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Modernising Medical Careers

Volume 458: debated on Monday 19 March 2007

(Urgent Question): To ask the Secretary of State for Health if she will make a statement on modernising medical careers.

In the written ministerial statements of 7 and 13 March, I set out the Department of Health’s plan for an immediate review of the first round of the new national recruitment and selection process for doctors in postgraduate training. As part of the modernising medical careers reforms of postgraduate medical training, new specialty training programmes will be introduced in August 2007.

To support implementation, a new national recruitment and selection process was introduced earlier this year, facilitated by the online medical training application services. That process sets out national recruitment and selection criteria and documentation and standards, thus replacing the countless local application processes that had previously been in place. The new arrangements were developed with the help of the medical royal colleges, trainee doctors and others. We will continue to work with them to ensure that trainee doctors are properly supported and fairly treated, and that the NHS is able to train and recruit the best doctors for the future.

Doctors have been applying for their preferred specialty training programme since 22 January and interviews have already begun. A large number of posts will not be filled in the first round and we have stressed to those interviewing in round 1 that they should not appoint unless they are absolutely satisfied with the calibre of candidates. It is clear that there have been concerns about the selection process, and that the process as a whole has created a high degree of insecurity amongst applicants, and, indeed, more widely in the profession. We therefore commissioned an immediate review to establish what had gone well and what needed to be improved to create greater confidence in the process.

The review is independent. It is being led by Professor Neil Douglas, vice-president of the Academy of Medical Royal Colleges and president of the Royal College of Physicians of Edinburgh. Members of the review group include representatives of the royal colleges, the British Medical Association, the four United Kingdom health Departments and employers. The review group has considered a wide range of evidence and listened carefully to the concerns of the profession and NHS employers. As a result, the review group has agreed, and the Department is implementing, immediate action, but the group will also continue its work throughout March.

The review group decided that round 1 should continue, with a number of changes to strengthen implementation at every level. All eligible applicants for level 3 and 4 specialty training will be guaranteed an interview for their first or second choice of training post. All applicants at ST1—specialty training level 1—who have not been shortlisted for any interviews will have their applications reviewed and may be offered an interview in round 1. If not, they will be offered career guidance and support to enter round 2. All applicants for ST2 who have not been shortlisted for interview will be offered a face-to-face review with a trained medical adviser to determine whether they meet the shortlisting criteria. Those who meet the criteria may also be offered an interview in round 1. Those who are not selected for interview will be offered support to enter round 2.

As a result of those changes, agreed and asked for by the review group, we expect more than 5,000 more doctors to be interviewed in round 1. We will also publish on the MMC and MTAS websites details of competition ratios by specialty and entry level to help applicants to consider their options for the second round, together with further advice and information for candidates. In addition, further significant changes will be made to the application form and the scoring system to improve selection in the second round. The revised approach will be tested and agreed with the royal colleges, junior doctors, postgraduate deans and employers. I am very grateful to Professor Douglas and his colleagues for their continuing work on the review group. We will publish the group's final report once it is completed.

Having dragged the Secretary of State here to make a statement, I am truly sorry that it fails to answer most of the key questions. Before I reach those questions, however, let me ask the right hon. Lady why neither she nor any other Labour Minister took the trouble on Saturday morning to join 12,000 junior doctors who were marching because of their concerns about the arrangements. My right hon. Friend the Leader of the Opposition and I went, and we listened. Had the Secretary of State come, she would know why the process has been such a shambles. Those junior doctors would have told her, from their personal experience, how years of training, clinical experience and academic achievement are being thrown away. They would have told her how they want real training, not a dumbed-down system in which they go down from 21,000 hours of training to only 6,000 hours. Why did the Secretary of State not just listen as junior doctors related their experiences?

Let me ask the Secretary of State these questions. First, how many applications have been made and how many training posts—real training posts—will actually be available in England? Secondly, will the review group that she talks about really be independent? Junior doctors need to know that they will have additional representatives on the review group. Indeed, will she appoint to the review group some of the consultants who have decided that they cannot proceed with the interview process as it is, so that they are represented on the review group, too? That would be advisable. Will she promise that the consultants who do the interviewing and shortlisting will be able to see the full application, not just parts of it, and that applicants can send a full CV to those who are doing the shortlisting?

