Select Committee on Health Third Report


Conclusions and recommendations


The gathering storm: 2003-2007

1.  The initial implementation of the Modernising Medical Careers (MMC) programme went relatively smoothly through the introduction of the new Foundation programme in 2005. As the Department prepared for the subsequent reform of Specialty Training, however, a number of warning signs indicated that all was not well. Concerns were raised both within and outside the Department about the inflexibility of the new training system, the inadequacy of the new national recruitment system, and a possible shortage of training posts. In spite of these issues, and heedless of the warnings of the Royal Colleges and of an official "Call for Delay" by the BMA, the Department pressed ahead with its plans for wider reform in 2007. We recommend that the Department ensures that it heeds such warnings in future. (Paragraph 39)

The 2007 crisis

2.  The introduction of the new Specialty Training arrangements in 2007 was disastrous. The failure to restrict overseas applicants and the manifest weakness of the national recruitment system made the collapse of confidence in the selection process inevitable. The design of the initial application forms was particularly inappropriate, failing to recognise doctors' key achievements and giving undue weight to "white space" questions. The short-listing process, critical to the futures of so many, therefore descended into little more than a creative writing exercise. Candidates and assessors alike were justifiably outraged by the sheer inadequacy of MTAS. (Paragraph 76)

3.  The period between February and August 2007 was characterised by unrelenting chaos and severe anxiety for thousands of junior doctors. The repeated changes to the recruitment system, a High Court challenge and the failure to protect the privacy of candidates' personal information ensured that the process was miserable for all the applicants involved. The Review Group, faced with an impossible situation, was unable to restore confidence in the recruitment system. The wave of resignations by senior medical leaders and series of emergency Ministerial statements which followed were both acutely embarrassing for the Government. The reputations of both the Department of Health and the leaders of the profession were severely diminished by the events of 2007. (Paragraph 77)

Fall-out: 2007-2008

4.  The independent Tooke Inquiry produced a perceptive and comprehensive analysis of the problems which affected the MMC programme and the causes of the 2007 crisis. The Secretary of State was right to quickly accept many of the Inquiry's recommendations for change and improvement. Decisions on the Inquiry's most significant and far-reaching proposals, however, were deferred. We recommend that the Department publish an updated response to the Tooke Inquiry, setting out its final decisions on all 47 recommendations, immediately after the Darzi review has been published. (Paragraph 104)

The medical workforce

The Foundation Programme

5.  The implementation of the new two-year Foundation programme did not suffer from the errors which marked that of specialty training. We heard evidence of significant benefits from the new schemes as well as a number of continuing problems. It is too early to judge whether the new Foundation programme has proved an overall success and we therefore recommend that the current two-year scheme is retained while a full evaluation of its impact is carried out in due course. (Paragraph 122)

6.  We note the Tooke Inquiry's concern that the current arrangements for the Foundation programme are not legally sound. We recommend that the Department address this question as a matter of urgency and, if necessary, consider introducing legislation to safeguard the legality of the current two-year programme. Only if no lawful alternative can be found should the Tooke Review's recommendation to split the Foundation programme be accepted. (Paragraph 123)

Specialty training

7.  It is clear that the creation of run-through posts across all specialties in 2007 was a serious error. The rigidity of many 2007 run-through schemes contradicted MMC's principles of increasing flexibility and providing a broad-based beginning to specialty training. Run-through training was especially unsuited to the needs of a number of large specialties, include general medicine and surgery. Such specialties have already un-coupled their run-through programmes for 2008 and we support this development. (Paragraph 136)

8.  We do not agree, however, with the Tooke Review's recommendation that un-coupling should take place across the board. It is clear that the run-through model has advantages for some specialty areas and may help to attract doctors to traditional shortage specialties. It is also evident that flexibility can be built into run-through schemes, as the case of Paediatrics has demonstrated. Most persuasively, it was the imposition of a "one size fits all" structure which caused such problems in 2007. Forcing all specialties to un-couple would risk repeating this mistake. We therefore recommend that the "mixed economy" of specialist training structures introduced in 2008 be retained and that any future changes be supported and led by the specialties concerned. We further recommend that specialties be permitted to offer a mixture of run-through and un-coupled training posts where this best meets their needs. (Paragraph 137)

