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In the London Deanery alone, 18,500 candidates were interviewed over four months. It was a Herculean task. In Birmingham, the professors gave up and walked out. In round two, applicants encountered new, unforeseen rules. Having declined a job offer in round one, they were not allowed to apply in round two. An undertaking was given that those doctors who had completed their first year of specialist training—ST1s and ST2s—would qualify automatically for a “run through” training position. This meant that they were guaranteed training posts until they applied for a consultant position, known as the golden ticket. Those who had been forced into locum posts or who missed the earlier round and decided to improve their chances by changing their specialty were refused interviews. Is it any wonder that so many of these young doctors left the country to go to Australia and New Zealand?

The next round is just beginning. Jobs unfilled in February are being advertised nationally. Anyone can apply but what these young doctors want to know is whether preference is being given to the ST2s again. An application form is online but has not yet been released. When will it be available? How will the next round of applications be structured? What rules will apply? Will it all be changed again next year?



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At the present time there is a two-tier system of injustice. The ST1s and ST2s are virtually guaranteed a job in their chosen field whereas those who, through no fault of their own, have missed out in earlier rounds are now unemployed. Others have taken temporary posts or have found themselves working in the wrong speciality for fear of being unemployed last year. There is another large group of doctors who are working miles away from their families because they chose specialty over geography. There are a total of around 23,000 junior doctors chasing 8,900 training posts. What does the future hold for the unsuccessful but highly and expensively trained young men and women? Perhaps the Minister could tell us. In the words of Dr Bryony Eccles, who wrote to me this week:

How right she is. What a shambles.

I now want to address the Tooke report's 47th recommendation and the Government's response to the setting up of Medical Education England. I have long believed in devolving decisions to the lowest sensible level. My report on community nursing was not called Neighbourhood Nursing for nothing. When I chaired social services, my county pioneered patch-based social work. I strongly believe that if services are to make sense to local people, local decision-making is an imperative. Many of the Government’s mistakes have been made because they do not trust local people, and it has taken them 10 years to see the light. Devolving workforce education and training to SHAs has been a glimmer of their recent conversion.

Some strategic health authorities are taking their responsibilities really seriously. In London, they are thinking ahead: what skills will doctors working in a polyclinic need? They are, I understand, colloquially called “Darzi docs”, and while that is a relevant initiative for London it is perhaps not so relevant to the Lake District, where polyclinics and Darzi docs may not be much in evidence. Others may say, “But medicine is a national resource and doctors may work in any part of the country. Who knows whether a Darzi doc will be needed one day in Cumbria or Westmoreland?”. They will also say, “Of course, SHAs will want to keep their major budget, which they have found so useful to bail out trusts in financial deficit in the past”, as the noble Baroness, Lady Finlay, has just said. A central body will have ring-fenced money—but I have a word of caution for your Lordships. It is a little na├»ve to think that money held centrally would not be top-sliced. In central hands, it can be not so much top-sliced as available.

For SHAs that are now in charge of planning the total workforce, it makes sense to see how the service can be provided using all the skills within the different professions. That, of course, raises another fear among doctors; of dumbing down. Are we to see nurses as mini-doctors, and what is the role of the doctor anyhow? Sir John is right: that needs to be clearly defined.

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Incidentally, I hope to help by chairing a Royal College of Physicians’ working party to look at the future of society and the doctor’s role within it.

In my mind, there is no question either that a central body for medical education is necessary to oversee, scrutinize and review, or that the SHAs and their deaneries have a part to play. The clever trick will be to ensure coherence between local demand, the characteristics of the local area and the national body. I have been impressed by the model of NHS Education South Central, or NESC, which was established as an integrated organisation. It manages and delivers both postgraduate medical education and non-medical education and training, and it holds budgets amounting to £264 million. Its mission is to provide high-quality and relevant education and training, where and when it is needed. It must meet the changing needs of the NHS and the workforce, which in turn must lead to measurable improvements in patient care. It has the advantage of being an arm’s length organisation, while at the same time being sensitive to local priorities.