The Department and the review group seem to be carrying on with an absurd scoring system. How can applicants’ clinical experience, academic achievements and references be treated as so unimportant in decisions on appointments to training posts? Who designed this crass process of application by anecdote rather than by achievement? I have an example of the scoring system before me. Has the Secretary of State ever read one? How can she justify relevant academic and research experience being worth a maximum of nine points out of 45? A PhD is worth one point, but composing a 150-word answer to a question about how the applicant has coped with stress is worth up to four points. Why do the Government not want the best training posts to go to the best doctors?

If it is clear that the system cannot deliver a fair outcome to thousands of highly qualified doctors, who will be left without good training posts, will the Secretary of State abandon the online system and revert to a conventional application and interview process? If it is deemed necessary by the review group, will she sanction extra training posts by reclassifying staff or trust-grade posts? Will she explicitly repeat the assurance that her former Minister, Lord Warner, gave just three months ago, that

“Doctors in training in England should consequently be pretty confident about securing a training post.”?

I have received hundreds of letters and e-mails from distressed and angry junior doctors, and 12,000 of them marched on Saturday. They are the future of our medical profession, and if we want a consultant-led specialist-delivered service in the future, we will need them. As it is, we risk losing them; we will lose some from the profession, and many others to Australia, Canada and elsewhere. Instead of sticking her head in the sand, will the Secretary of State promise doctors that modernising medical careers will be changed? Finally, will she just say sorry to them?

The hon. Gentleman referred to modernising medical careers as being dumbed-down, but it is nothing of the kind. Modernising medical careers is the outcome of years of work by the medical royal colleges—[Interruption.] I realise that Opposition Members are not in the least bit interested in the views of the medical royal colleges, but they play an important part in the training of our future doctors. Modernising medical careers is the outcome of work by the medical royal colleges, postgraduate deans, the British Medical Association, junior doctors and other key partners, including NHS employers across the country.

If the hon. Gentleman really thinks, as he seems to, that the new system is a disaster compared to the old, perhaps he needs to listen to Dr. Simon Eccles, a consultant at Homerton University hospital, and a former chairman—[Interruption.]

Order. I remind hon. Members that I agreed to a request from the Opposition Front-Bench spokesman for the Secretary of State to come to the Chamber and make a statement; she must be listened to.

Thank you, Mr. Speaker. Dr. Simon Eccles, the former chairman of the BMA junior doctors committee—[Interruption.] I said that he was the former chairman; the hon. Member for South Cambridgeshire (Mr. Lansley) should listen. Dr. Eccles said:

“We mustn’t forget how bad the old system was. I would be given four hundred and fifty CVs to shortlist for twelve places, so…my hospital would send out some four hundred and twenty rejection letters twice a year. Nobody protested and marched through the streets of Hackney because it only happened in a staggered process.”

He described how consultants would decide who to shortlist by simply dividing the piles into two and tossing a coin. One was the lucky pile, and would make the shortlist; the other one did not. That was scarcely—[Interruption.] I am simply quoting a former chairman of the BMA junior doctors committee, referring to some of the reasons why the old system needed replacing.

Both the BMA and the royal colleges have representatives of their junior doctor members on the review group. It has always been the case under the new system that when applications are submitted, the full CV and portfolio can be, and generally are, attached. There was confusion about the interpretation of guidance from the independent Postgraduate Medical Education and Training Board—PMETB—but I am glad to say that that guidance has been clarified. On the issue of MTAS, let me quote the independent PMETB:

“The substance of the application was determined by UK Postgraduate Deans…A similar system has been operating successfully in the USA for over half a century.”

The hon. Member for South Cambridgeshire, however, believes that we should go back to the old non-computerised system, under which junior doctors had to fill in a different application, with different information and using a different format, for every post around the country for which they wanted to apply. It was a completely absurd system.

On the question of numbers, there are just over 32,000 eligible applicants for the available places on training programmes—those figures apply to the UK as a whole—and the number of training posts is about 23,000. May I stress the fact that in many regions, as the postgraduate deans have confirmed, the system is working well, as it is for GP applicants? However, that is not the case everywhere, which is precisely why we set up the independent review group, why we brought in the Academy of Medical Royal Colleges and the BMA, and why every one of their recommendations has been accepted and is now being implemented. Finally, the hon. Gentleman is keen to ask us to spend even more money than we have already invested in the national health service, but he is not willing to vote for that extra investment. His party’s economic policy would mean cuts of billions of pounds in the national health service in one year alone.

