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The Tooke report argued for better co-ordination by bringing all stages—undergraduate, postgraduate and continuing practice—under one roof. That was also identified in the 2007 White Paper Trust, Assurance and Safety, where the Government recognised the gains to be secured from single oversight of education and training. The Tooke report recommended that the PMETB should be assimilated in a regulatory structure within the GMC that would oversee the continuum of undergraduate and postgraduate medical education and training, continuing professional development, quality assurance and enhancement and that this assimilation should occur as quickly as possible. More than 80 per cent of respondents to the consultation on the Tooke report were in favour of the assimilation of the PMETB into the GMC. The recommendation is supported also by the Chief Medical Officer, Sir Liam Donaldson. In his recent evidence to the House of Commons Health Select Committee he indicated that he had changed his mind from his previous position, which was for the GMC’s role in education to be taken over by PMETB. It is to be hoped that the Government might find time to bring forward the necessary legislation
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The GMC believes that the assimilation of PMETB into the GMC should take place as soon as is practicable. It is beginning work with UK health departments, PMETB and other parties to achieve this smoothly and efficiently. I would very much like to hear the Minister comment on the pace of this particular change, particularly given the concern about employers’ involvement expressed by the NHS Employers.
Regulation is a key issue in postgraduate medical education and training. Regulation is a dynamic process; it should not stand still. It has to be scrutinised, challenged and improved to ensure that it takes account of our changing society and the changing healthcare environment. To be effective, regulation has to command the confidence and support of all those with an interest in ensuring the safety and quality of healthcare—patients and the public, doctors, the NHS and other healthcare providers, and the medical schools and medical royal colleges.
The Government had the ideal opportunity to do that in their response to the inquiry's recommendations, but, worryingly, instead of following the advice of the medical profession and accepting all the recommendations that were made—which were widely welcomed outside the medical profession, as well—it seems that much that was welcomed by the profession and others has been sidelined by the department. This raises profound concerns that the key structural changes that were recommended may have been placed into the “too difficult” box in perpetuity.
There are no timelines on the proposed reforms to Foundation to integrate the first year more closely with the undergraduate programme. Nor is there any mention of the creation of core programmes which would provide the necessary broad-based beginnings, as well as providing the NHS with the flexibility for retraining it will require as technological advances, which emerge at amazing rapidity, change medical practice. Until the initial stages of reform to the structure are sorted out and implemented, it will not be possible to build on them to create the later stages of higher specialist training. Instead, some recommendations, the easiest, seem to have been accepted unconditionally, while the others appear to have been swept into the long grass. I hope that the Minister will be able to give this House some reassurance on this.
The Government’s response was that,
- “very careful consideration was required to ensure that decisions are informed by evidence and evaluation”.
Yet it might be worth asking how often consultations achieve a total of as many as 1,440 responses, of which only 4 per cent express any measure of disagreement with the recommendations. Universities UK emphasised
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I do not have much time left and I very much want to hear what the Minister can tell us. But it seems me that the Tooke report’s proposal for the creation, in the first instance, of NHS Medical Education England, to oversee training, accepting that this would be extended to other professions in the near future, would effectively take oversight away from the workforce planning area of the Department of Health and put it back into the hands of the medical profession. We know that such a move would regain the faith of doctors and that doctors are very pleased with the recommendation to ring-fence the budget for medical education and training.
Of course doctors can be precious as a professional group—as can all professions, rabbis included. But the situation with MTAS has been serious and we heard the noble Baroness, Lady Cumberlege, make that very clear in one of her examples. Reassurance is what is needed now. All medical bodies believe that both of those changes are essential if we are to ensure high quality medical training in the future. For several years now trusts have been raiding funding set aside for professional education and training to meet the deficits, and others have made that point.
It is important that funding for training is ring-fenced at Trust level to ensure that doctors are trained to their full potential. The Government have indicated that a decision on this will be taken alongside the Minister’s Next Stage Review, due to report in June this year. But like the noble Baroness, Lady Finlay, I believe that there is no good reason why that decision could not be taken now. It is not something that fits particularly with the review the noble Lord is conducting, and indeed, it would be good to get one major issue off the agenda for that review at this time. This new body needs independence from the Department of Health's direct influence, although with accountability to the Chief Medical Officer, as is the case in the other three home countries. We support this suggestion as a means of ensuring equity of provision for patients across the UK, giving, as it does, a coherent, co-ordinated approach to medical education. Recent history has demonstrated that such oversight and scrutiny is vital. I hope the Minister will be able to confirm that he has listened to his professional colleagues and others and that it is his intention to set up in the very near future a national body charged with the oversight and scrutiny of medical education, to be extended to the other healthcare professions as soon as possible.