Academic medicine

9.  Academic medicine is a vital part of the training system which appeared to be badly neglected and damaged by the MMC reforms. Research opportunities should be accessible to all doctors in training, while dedicated academic training posts must be made more attractive. To this end, we echo the Tooke Review's recommendations that integrated training schemes be developed and that doctors be allowed to transfer to and from the clinical training system in order to conduct research. We further recommend that the number of centrally funded academic training posts be increased and that the academic training system run parallel to that for mainstream clinical training. (Paragraph 143)

Recruitment and selection

10.  The crisis of 2007 was caused in large part by the failure of the recruitment system for specialty training. In response, the Department has handed control of recruitment back to the Postgraduate Deaneries who largely reverted to traditional selection processes in 2008. We support this move and recommend that the Department devolve all responsibility for recruitment to Deaneries as soon as possible, including allowing them to set their own timetables. Deaneries should in turn do more to involve local employers and individual consultants in the design and implementation of selection systems. (Paragraph 154)

11.  The delegation of responsibility for recruitment to regional and local organisations should not prevent Deaneries from organising national selection processes when this approach best meets the needs of particular specialties. Nor should it stop Deaneries from using centralised infrastructure, including IT software, where they consider it necessary to improve recruitment and when adequate piloting has taken place. (Paragraph 155)

12.  The imposition of a single start date for all training programmes in 2007 was a serious error which reduced the flexibility of the recruitment system and had the potential to compromise patient safety. We recognise that a staged approach to recruitment has been introduced in 2008 and we support this move. We recommend that a staged recruitment process, with at least three substantial recruitment rounds per year, be established in the future. (Paragraph 156)

13.  The serious problems experienced in 2007 should not prevent Deaneries from exploring future changes to selection methods. It is vital, however, that such changes are carefully tested and evaluated prior to implementation. We note that the MMC Programme Board has established a pilot programme for new selection methods and we support this approach. In particular, a recognised national test or exam, also referred to as a national "metric", has the potential to increase the objectivity of short-listing and to make recruitment more efficient. We recommend that the Programme Board consider the case for introducing a national "metric" as a matter of priority. (Paragraph 157)

Staff Grade and Associate Specialist posts

14.  Reforming the Staff Grade and Associate Specialist (SAS) grades was one of the original aspirations of the MMC programme. To this end, the establishment of a new way of achieving specialist registration, the CESR route, is a welcome development. Wider progress, however, has been limited and access to training and CPD remains patchy. In particular, the failure to implement a "credentialing" system has prevented training and experience gained by SAS doctors from being formally recognised, meaning that SAS posts continue to be regarded as inferior to traditional training posts. The introduction of a new contract for SAS doctors has also been delayed, further hampering progress. We recommend that the introduction of this new contract be given a high priority by the Department. (Paragraph 171)

15.  The failure to substantially reform the SAS grade is highly disappointing, in particular because SAS posts have the potential to provide an attractive alternative to the formal training system. This potential must be realised in the future. Such a development would not only belatedly improve prospects for SAS doctors themselves, but would also reduce pressure on the traditional training system. In order to achieve this, we recommend that:

16.  These changes would ensure that the SAS grades become a recognised part of the training system, providing a genuine alternative to traditional training posts and giving doctors the opportunity to develop specific skills to a very high standard. This would significantly increase the overall flexibility of the training system and greatly reduce the need for temporary FTSTA posts. It would also ensure that the UK no longer has a two-tier medical workforce and that in future all doctors are either in training or fully trained. (Paragraph 173)

The consultant workforce

17.  The changes introduced by MMC also have significant implications for the consultant workforce. Shorter overall training times and increasing sub-specialisation both point to a need for greater differentiation within the consultant grade. We recommend that the Department of Health and the relevant medical Royal Colleges examine the introduction of a hierarchy within the consultant grade similar to that used in clinical academia. (Paragraph 184)