Will my right hon. Friend confirm that both the MMC and the MTAS schemes were quality assessed and assured by experts in the field, which is why they were introduced? There was a process to bring them into line with current thinking, both in Europe and in this country.

My hon. Friend is right. A great deal of development work, quality assurance and so on went into the MTAS process and, more broadly, into modernising medical careers. There have been real problems this year, as I said in my statement, which is why we are working with the review group to sort them out and learn further lessons for round 2, and for next year.

Given the shambles, let me begin on a charitable note. The Government have clearly and openly acknowledged the shortcomings in the recruitment system, yet the BMA stated last year that the system was badly organised, did not draw out people’s expertise and would not cope with demand. Was it those shortcomings that the Government had in mind, and do they regret not agreeing with the BMA and failing to act earlier? Do they agree with the Royal College of Physicians that the system was rushed? Do they agree with the royal colleges that CVs should be taken into account, and that previous achievement should not be neglected in application forms? Where else does that happen? Do they agree with Jo Hilborne, chair of the BMA training committee, that junior doctors do receive careers guidance early enough? Do they regret their failure to listen, having scored such an unnecessary own goal?

Turning to other matters, why did the website crash, and how often did it crash? Was that another IT systems failure or another example of lack of anticipation by the Government? Who is responsible for it, and were any warnings given by IT providers? Does it not bode ill for “Connecting for Health”, if and when it is ever up and running? What assessment has been made of the likely destiny of unsuccessful applicants, even under the reformed system? Are 8,000 people to be rendered jobless in this country, and how would that affect future training programmes? How many people in total can expect hospital posts? Finally, on an issue of principle on which there is more than one perspective, do the Government agree with the royal colleges that it was a mistake to take statutory training responsibility away from them, and will that, as well as the fate of our young doctors, fall within the remit of Professor Douglas’s review?

On the last point, as I have already indicated, there has been widespread consultation and agreement about the need to introduce modernising medical careers. The problems that have arisen with implementation this year do not in any way undermine support for the principles and the organisation of MMC.

The hon. Gentleman speaks of introduction being rushed, but work on modernising medical careers and on its implementation has gone on since about 2003. That could not possibly be described as rushed. A great deal of work was done, especially in the second half of last year, to ensure that the systems were as robust as they could be, and that implementation was properly prepared for. What has happened is that, particularly in some parts of the country, and particularly for some specialties, there have been significantly more applications than was predicted. We certainly need, at an appropriate point, to learn the lessons from that for future years.

My understanding is that it is not true to say that the MTAS IT system crashed, although because of the volume of applications there were undoubtedly delays at various stages in accepting them. Although the hon. Member for Southport (Dr. Pugh) did not refer to it, I have heard others suggest that some candidates’ applications were lost in the process—and I understand that that too is untrue.

The hon. Gentleman asked whether there would be 8,000 jobless doctors. There will be nothing of the kind. Of the 32,300 eligible applicants, the vast majority—over 29,000—are already working in the NHS, on foundation programmes, in other training places or in other medical posts in the NHS. Those doctors will continue to be needed, so the shroud-waving about unemployed doctors is absurd.

The hon. Gentleman and the hon. Member for South Cambridgeshire need to recognise that because of our Government’s investment in the NHS, and because we are training more doctors—[Interruption.] The Opposition do not like to hear it, but because we are training more doctors than ever before, competition for consultant training places is greater than ever before. We need to ensure that those candidates, our future doctors, are given all the support they need as they go through an increasingly competitive and inevitably stressful process, and that is precisely what we are doing.

Will the Secretary of State allow me to emphasise how inadequate the previous system was? Did not she receive, as I did, complaints from women doctors and black doctors that they did not get a fair look-in for training opportunities, and that they felt that the old system was run as an old boy network? And can she give an undertaking to one junior doctor who e-mailed me: will a majority of the review panel be composed of people who did not set up the original scheme?

