that we need to continue to attract students who are bright and can stay the course, so that at the end of all this they can meet everything that patients ask of them.



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I hope that the Government, in talking about defining the role of doctors, do not spend a lot of time thinking about the many important contributions that other health workers make before they do so. I believe that we now know what doctors should be doing and we should be putting all our efforts into ensuring that our training programmes are designed in the best way possible to achieve those aims.

One other matter which causes me a little concern is the Government’s response to the proposal that a “senior responsible officer” should be appointed to oversee medical training. In England, unlike in Scotland, Wales and Northern Ireland where this responsibility will reside with the chief medical officer, it rests with the workforce planning division of the Department of Health in the form of the director-general of manpower planning. That does not give me a great deal of confidence that educational objectives will be paramount here, and the needs of the workforce might take precedence. Can my noble friend comment on this?

I turn now to the proposal that the Postgraduate Medical Education Training Board should merge with the General Medical Council. This sounds a reasonable idea as it would bring together undergraduate and postgraduate education and training under one body. But it may not be widely recognised that the educational role of the GMC is fulfilled by a separate education committee which has its own statutory responsibilities distinct from the GMC itself. A good case can be made for merging PMETB, which has had a rather unhappy few years of existence, with the education committee, which has a very good record of overseeing medical schools. It checks their curricula, makes sure they are fit for educating future doctors, conducts inspection visits and generally keeps a close eye on the medical schools. But the Government’s intention seems to be to take away the statutory responsibility of the education committee and merge it into the GMC, which itself is not immune from criticism. It seems quite perverse to get rid of the one body that is working well and merge it with two bodies that have not yet commanded everyone’s confidence. Furthermore, education is sufficiently different from regulation and judgments about failing doctors, the proper province of the GMC, to warrant their separation. I hope that in the ongoing consultation exercise the Government will think very carefully before going down that route.

Finally, I want to say a few words about the relationships between the NHS and the academic community. Much is made in the report and the Government’s response of the need to have good and robust interactions between universities and trusts, and between the Department of Health and the Department for Innovation, Universities and Skills. After all, clinical academic departments are not only responsible for undergraduate and much of postgraduate education, they also deliver much of the NHS service in their disciplines. For example, my own department provided most of the gastrointestinal services for my hospital, with my academic colleagues in surgery. And of course academics provide a high proportion of the expertise at national level for the NHS, to say nothing of their research contributions.



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Yet the history of relationships between the Department of Health and DIUS or its predecessors is littered with desultory efforts at collaboration. Bodies rejoicing under such acronyms as SGUMDER and STLA seemed to achieve little or nothing and faded into oblivion. Joint planning and funding arrangements between NHS trusts and medical schools has worked in far too few places. I wanted to bring this up because while the Government recognise the importance of academic medicine and have put considerable funds into medical research, their response to the Tooke report fails to set out clearly how trusts and universities might work more closely together in, for example, the training of clinical academics as well as in designing patterns of service. I know that this topic is close to the heart of my noble friend on the Front Bench, and I hope he can say whether a few more teeth can be put into the Government’s rather vague response.

I may have sounded somewhat critical, but I would hate to give the impression that I do not applaud the vast majority of the report and the response. I reiterate what I said at the beginning: this is a brave effort and should be welcomed.

4.54 pm

Baroness Finlay of Llandaff: My Lords, I thank my noble friend Lord Patel for securing this debate on Sir John Tooke’s forensic and timely report, which analyses all the points of failure in Modernising Medical Careers and makes many sensible and important recommendations for how to bring the profession out of its current crisis. The report is unique in its analysis of the evidence of what did and did not happen last year, and for its far-reaching conclusions. It is also unique in that it has taken the whole profession with it. Never before have the juniors, the consultants, the deans of medical schools, the Royal Colleges and the BMA all stood firm in support of such recommendations on their own future.

Why has Sir John’s report commanded so much respect? I suggest that it is for several reasons. In so doing, I declare all my interests as a doctor, an attendee at the Medical Schools Council, a postgraduate trainer, president of the Royal Society of Medicine and parent of doctors in training. The Tooke report does what it espouses: it makes recommendations based on evidence and is not ashamed to recognise that doctors have a unique training that is complex and demanding and which ensures they are fit for purpose in managing the most complex of conditions that threaten life daily.

Before turning to individual recommendations from the report, I want to stress why it must be acted on. There are two issues at stake here, both of which are important. The first is the future of the country’s health service and the safety of patients. Patients expect to be treated by a doctor of the highest competence and they expect the doctor to carry the overall responsibility for their care, particularly when very ill, and they are right to expect that. The second issue we face is the large number of highly skilled individuals who will not be able to progress in their careers. These are doctors who have done everything that they have been asked to do; they have made it through their

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initial training with all its rigorous assessments and incurred huge debts in the process, only to be let down by the system—by a chronic failure in adequate and appropriate workforce planning.

I turn to the recommendations on the role of doctors and workforce planning, on the training programme and on NHS Medical Education England, or NHS:MEE, as it is known. First, the role of the doctor must be clearly understood in the modern healthcare team. The current Department of Health policy seems to envisage a blurring of boundaries between the professions but without defining safe boundaries and without defining the separate, complementary roles as good governance requires.