18.  We were surprised that the Secretary of State was not able to say whether he remains committed to the NHS Plan aspiration of moving from consultant-led to consultant-delivered care in the NHS. This is a critical question with fundamental implications for the size and nature of the consultant workforce, and for the role of the training system. We recommend the Department resolve this issue conclusively as part of the NHS Next Stage Review. The Department must recognise that moving away from its commitment to consultant-delivered care would have significant implications, potentially throwing medical workforce planning into still more confusion and further damaging relations with the medical profession. This decision should not be taken lightly. (Paragraph 185)

19.  We are also concerned by the apparent absence of any systematic basis for calculating postgraduate training numbers, something which should have been established as part of the MMC reforms. It is unclear whether the number of training posts is determined by the number of doctors seeking training, by the current capacity for training in the NHS, by the future clinical needs of the health service, or by some combination of these factors. We agree with Professor Tooke that "workforce policy objectives must be integrated with training and service objectives". We recommend that the Department of Health, other relevant Government departments and the medical profession work together to establish and publish and regularly update a clear rationale for deciding future training numbers. (Paragraph 186)

The supply of doctors

20.  The Committee supports the Government's long-standing policy of increasing the self-sufficiency of the UK for its medical workforce. The welcome expansion to the number of doctors trained in the UK, which began in 1999, means that the number of non-EEA doctors entering the UK training system needs to be carefully managed. There is a widespread consensus that some restrictions to opportunities for non-EEA doctors are required in order to protect opportunities for UK graduates and the considerable investment of UK taxpayers. (Paragraph 228)

21.  The Government's handling of this important and sensitive issue has been appalling. Despite beginning its pursuit of self-sufficiency in 1999, the Government made no real attempt to change the status of non-EEA doctors until 2006. In particular, we found the CMO's excuse (outlined in para. 210) weak and unconvincing. Its efforts since then, involving the Department of Health, the Home Office and the Treasury, have been poorly planned, badly communicated and inadequately co-ordinated. This lack of co-ordination was amply demonstrated by the failure of the Department of Health and the Home Office to arrange for their respective Ministers to give evidence to the Committee on the same day. (Paragraph 229)

22.  Worst of all, the Government's many initiatives failed to prevent open access to training places for doctors from across the globe in both 2007 and 2008. Hundreds of UK graduates have been unable to continue with their training as a result. Tens of thousands of non-EEA doctors, meanwhile, have suffered inconsistent and undignified treatment. (Paragraph 230)

23.  The Department of Health proposes to use its guidance to employers to protect opportunities for UK graduates in future. The legality of the guidance remains in question, however, and will not be finally established until May 2008. The Department has already twice failed to enforce its guidance and is running a grave risk by relying on a single legal decision as the basis of its medical workforce policy. The Department's guidance does, however, represent a good way to restrict non-EEA applications while allowing overseas doctors to train in hard-to-fill specialties. Belatedly implementing its employment guidance therefore remains the best option for managing non-EEA doctors available to the Department, and we recommend that this be done immediately if the guidance's legality is upheld. (Paragraph 231)

24.  If the Department's guidance is not found to be lawful then the situation looks uncertain. Surprisingly, the Home Office made no suggestions for dealing with this eventuality. Recent Immigration Rules changes are limited in scope, contradict wider immigration policy and were acknowledged to be only a "stop gap" solution by the Home Office itself. Charging non-EEA doctors for postgraduate training would be impractical and the impact would be difficult to predict. Primary legislation by the Department of Health to enforce its guidance might prove effective and we therefore recommend that the Department look further into this option if the House of Lords' verdict is unfavourable. (Paragraph 232)

25.  The general move towards increased self-sufficiency should not prevent the NHS from offering a limited number of training opportunities to non-EEA doctors for international development purposes. We recommend that the Department of Health work with the Royal Colleges and Postgraduate Deaneries to increase the number of dedicated opportunities for doctors from the developing world to train in the NHS for fixed periods, provided that the necessary capacity can be found within the training system. (Paragraph 233)