My right hon. Friend makes extremely important points about the old system. There is no doubt that the old system depended a great deal more on who candidates knew, not what they knew. The result was a great deal of discrimination within the system, which could never be properly addressed or corrected because it was invisible. That is one of the many reasons why modernising medical careers is such an improvement on the old system. It is fair, it is transparent and it sets the same criteria, the same interviewing processes and so on, right across the country. That never happened in the completely devolved and shambolic system that was used previously. On the review group, it is essential that we have not only the representatives of the junior doctors, but the representatives of the medical royal colleges, as they are responsible both for the training and for the development of the specialist curricula for which the doctors are competing.

Does the Minister not realise that the new scheme is likely to lead to serious managerial problems in many of our hospitals, which will lead to a diminution of care and an extended waiting list?

No, I do not accept that. Hospitals will benefit from a much better, much more thorough training system that will get rid of the old system—in which, as a former chairman of the Academy of Medical Royal Colleges described it, senior house officers were a kind of lost tribe filling in time between properly structured and assessed training. There is no doubt at all that the improvements in training that will come with modernising medical careers will be good for doctors and good for patients.

The House accepts that the old system was unsatisfactory and that a lot of work has gone into the new system, but it has left junior doctors genuinely in uproar. Some of them contacted me this morning to ask me to put this to the Secretary of State: given that the implementation of the new system appears to be fatally flawed, is it right to continue to allocate jobs before the review gives its final report at the end of the month?

Whether round 1 should be delayed or scrapped was one of the first issues that the review group considered at its first meeting, and it has come back to it since. The review group has been clear that round 1 should continue, because otherwise the interviews of thousands of junior doctors would be completely disrupted and hospitals could well find themselves in August without the junior doctors they need in place to continue operating. For that reason, the review group recommended, and we accepted, that round 1 should continue but with the immediate changes that it recommended, and we have made, to ensure that the system works properly, that it is fair to junior doctors, and that it enables the NHS to get the best doctors for all the places that it is seeking to fill.

Can the Secretary of State explain how going ahead with the first part of the stage 1 interviews and appointments can be fair if the other doctors who are now excluded but will be brought in later are being considered on a different basis? Will she take up the suggestion that she use the MTAS system to carry out a ballot of all the doctors in training to ask them what they think would be fair, and whether it would be better to stop and start again on an equal basis, or to continue on this unequal basis? Will she please get her people to talk to the directors of medical education and ask them to nominate the people who they know should have been interviewed but have not, just to show what has so clearly gone off course?

In a sense, the hon. Gentleman’s suggestions have already been considered by the review group, which has received evidence and listened to representations from a very wide range of people. For instance, 84 per cent. of the most junior of the junior doctors—the ST2 junior doctors who have completed the two-year foundation programme—have already been given a round 1 interview. The remainder are having their applications reassessed, and many will, as a result, also be given a round 1 interview. However, the review group has been very clear—and I support it in this—that the way to proceed is to make immediate changes so that round 1 operates better and more fairly, as it is already doing in other specialisms and in some parts of the country, and then, if necessary, to make further changes for round 2 so that lessons from round 1 are learned. As I stressed earlier, we have made it clear to those making the appointments that they should not appoint from round 1 unless they are absolutely satisfied with the calibre of candidates—although several of the postgraduate teams who are already involved in those round 1 interviews say that they are delighted with the calibre of candidates, and where they are considering making appointments, they are finding it even easier to do so than in the past.

I am concerned about the impact that the bad publicity about this scheme could have on the new medical schools, particularly the Hull York medical school. What reassurance can my right hon. Friend offer me?

There was enormous public and student welcome for the creation of the new medical schools and the additional medical places that we have been able to create as a result of the investment that we have made. It is important that we restore confidence, where that has been damaged, in the whole process of recruitment for consultant training, and that is exactly what we are doing with the help of the review group. When we publish its final report, we will be able to see what additional changes are needed to ensure that next year’s process works without the difficulties that we have encountered in this first year.

We are still waiting for two things: first, an apology from the Secretary of State and, secondly, an unambiguous answer to the question that the hon. Member for Norwich, North (Dr. Gibson) asked about quality assurance, which is one of the safeguards available to anyone who introduces new systems, however much they are needed. Will she give an unambiguous answer? Have the final MMC and MTAS systems been subject to formal quality assurance—yes or no?

Will the Secretary of State put herself in the position of one of those extremely anxious junior doctors? Where does she think that she would be today if the Prime Minister had not been able to take into account her previous achievements before he appointed her?