Doctors are trained in scientific deduction. They have learnt skills from their seniors. Knowledge from structured teaching and appropriate positive compassionate attitudes to modern multiprofessional team working are required of every UK graduate. Medical training teaches deduction with good communication skills to be able to elicit a diagnosis based on solid scientific foundations, and to sort out the multiple problems that so many patients present with. The undifferentiated patient presents increasingly with multiple pathology. Each individual patient is unique; their needs are beyond any diagnostic protocol or algorithm. Good diagnosis is the foundation to ensuring that the appropriate tests are done to confirm what is suspected and to set the patient on the correct care plan journey. In that process, the other team members come into play to manage the patient on that journey to recovery or improvement within the boundaries of ongoing disease.

The evidence from the latest national confidential inquiry into peri-operative deaths found that being seen initially by a consultant in trauma care improves survival and outcomes for trauma patients. When there is a major accident, it is the consultant who leads the triage because the complexity of the decisions needs that level of diagnostic skill to determine the optimal use of scarce resources. Evidence on the outcomes of head injury shows that being seen initially by a consultant improves outcomes—but at night that often does not happen.

Problems out of hours are not unique to the UK or to trauma care. Increased mortality out of hours has also been identified in patients with heart attacks and cardiac arrests, and those being discharged from intensive care, to name but some. It is vital, therefore, that there are sufficient consultants to ensure that all patients can achieve the best outcome. The answer is to get fully trained specialist doctors to the front line at all times. As the Tooke report recommends, the medical profession must be engaged in NHS management of trusts because that is how changes will be brought about at local level

In the Health Service Journal last week, Sir John Tooke stated that,

The Government seem to have accepted recommendation 6, which means that the CMO in each country is indeed the senior responsible officer

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for medical education. However, while I, in Wales, look to the CMO as the leader for medical education, my colleagues in England will have instead to turn to the director-general of workforce. That seems contradictory and illogical. Indeed, many colleagues have expressed extreme disquiet that a person with no direct experience of medical education could even contemplate taking the lead in this area, which is fundamental to the future of the health service. I would welcome an explanation from the Minister.

In Wales, as in Scotland and Northern Ireland, the CMO works closely with the postgraduate dean and the universities, providing significant benefits. The proposed graduate schools will cement the interface between the service, the profession, academia and workforce planning.

What about the structural changes proposed by the inquiry? Will those be taken up? There is much concern that deferring issues to the Minister’s NHS Next Stage Review—the Darzi review, as it is know—will impede rather than facilitate change.

All 30 medical schools in the UK supported uncoupling F1 and F2, with the proposal to incorporate F2 into core specialty training. Yet, those are on the “wait and see” list. Whether F1 and F2 are pre-registration or uncoupled probably matters little in the long run, but there must be guaranteed foundation posts for those who have qualified for them to stand a chance of being registered; if they are not potentially registerable they would have failed their final exams. Post-registration, the core broad-base training welcomed in the e-consultation, ensures that doctors enter different specialties with a solid foundation of consolidated skills assessed under supervision before they focus on specific training, whether for general practice or for a hospital specialty. No training in medicine is ever wasted.

The failure to commit expeditiously to the five-year training programme for general practice is another missed opportunity. It has been strongly supported as vital to address the increasing co-morbidities experienced in ageing populations and the pressures of chronic disease management in the community. It could ensure that every doctor has training in end-of-life care to ensure that every patient has good symptom control and compassionate psycho-social care to enhance the quality of the days or hours until death comes.

We are told that the recommendation that NHS Medical Education England be created will be considered in the NHS Next Stage Review. NHS:MEE is fundamental for success. That includes ring-fencing training budgets to help to ensure that training is not compromised. If training is compromised, the end product is also compromised—in this case patient care. Training budgets must be used for precisely that: training. It is not a pot to raid to cover inefficient management and financial deficits from high staff sickness rates and so on. Oversight and scrutiny by NHS:MEE will prevent future raids.

I hope that the Minister will not lose his nerve under pressure and will have the courage to do the right thing; listen to the whole profession and adopt the Tooke report recommendations in full as they stand.



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5.04 pm

Baroness Cumberlege: My Lords, it was very sad that we were jumped on by Northern Rock. I congratulate the noble Lord, Lord Patel, on his perseverance in getting this debate and on his clear and compelling introduction.

Sir John Tooke and his panel have been likened to a team who arrive at the scene of a terrible air crash. There are bodies, blood and wreckage everywhere and the air is filled with rumour, speculation and blame. How did this awful thing happen and who is at fault? So wrote Richard Smith, former editor of the BMJ in November last year. It is tempting to launch a blistering attack on the Government and to lay the blame, especially from these opposition Benches; but, like the noble Lord, Lord Turnberg, I resist. We have a different ministerial team and I take heart from the fact that in this House prior to becoming a Minister—and a politician—the noble Lord, Lord Darzi, in his professorial role has been living through the consequences of MTAS.

Through my company, Cumberlege Connections—I declare that interest and that with the medical school at Sussex University—I am in close contact with at least 80 specialist registrars once a month. I am so impressed by them—their commitment, their intelligence and their dedication to the careers that they have chosen. In the first round of MTAS, they had to choose between geography and specialty. If they wanted to stay close to their partner and family, they had to sacrifice their chosen specialty. If they wanted to train in their chosen specialty they had to accept a post as potentially as far away as Scotland from Cornwall. In addition, when they applied for a job they were not allowed to submit a CV. Professors, when interviewing those who had been shortlisted, had no means of knowing who were the brilliant and who were the also-rans.


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