The Minister, in his report, Our NHS, our future, set out his emerging vision to develop a world-class NHS, focused on improving the quality of care based on patients having control and choice, and on there being local accountability. A regional body such as NESC is strategically placed to enable such a vision to happen. It is similar in size to NHS Education for Scotland; the arrangement works well in Scotland, and the development of NESC shows how such an organisation can be effective in England. I hope that the Minister will study that structure and use it as a pilot. It appears to me to provide the missing link between local and national. It is well led, it works and it has already made a difference. It is impressive—and necessary.

5.13 pm

Lord Walton of Detchant: My Lords, the medical profession at large owes a substantial debt of gratitude to my noble friend Lord Patel for initiating this debate, just as it owes a great debt of gratitude to Sir John Tooke and his colleagues for producing such a comprehensive, compelling and persuasive report. It is good to know that more than half of the recommendations in the Tooke report have already been accepted by the Government. I look forward to hearing from the Minister about how those recommendations are to be implemented and, above all, the speed with which they will be achieved.

Many speakers mentioned the appalling situation that arose in 2007 when a mechanism which was designed with the best of intentions turned out to be totally unfit for purpose and resulted in grave injustices. I refer to the well publicised case of a highly qualified young lady doctor looking for training who applied for 79 posts and was unsuccessful in obtaining any. There were many other examples of the best qualified young doctors failing to obtain an interview. Are there mechanisms in place to improve the process this year because, as a result of last year’s disaster, some of the doctors most needed by the National Health Service to maintain a high standard of practice in the future emigrated due to their failure to obtain an appropriate post?



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I have four questions for the Minister with regard to the situation this year. First, does he have clear figures on the number of specialist registrar posts that will be available for those emerging from foundation years one and two? I say in passing that the one recommendation of the Tooke report of which I am not totally in favour is for these two years to be disaggregated. It is sensible to treat years one and two as a cohesive whole, and that has worked well on the whole.

Has the Minister any evidence about the number of individuals who will emerge from those foundation years and apply for specialist registrar appointments in all branches of medicine? Can he indicate the number of specialist training posts that will be available for such specialist registrars? Recent press reports suggest that the Government have funded an additional 300 posts. That may be a useful contribution but, according to the evidence of the profession, it will certainly come nowhere near meeting the need.

Secondly, there is a proud history in this country of collaboration between the universities on the one hand and the National Health Service on the other. For many years the training offered in the National Health Service has been funded by SIFT—the Service Increment for Teaching. Funds have been specifically allocated under that heading to support education and training in NHS hospitals and, to a degree, in the community. Can the Minister confirm that, contrary to recent reports, the education and training funds that were raided when SIFT was no longer ring-fenced by certain cash-strapped health authorities to provide services as opposed to training will again be ring-fenced, because that is essential if education is to continue to be provided?

My third question concerns the future of academic medicine. For many years there was a proud tradition that individuals holding clinical lectureships, clinical training posts and even clinical research posts were given honorary registrar or senior registrar status in the NHS. In order to maintain and enhance the future of clinical academic medicine, will the Minister assure us that individuals holding these appointments, including those who take time out to undertake research leading to a PhD or who undertake a period of training overseas, whether in an academic appointment or in a third-world country, will not be disadvantaged by that experience when they return and will continue as specialist registrars or honorary specialist registrars before applying for a senior post either in the universities or as consultants in the NHS?

Fourthly, as regards overseas doctors, it is absolutely right that we should give priority to UK-trained doctors when they apply for specialist training posts. Of course, one has to recognise that doctors from the European Union have the absolute right to compete for all those posts on an equal footing with UK-trained doctors. But in my former department of neurology in Newcastle upon Tyne, I regularly accepted for training young doctors from India, Australia, Canada, the USA and other parts of the old Commonwealth. They got a useful training experience and many subsequently became leaders of the profession on returning to the countries from which they came. Some were self-funding on travelling fellowships. Others, particularly from the

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Indian subcontinent and recommended by colleagues in whose ability I had total faith, had to compete for the appointments as senior house officers and registrars. Is there a mechanism for that kind of sponsorship arrangement, whereby highly trained immigrants to this country, sponsored by host departments in the country from which they came, may still have the opportunity to train in the NHS? I believe that is crucial to the future.