It is precisely because I put myself in the position of a junior doctor, who had worked incredibly hard and found himself or herself without the interview for which they had longed or for the specialty to which they were committed, that I was so determined to sort out the matter. That is why the minute that the scale of the problem became clear, we sat down with the academy, colleagues from the medical royal colleges and the BMA and asked them to lead an independent review process. We are now making the changes that will ensure that junior doctors can have genuine confidence in the process, which is a great deal better than the old system of medical training, that they will be treated fairly and, above all, that the NHS can appoint the best people for the large number of jobs that are now available.

Mr. Goodare of Poynton in my constituency is currently a senior house officer in anaesthetics. He and his mother have contacted me, and both were in London on Saturday for the march and demonstration. What assurance can the Secretary of State give my constituent, who is a highly trained and motivated young man, that he will have a job next year? She has admitted that there has been a problem. The simple thing for her to do is apologise and give an assurance that people who are so worried and can help the health service have a job.

As the hon. Gentleman knows, more doctors and other professionals are employed in the NHS now than ever before. However, the NHS has never been able to guarantee employment, especially not in the specialty or place of an individual’s choice to every individual who comes through medical training. We have increased the number of medical trainees to such an extent that competition is even greater. Given the hon. Gentleman’s description of his constituent, I am sure that he will have not only a fair hearing in the training and assessment system that is being improved, but every chance of success.

I am sorry that the Secretary of State did not give my hon. Friend the Member for North-East Cambridgeshire (Mr. Moss) a more comprehensive reply. Like me, he will have received at the weekend an e-mail from a senior clinician at Peterborough and Stamford Hospitals NHS Foundation Trust. It made the point that, as of July, only two out of 22 anaesthetists—senior house officers—will be available. That will have a massive impact on clinical care, especially on epidurals for pregnant women and other issues related to pregnancy. When will the Secretary of State apologise for that likely state of affairs, admit that the Department got it wrong and move on?

It is a matter for each hospital to ensure that it employs the right number of people with the right specialist skills to offer a safe service to pregnant women or any other patient. I am sure that the hospital to which the hon. Gentleman refers and every other hospital will continue to do that.

Earlier, the Secretary of State failed—inadvertently, I am sure—to answer a question. May I therefore be helpful and ask it again? How can we have any faith in a system that awards one point for a PhD yet four points for dealing with stress?

As I said when I cited the independent Postgraduate Medical Education and Training Board, the scoring system and the whole process for applications was developed by the postgraduate deans, working with the Department and other partners. It is not up to Ministers to determine the number of points that should be awarded for different aspects of what is inevitably a complex system. The review group will be able to consider that as it examines other aspects of the system. If it wants to recommend changes, we will, of course, take that seriously.

The Secretary of State began her review when the scale of the problem became known to her, but the scale of the problem was pretty clear on 13 October to the junior doctors committee representative from the BMA who, in my presence, made quite clear to junior doctors at East Surrey hospital the scale of the disaster that was about to happen and made it clear that the BMA’s junior doctors’ representatives were begging the Department of Health to postpone this process. The parliamentary questions that I have tabled on this matter have resulted in answers of the most stunning complacency. I have now been told of a further issue that will arise out of this virtual nationalisation of junior doctors beginning their new jobs. Apparently, between 1 and 3 August, almost every junior doctor and registrar will be involved in induction training in hospitals up and down the country, leaving only consultants available to provide doctor cover. Is the Secretary of State aware of this potential problem, and is she going to do anything to avert it before it happens?

I remind the hon. Gentleman that in the summer of last year—and, if I remember correctly, in 2005 as well—we were told that we were about to have thousands of unemployed doctors all over the country. Of course, that was not the case, any more than it will be this year. We are looking at what will happen in August, but the immediate priority is to ensure that we sort out the changes that need to be made for round 1 and round 2 to ensure that this first year—which was bound to be a transitional year—of appointments to the new consultant training system continues in a way that will be fair to everyone and that restores the confidence of junior doctors.

Horton general hospital in Banbury is possibly going to lose 24/7 paediatric cover and, as a consequence, consultant-led obstetrics because, we are told, there are insufficient junior paediatricians to go round. What this saga seems to demonstrate is that there are more qualified junior doctors than there are posts. Will the Secretary of State give the people of my constituency an assurance that any paediatricians who want training posts at the end of this exercise can go to Horton general hospital, where, for the past 75 years or so, we have had consultant-led obstetrics and, ever since Barbara Castle initiated a public inquiry, consultant-led 24/7 paediatric cover?