5.41 pm
Earl Howe: My Lords, it is to the credit of the Government that they should have responded so quickly to Sir John Tooke's excellent report on postgraduate
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For example, it is a great pity that the Government do not regard it as possible to begin the process of merging PMETB with the GMC until 2010. Perhaps the Minister could tell us why this should be. I understand that the change could be effected by statutory instrument. Similarly, it is not clear why we should have to wait until 2011 before the recommendations for longer training times for GPs should be taken forward. That recommendation arose in large measure from the concerns relating to the impact of the European working time directive, about which I shall say more in a moment. But on a general level, without “urgent action” to reform postgraduate medical training, as Sir John himself has said, we cannot plan effectively for the future.
Nowhere is the need for action more pressing than on the one recommendation of Sir John's mentioned by all noble Lords—the creation of NHS Medical Education England. Of course proper consultation on this is essential. I completely take the Government's point that we need to agree on precisely what the remit of this new body should be and to whom it should be accountable. Moving responsibility for a large amount of public money away from central government and into a quango is never something that should be done lightly. At the same time it is quite clear why the profession has spoken with a united voice on the matter. It wants to regain ownership of the principles underpinning postgraduate medical training; it wants the funding to be safeguarded; and it wants to make sure that this area of policy is properly co-ordinated—something that the department has shown itself signally unable to do. Yet the Government have equivocated.
We are asked to be patient so that the noble Lord's Next Stage review of the NHS can add its own slant to the debate, supposedly so that Sir John's ideas can be considered in the context of the future needs of the service. That argument seems to me exceedingly weak. The proposed functions of MEE are not affected by future patterns of service delivery. Accountability for those functions does not need to lie with government. What Ministers need to remember is that the confidence of the profession has taken a terrible knock. If the Government were to come out and say that they agree in principle with the idea of NHS Medical Education England and will work with the profession urgently to put together a working plan for it, that would do more than anything else to restore confidence in the training system on the part of doctors. I am talking, of course, about long-term confidence.
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This year, we are likely to experience if anything even more serious problems in postgraduate training than we did last year. It is therefore extraordinary that, even after the publication of Sir John’s report, accountability in the department for this area of policy should still be blurred. The very serious failings on the part of the department, which were exposed by Sir John, revolved around weak governance and ambiguous accountability structures. Yet we know from recent answers that responsibility for this area of policy is still currently shared between two people: the CMO and the head of human resources. That divided accountability does not, on the face of it, sound sensible.
I return to the subject of the European working time directive. In his report, Sir John says:
“The effect of the current interpretation in UK legislation impedes the acquisition of experience, of confidence and the ability to shoulder responsibility ... few other professions in the UK, nor medical career structures in Europe embrace the Directive in the same way that it has been embraced in the UK”.
Sir John was concerned here with the need to see whether, in his words,
It would be helpful to hear from the Minister whether he believes this is feasible.
In 2004, Ministers gave a commitment that they would seek to amend the working time directive in the wake of the SiMAP and Jaeger judgments. Attempts were made in 2005-06 to do this, but nothing tangible appears to have happened since. The matter is of considerable importance, as an amendment could make a huge difference to the timing of rest breaks, and could mean that inactive times spent on call in the workplace would not be counted as working time. We know too that it is open to Ministers to negotiate to postpone the effect of the directive until 2012; yet apparently they do not now propose to do so. Why is that?
The Minister will know of the grave and widely held anxieties about the adequacy of medical training hours, particularly in surgery. I hesitate to refer to surgery in his presence, but if he reads the Royal College of Surgeons’ bulletin, he will be aware of the catastrophic effect that the directive is already having on both the quantity and the quality of surgical training and the clear perception among the profession that patient care is suffering. Almost all surgeons believe that the old on-call system provided vastly superior training, and that the new shift system damages both the continuity of care and doctors’ quality of life, which ironically is the very opposite of what the directive was supposed to achieve. To gain skill in a craft specialty requires practice, practice and more practice. Surgeons of the Minister’s generation could expect to have about 35,000 hours of career training. Surgeons currently have about 8,000. When the new regulations come in, they will have about 6,000. Does the Minister think that that sort of level is adequate?
This year, trainees in some disciplines are facing competition ratios in excess of 10:1. The lives and the aspirations of many of our finest and most altruistic graduates look set to be devastated—a huge loss to the
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5.49 pm
The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): My Lords, I congratulate the noble Lord, Lord Patel, on his success in securing this important debate on the recommendations of the Tooke report on modernising medical careers. It has been a lively and informative debate, as I expected, and I thank all noble Lords for their very valuable contributions. I will not have time to answer most of the questions that have been asked but I will try my best, and I ask noble Lords to forgive me if I do not cover all of them. I will certainly deal with them in writing.
As Sir John’s report makes clear, trainee doctors pre-MMC faced considerable uncertainties in a system that was neither particularly transparent nor fair. For doctors in senior house officer posts there was a variation in training content and standards. There were no clear career pathways and ill-defined educational goals. There was also no time limit to the SHO grade and a poor distinction between training and service posts. SHOs had in many ways become the lost tribe. Let us be clear about the effects of this old system referred to today: it was not good for patients or for the NHS and it was certainly not good for the junior doctors themselves.