I turn finally to the governance of medical education. As chairman of the education committee of the GMC, and subsequently as president of the GMC, I was much involved in that process. As the noble Lord, Lord Turnberg, has made clear, the Medical Act 1983, following the report of the Merrison committee, imposed upon the education committee of the GMC—not upon the General Medical Council itself—the authority to oversee standards of medical education, to promote high standards of medical education and to co-ordinate all stages of medical education. There was some conflict with the royal colleges and specialist training societies, who took the view that they were responsible for postgraduate education and training, but in the end that was satisfactorily resolved. The education committee of the GMC contained within its membership, elected from the very large council at that time, many people who had academic posts in the universities and many people who were consultants in the NHS with wide experience in training young doctors in all specialties.

Admittedly, the mechanism so established of the joint committee on general professional training and the joint committee on higher medical training became, for a time, complex and somewhat cumbersome. The Government replaced it with the Postgraduate Medical Education and Training Board which, despite the best efforts of its members, has turned out to be ineffective. Many complaints have arisen about the way in which it has operated and about delays in accepting specialist registration. May I take it that, if Medical Education England is to be created, as the Tooke report suggests—and that is a mechanism that I think is greatly to be commended—the resulting mechanism will be with the education committee of the General Medical Council and not with the council itself? To my knowledge, that particular provision of the Medical Act 1983 has never been revoked.

For that reason, it is crucial that this education body should contain within its membership not only substantial numbers of medical educators, but also lay people who have an experience of education in the broad and also non-doctors who are interested in the education of other healthcare professionals. It must not be a small body limited by GMC membership, but must have a much wider remit. I would welcome that greatly because, provided that the committee has the appropriate range of expertise within its membership, we could be sure that the future control and governance of medical education would be satisfactory. I hope that the Government will support that recommendation.

5.24 pm

Baroness Emerton: My Lords, I, too, thank my noble friend Lord Patel for raising this debate on the recommendations made in the final report on modernising

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medical careers. I congratulate Professor Tooke, not only on the recommendations, but on the speed with which he completed the work, against the background of so much unhappiness in the medical professions, so ably described by the noble Lord, Lord Patel, in his opening remarks, and by many others who followed.

Such a debate is also timely given the current review of the NHS under the direction of the noble Lord, Lord Darzi. The title of the report, Aspiring to Excellence, indicates a desire to deliver a service of excellence with high quality care. The noble Lord, Lord Turnberg, will not be surprised that I do not agree with him on the definition of the doctor being first and others later. The report’s recommendation 5 states:

One hopes that that will be taken into account in the final report of the current review of the National Health Service, for if there is clarity of each healthcare professional’s role with the parameters of that role identified, together with the authority and accountability, the multi-professional teams can truly work towards the aspiration of excellence in order that the highest quality of care to patients can be delivered.

The Chief Nursing Officer has produced a report on modernising careers for nursing, and the proposals for flexible career frameworks have been welcomed, but they will, like medicine, require post-registration education and training to support the frameworks. However, the all-important question will be the same as that of Professor Tooke; will there be sufficient funding and how will the funding be protected? This is an opportunity to tackle this vexing question in the context of the NHS review. Currently, there is no evidence of equality. There are 120,000 registered nurses undertaking part-time post-registration training, the budget for which is £120 million, which equates to £1,000 per student. The medical postgraduate budget is £1.6 billion for 40,000 students, which equates to £40,000 per student. Obviously, one would expect there to be a difference; but is a ratio of 1:40 fair?

The organisation and mechanisms for allotting postgraduate and post-registration funding and study leave will, I hope, be addressed in the context of the review. Professor Tooke also raised the problems of clinical placements for doctors, and the same problems arise for the nursing profession and other allied care professions. There is no doubt that the correlation of theory to practice is vital for all the professions, and there needs to be an agreed system of allocation of clinical placements fairly between them, with adequate supervision from clinical tutors.