It is entirely a matter for the hospital and for the NHS in each region to decide how many training places should be made available and in what specialties. I would never seek to dictate that from the Department of Health. How and where services are most safely and appropriately provided is also a matter on which decisions need to be made locally by the local NHS, in full consultation with the public.

I, too, was contacted today by a junior house doctor, who specifically wanted me to ask the Secretary of State whether she was aware that, under the new system, a surgeon will have only about 25 per cent. of the number of training hours that they currently receive. Would the Secretary of State be happy to be operated on by such a surgeon?

On that, and on other relevant matters, it is more relevant to listen to the views of the Royal College of Surgeons, which has been closely involved throughout the development of the modernising medical careers programme. The programme is designed to replace a rather disorganised old system with one that focuses clearly on the competences and the level of ability that doctors need as they progress through their specialty training towards becoming a consultant.

It is not only junior doctors who are missing out—first-class hospitals such as St. Richard’s cannot get the best doctors to train. My constituents will therefore not get the treatment they would otherwise be able to obtain. This is an absolute shambles. Cannot the Secretary of State see the scale of it? Will she now, as numerous people have asked, just say sorry?

The hon. Gentleman should have listened to the review group. We published a further statement from it last Friday, which I have just repeated in my statement. The changes that we have already agreed for round 1 mean that junior doctors who did not get an interview, or did not get an interview for their first or second choice of specialty, will now have their applications reviewed, in some cases through a face-to-face interview. Where appropriate—depending, of course, on whether they meet the selection criteria—they will then be added to the interview process. In addition to the very fine young junior doctors who have already been given interviews in round 1, including 84 per cent. of the second-year foundation training programme graduates, more doctors—we estimate that there will be more than 5,000—will be given round 1 training interviews. That will not only ensure fairness to them, but will enable the NHS to choose from the best candidates for all jobs.

Apart from the misery that is being caused to thousands of junior doctors and their families, this is another NHS information technology project failure. Can the Secretary of State tell us how much the MTAS system has cost to date, and will she consider inviting the National Audit Office to inform her and the House whether it has been value for money?

I do not know how much the MTAS system has cost, but I am happy to write to the hon. Gentleman about it, and I will certainly consider his suggestion about the NAO.

I am astonished to hear the Secretary of State continuing to defend the system when she should be apologising for it. I met about 20 junior doctors from Bournemouth hospital at the weekend. They said that the online system was a joke, that proper training was being jeopardised, and that come 1 August thousands of able doctors would be made redundant. Is the Secretary of State willing to meet those doctors so that she can hear their views directly, and does she agree that of all the cock-ups that the Government have caused in the NHS, this has to take the biscuit?

I am glad to say that I have the opportunity to meet junior doctors and other NHS staff all the time, and will continue to do so.

As soon as it became clear that the new system was not working properly, I sat down with the royal colleges and the BMA and established an independent review group. We are acting on its recommendations, and I think that that is the right way in which to proceed.

Will the Secretary of State give us any idea of how many doctors will be out of a job after August, and has she made any assessment of the work load that will be placed on those who will be left in the system?

I do not think that the hon. Gentleman has been following the discussion. He assumes that thousands of doctors will be out of work, but the applicants—more than 29,000—who are currently working in the NHS will continue to be needed in the service, whether they have moved on to run-through training programmes or are working in staff and other NHS jobs. Those jobs will continue to be needed, because those doctors are at the heart of the NHS.

One question that has been asked repeatedly this afternoon remains unanswered. I will repeat it, for the sake of good order, and I hope that the Secretary of State will answer it. Will she say sorry?

As I have said, the system was not working as well as it should have been, and as soon as that became clear—and because of the distress being caused to so many junior doctors—we established an independent review group. We have already made changes in the system, which have been communicated to the junior doctors both directly and through the websites. Further changes are now being made, and will continue to be made.

I only hope that the hon. Gentleman and other Members, while complaining—perfectly reasonably—about problems, will acknowledge that we are sorting those problems out. I also hope that they will, just occasionally, give credit for the real progress that has been made.