Modernising medical careers was introduced to address those problems. For the first time, we introduced national standards for training—consistent national standards. There is now a structured and approved curriculum to allow standardised, rigorous and competency-based assessments. Selections are now transparent and standardised. Certainly the principles of MMC were right and enjoyed wide-ranging professional support. Unfortunately, as I have alluded to in this House before, the translation of those principles was too rapid through a flawed national IT system. That caused a great deal of trauma for trainees, for their families, and, speaking from experience, for their trainers as well. The then Secretary of State apologised for this and we have been working over the past year to rectify the problems. This is absolutely a case where we should concentrate on getting it right rather than doing it quickly.
Postgraduate medical education and training must reflect the needs of a service that aims to deliver the world-class care to which we aspire. It is crucial that training post numbers meet predicted future workforce requirements, but workforce planning has become a difficult science in an age of a flexible and responsive health service. The medical workforce is now a global
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Last year, around half of all applications for specialty training came from the international medical graduates—a point alluded to by the noble Lord, Lord Walton. The department has recently launched a consultation on the guidance that would give preference to UK and European Economic Area applicants when recruiting to speciality training. I reassure the noble Lord that we are not talking about the NHS service posts for which international medical graduates are still free to apply. As the noble Lord said, doctors from abroad have made, and will continue to make, a valuable contribution to the NHS in this way.
The Government have now given their formal response to Sir John’s final report and recommendations. I am pleased that our response has been broadly welcomed. Sir John’s report marks a significant step forward in ensuring that excellence and high achievement remain at the heart of medical education and training in this country. While not all Sir John’s recommendations are the direct responsibility of the department, we have accepted the overwhelming majority. Of 47 recommendations, there were perhaps three areas which gave rise to particular comment and discussion, as some noble Lords have alluded to today.
The first is the merger of the Postgraduate Medical Education and Training Board with the General Medical Council. The issue raised by Sir John was not about PMETB’s contribution—he acknowledges that it has brought about many key improvements—but about the merger in the context of the continuity of training between undergraduate and postgraduate training. We agree with Sir John that the merger should take place as soon as possible. This requires a good deal of legal work, as the noble Earl, Lord Howe, will agree. We will give it our best to get it through as quickly as we can.
Secondly, there was also a proposal to change the structure of the foundation programme. The noble Baroness, Lady Finlay, referred to the separation of F1 and F2. We have consensus advice on that. Sir John hinged his recommendation on legal advice which suggests that F1 and F2 need to be separated to provide a legal guarantee of employment to UK graduates, a noble cause that I agree with. However, our advice is that Sir John’s legal advice is flawed. Separating F1 and F2 will not achieve Sir John’s aims. Therefore, it is sensible that we revisit this recommendation and we hope to have a debate about this and the foundation programme in early summer.
The noble Lord, Lord Patel, raised an interesting point about why universities do not play a larger role in postgraduate medical education and training. Of course, it is crucial that universities and postgraduate deaneries continue to work together within medical education. It is interesting to note that in some countries outside the UK, universities have a greater role in postgraduate education. The UK has a clear distinction
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The third area of great interest and discussion is the creation of a single body to oversee doctors’ training; namely, the NHS Medical Education England. While this suggestion has been welcomed by some within the medical profession—I can understand why, and noble Lords have referred to it today—Sir John has pointed to the need for clear governance and accountability structures. Perhaps I may remind the House that this was not in Sir John’s original discussion document published in October. It was in his final recommendation received in January. Given the importance of securing stability and the best possible solutions for future doctors, representatives have also reminded us of the need to proceed in a careful and evidence-based fashion, engaging with key stakeholders. That is particularly relevant when the budget under consideration for control of NHS Medical Education England would amount to about £1.6 billion of public money.
The proposals for the future of post-graduate medical education cannot be seen in isolation from the future of the health service more widely. The overarching aim of postgraduate medical education must be to train doctors to deliver excellent quality care. This chimes exactly with the goals of the NHS Next Stage Review, which I am leading. I can reassure the House that within the next three months, every attempt will be made to engage the profession through the NHS review, with Sir John in the final recommendations in relation to this area. It is to be published in July as the enabling report for the NHS Next Stage Review.
On other issues raised in this debate, first, I turn to the European working time directive and some of the challenges of training—certainly in areas of craft specialty, such as surgery. I agree that the number of hours have been reduced significantly. But what we did in the past may not necessarily be the best training. I certainly remember the days when I happened to be on call on a one-in-two basis and the nights when I slept in the operating theatre between cases. That is not the future of surgical training. We need to innovate the way in which we design our curriculum and the ways in which we can improve the quality of training. Yesterday, I attended a London deanery event where there was a significant discussion on the role of simulations, for example, in acquiring some of those skills. But the European working time directive is a law, which has been challenged in the past. However, I shall seek legal advice within the context of the NHS Next Stage Review.
The noble Lord, Lord Walton, raised the issue of clinical academics not being disadvantaged—again, an area close to my heart. I am sure the noble Lord will acknowledge the Government’s investment in
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