I declare an interest, in that for some years I led an experimental course funded by the Wolfson Foundation, where the training for state registration was two years, with a tutor teaching the curriculum correlating theory to practice throughout, with the third year being spent as an intern staff nurse. Many went on to take senior positions in the profession. The research demonstrated

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that it was an excellent way of teaching, but the cost for the numbers involved was too much. When I was chairman of the nurses regulating body, the UKCC, Project 2000 was developed, and it was always envisaged that a preceptor year would be introduced; that is an intern year. Again, because of cost, this was dropped. It is being discussed again, and I hope that the Minister will consider the inclusion of a preceptor year for all nurses, midwives, health visitors and professions allied to medicine.

Research evidence points to the delivery of high quality nursing care being dependent on the right number of qualified competent nurses being available at the right time. However, as mentioned in the debate introduced by the noble Baroness, Lady Eccles, currently not all graduate nurses are emerging from their programme of education with even the basic competence required to deliver safe and high quality care. In that debate, I quoted that, in a recent visit, I found that 250 applicants had applied for a staff nurse post, who were all recently trained at postgraduate level, and only two out of 250 gained 100 per cent in a simple numeracy test, demonstrating that only two were safe to do a drug round. All healthcare professional education at pregraduate and postgraduate levels requires clear lines of accountability and authority for commissioning with the universities, to include the costs of supervision for clinical placements.

The delivery of safe and high quality care to patients by doctors, nurses, midwives and other allied healthcare professionals is dependent on a correlation of theory and practice. As the noble Baroness, Lady Cumberlege, spelt out, there is a need for much stonger links between the service requirements and the education providers, at clearly defined levels, with clear, protected, funding arrangements, and built-in monitoring programmes through accountability reviews.

My closing comments relate to Recommendation 47. If the intent of multiprofessional teams is to succeed—the need recognised by Professor Tooke—there will be a requirement for the Department of Health to take a holistic multiprofessional approach to modernising careers rather than considering individual professions in isolation. Problems and issues in nursing and allied healthcare professional careers are every bit as serious as medicine. I therefore feel that this recommendation needs careful consideration, especially relating to the first function the committee suggests—to ring-fence budgets. Surely, all education budgets should be ring-fenced.

The recommendations of Sir John's report, together with the Minister’s review, pave the way to meet the aspiration of excellence for the public, for patients and all healthcare professions.

5.31 pm

Baroness Neuberger: My Lords, I, too, congratulate the noble Lord, Lord Patel, on securing this debate; somewhat belatedly due to the Northern Rock disaster. Anyway, we have it now. I am delighted to be speaking from these Benches in this debate, as I have taken a keen interest in these issues since the disasters of last year. I declare an interest as a former lay member of the GMC, including briefly of its education committee.

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I am also vice president of the RCN, an honorary fellow of several medical royal colleges and a former member of the BMA Medical Ethics Committee. I also declare an interest as not being the parent of any doctors in training. I tried my best to persuade them to become doctors, but they have become a social worker and a teacher. I do not know what one does about that. I am also extremely grateful to the Council of Medical Schools, the Council of Deans of Health, the GMC, the BMA, Universities UK and NHS Employers for their briefings, as I am to the many people who wrote to me individually about these issues.

On 28 February, the Department of Health in England published its official response to Sir John Tooke’s inquiry. It agreed to implement many of the recommendations, but has, worryingly, delayed making a decision on several others. The MTAS debacle last year was, in my view, the lightning rod that brought to earth the simmering concerns of the medical profession about what it saw as attempts to deprofessionalise it. Sir John Tooke’s report, as we have heard many times this afternoon, struck a dramatic chord with the profession. Indeed, I understand that one doctor was moved to write to the panel members, congratulating them and telling them that one night, as he read it from cover to cover, he was moved to shout out all the time, “Yes, yes!” like that scene in “When Harry Met Sally”.

So when 10,000 doctors took to the streets a year ago next week, we might have expected the Government to reverse their policy of “constructive discomfort” for the medical profession so well described in Simon Stevens's 2002 article on Reform Strategies for the English NHS and done all that they could to re-engage the profession. After all, the medical establishment was in favour, as was the GMC, now overwhelmingly a lay members’ organisation. The GMC congratulated Sir John Tooke and his colleagues on the quality and insight of their report and welcomed the proposals on streamlining the regulation of medical education and training set out in Recommendation 30 of the report.


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