Managing reform

26.  The management of the introduction of the MMC reforms by the Department of Health was inept. Key policy decisions and the processes for making and documenting them were ineffective and the medical profession, while frequently consulted, rarely influenced critical decisions. The governance systems for the programme were far too complicated, roles and responsibilities were ill-defined and lines of accountability were irrational and blurred. The arbitrary division of responsibilities between the Chief Medical Officer and the Workforce directorate was a fatal fault line within the management of the programme. (Paragraph 300)

27.  Project management for the introduction of changes to specialty training was equally poor. Much of the key planning for the 2007 changes took place in a mad scramble at the end of 2006. The "big bang" approach to the reforms and the failure to pilot any of the new arrangements proved particularly serious errors. Individual risks to the project were assessed, but problems were not made known to senior officials and there was no risk management of the project as a whole. As a result, the Department did not recognise the deficiencies within the programme and could not prevent implementation from going ahead prematurely. Project management decisions took little account of the needs and concerns of applicants themselves and communication with junior doctors was appalling. (Paragraph 301)

28.  The leadership shown by the Department of Health during this period was totally inadequate. Despite being the architect of the reforms, the Chief Medical Officer chose not to take on a clear leadership role and thus did not accept overall responsibility for the 2007 crisis. The confidence of the medical profession in the current CMO has been seriously damaged by MMC. Serious criticisms of the CMO have arisen in part because of the ambiguity of the role. We recommend that the job description be reviewed to define the role more accurately and then publicised to facilitate wider understanding of the CMO's duties and responsibilities. (Paragraph 302)

29.  The Department has already made a number of changes to programme management in light of the 2007 crisis and in response to the Tooke Inquiry. The governance systems for MMC have been simplified and improved and a single line of accountability established. The new MMC Programme Board appears to give the medical profession a more meaningful role in decision-making. And the Department has adopted a more conservative approach to implementing future reforms. (Paragraph 303)

30.  We welcome these changes. However, the constitution, independence and leadership of the MMC Programme Board remain too vague to provide assurance that it can develop and implement effective solutions to the challenges identified in this report. Members of the current Board themselves warned that the views of the profession are still not receiving adequate attention. We therefore recommend the following additional improvements to programme management for MMC by the Department of Health:

31.  In particular, these changes should help to ensure that the new Programme Board represents a genuine partnership between the Department of Health, the NHS and the medical profession. Such an approach is vital if the new Board is to avoid the weaknesses and pitfalls which affected the previous UK Strategy Group and the Douglas Review group. (Paragraph 305)

32.  We also recommend the following improvements, which the Department should apply to all future change programmes:

  • The Department should produce, and publish where appropriate, formal business cases to support major change projects. The expected costs and benefits of reforms should be clearly stated and, if possible, quantified.
  • Formal mechanisms for reviewing progress and risks across the whole of projects should be introduced. Regular reviews should inform decisions about whether timetables for the implementation of change are realistic.
  • The Permanent Secretary should monitor all substantial change programmes being conducted by the Department and should ensure that other senior officials are informed about the progress of key projects.
  • The Department must ensure that project management is adequately resourced and proper training provided. Managing major change projects should not be regarded as a task that can be tacked on to existing job roles.
  • Ministers and officials should set more realistic timescales for introducing major changes, and should be prepared to delay implementation if necessary. (Paragraph 306)

33.  The leaders of the medical profession itself were also ineffective, divided by factional interests and unable to speak with a coherent voice. The weak and tokenistic nature of the Academy of Medical Royal Colleges was exposed by the MMC crisis. We therefore recommend that the Royal Colleges review the role of the Academy of Medical Royal Colleges and consider replacing it with an executive body which has the authority to make decisions on behalf of all the Colleges. (Paragraph 307)

Organisational responsibilities

34.  There are a number of organisations involved in the design and delivery of medical training at local and national level. Although led by the Department of Health, the MMC programme placed an onus on all of these groups to work coherently and constructively. The causes of and responses to the crisis of 2007 provide clear evidence of widespread failure to co-ordinate thought and action. The Secretary of State attributed the breakdown of the MMC programme to a "systems failure". We agree. (Paragraph 344)

Commissioners and providers of training

35.  A number of measures are required to strengthen individual organisations, realign responsibilities and improve co-ordination. To this end, we recommend:

Regulation and inspection

36.  In order to improve the regulation and inspection of postgraduate training, we recommend that:

  • The amalgamation of the Postgraduate Medical Education and Training Board (PMETB) with the GMC be carried out in 2010 as planned. We advise the Department to proceed carefully with this reform and to recognise that merging the two regulators is a substantial and complex task which, if mishandled, could further destabilise the training system.
  • The relevant Royal Colleges and Specialist Associations be more closely involved in the quality assurance of the training system, drawing on their knowledge and experience in this area. Royal Colleges should work with PMETB, and subsequently the GMC, at a national level, and with Postgraduate Deaneries at a local level. (Paragraph 358)

The Department of Health

37.  Significant reform of the Department of Health's relationship with the medical training system is required. The Department became too involved in detailed implementation of MMC, and particularly of the MTAS recruitment system, losing sight in the process of the programme's strategic aims. Despite consulting frequently with medical groups, the Department also failed to adequately reflect the wishes of the profession in its plans, leading to a breakdown in this key relationship. We therefore recommend that the Department:

  • Establish a clear distinction between its policy-making activities and its support for the detailed implementation of policy;
  • Ensure that the MMC Programme Board, with representation from across the medical profession, remains the main forum for policy development and for approving plans for future changes to medical training;
  • Ensure that future consultation with the medical profession is more than a superficial exercise, that differences of opinion among consultees are reconciled where possible, and that the outcomes of consultation are clearly recorded; and
  • Reduce its direct involvement with policy implementation, ceding control to Postgraduate Deaneries, Royal Colleges and employers. (Paragraph 367)

NHS Medical Education England

38.  The Tooke Review's proposal to create a new arms-length body, NHS: MEE, to oversee medical training was strongly supported by the medical profession, but opposed by other key groups including Deaneries, SHAs and employers. NHS: MEE offers a number of potential benefits. First, a new body would provide a dedicated forum for improving medical training, free from external pressures and influences. Secondly, NHS: MEE would be able to work specifically on implementing many of the Tooke Review's other proposals. Thirdly, a ring-fenced budget would ensure that funding for medical training could not be used for other purposes. And finally, neither the Department of Health nor Strategic Health Authorities have proved themselves capable of leading the reform of the medical education system, as witnessed by the debacle of 2007. (Paragraph 381)

39.  The creation of NHS: MEE would also have a number of potential risks and disadvantages, however. Chief among these is that a body dedicated to medical education alone would cause medical workforce planning to become further isolated from wider health service planning. In addition, there are already numerous organisations involved with medical training, and it seems unlikely that creating another one would improve the coherence of the reform programme. Equally, if the Department is serious about devolving more responsibility to local organisations, then creating another national body would run counter to this ambition, as well as contradicting the Department's recent efforts to reduce the number of arm's-length bodies. Establishing a new organisation would be expensive and time-consuming and would potentially disrupt the implementation of future change. Finally, the theoretical independence of arm's-length bodies has often proved illusory in practice, at times allowing responsible Departments to abrogate responsibility for key issues without relinquishing ultimate control of policy. (Paragraph 382)

40.  In view of the scale of the 2007 crisis and the "systems failure" identified by the Secretary of State, there is a clear need for strong central co-ordination of future changes to medical training. The NHS: MEE as envisaged by the Tooke Review would be, however, a step too far. The MMC Programme Board already brings together the medical profession, the Department of Health and the NHS and can therefore assume this co-ordinating role, provided that it is swiftly strengthened and reconstituted as we propose. We therefore recommend that the Department does not create a new national body and focuses its attention instead on improving performance management and on supporting and reforming the Programme Board. (Paragraph 383)


 
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