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Modernising Medical Careers

Volume 459: debated on Monday 16 April 2007

With permission, Mr. Speaker, I should like to make a statement on the progress that we are making in relation to modernising medical careers. As I explained to the House in my written statement on 27 March, the independent review group continued its work over the Easter recess, which included making two important announcements to applicants for training places. Copies of those announcements are being placed in the Library today. The review group decided that it would be wrong to abandon the process of interviews now under way and concentrated instead on how to change the process in order to meet the needs of junior doctors and the NHS as a whole. Furthermore, it concluded that the problems that have arisen relate in the main to the implementation process, and not to the underlying principles of modernising medical careers.

Following the review group’s recommendations, recruitment to general practice training programmes, which has not generally given rise to problems, will continue as planned, although the timetable may need to be revised to make sure that it is co-ordinated with the revised timetable for other specialties. The review group is undertaking further work on recruitment to academic medical programmes, and it will make a further announcement on that shortly.

On recruitment for speciality training, which is where most of the recent problems arose, the review group’s statement on 4 April sets out the changes needed. The group’s proposals have the support of the Academy of Medical Royal Colleges and the British Medical Association and are now being implemented by the NHS with the postgraduate deaneries. For applicants who have already been shortlisted, all interviews already conducted in round 1 will be honoured and the outcomes will count. Eligible applicants will also be able to revise their preferences later this week in the light of published competition ratios, and they will be offered an interview for their first preference post, if they have not already had one. Eligible applicants who were not previously shortlisted will also be able to revise their preferences and will be guaranteed an offer of an interview for their first preference.

We expect job offers to begin to be made in early June, but not all jobs will be filled at that point. There will then be a second round of recruitment for applicants who do not get a job in the first round. That second round will be based on a revised short listing and interview process, which will include a structured CV.

This has been a time of great distress for junior doctors and their families, and I apologise to them unreservedly for the anxiety that has been caused. I believe that we now have the right way forward for this year’s recruitment to general practice and speciality training, and that applicants can be confident that they will be treated fairly. I want to record my thanks to Professor Neil Douglas and his review group for the very considerable amount of time and expertise that they have already contributed. They will continue their work and, as I have said previously, we will publish their final report. I want to thank, too, the NHS consultants and deaneries who are being asked to conduct a large number of extra interviews within a short space of time. We will keep the timetable under review. The Health Departments in the other home countries will be making their own announcements on the arrangements that apply there.

Finally, the review group was set up to deal with this year’s recruitment process. We are now some two years into the modernising medical careers programme that began with the successful launch of foundation programmes in 2005. The time is now right to undertake a wider review, to clarify and strengthen the principles underlying MMC and to ensure that, where necessary, we make further changes for future years. Historically, Britain’s medical education and training system has been rightly regarded as second to none. The creation of a competence-based training system that is widely accepted remains the right way forward, but all involved must be confident that the pursuit of excellence remains at the heart of the system. I am therefore establishing a second independent review to consider those and other broader issues. I am very pleased that Professor Sir John Tooke has agreed to chair the independent review. Sir John is dean of the Peninsula medical school, chair of the Council of Heads of Medical Schools and chair of the UK health education advisory committee. We are working with Sir John on the terms of reference and membership of the review, and I will make a further announcement shortly. Modernising medical careers is a UK-wide programme, so the devolved Administrations will be fully involved in the process. We will, of course, publish Sir John’s report.

I am grateful to the Secretary of State for her statement and for the chance to see it beforehand. I am glad that she volunteered a statement on this occasion, instead of being dragged to the Chamber, as she was on 19 March. She has had to eat three helpings of humble pie this afternoon—first, in making an apology, which she should have done on 19 March, but I am glad that she has done so now; secondly, in saying that at least in the second round of interviews there will be access to a structured CV, which, she maintained, would be true in the first round, when she spoke to the House on 19 March; and, thirdly, in accepting the need for a further strategic review, which she has not been willing to concede previously.

In her statement, the Secretary of State said that it was the implementation process that went wrong, not modernising medical careers itself. She is right that MMC has attracted support in principle, including from the Opposition, but questions about implementation were raised by the British Medical Association and the royal colleges, which she and her Department have overridden—if only she had listened. When Professor Alan Crockard resigned as national director of MMC he said that the medical training application service

“was developed and procured by the Department of Health outside my influence.”

He went on to say:

“From my point of view, this project”—

namely, MTAS—

“has lacked clear leadership from the top for a very long time.”

Subsequently, when Professor Shelley Heard resigned as the MMC national clinical adviser she said that the principles that the Secretary of State says have so much support

“have been lost in the detail and acrimony of a recruitment process which should have supported and not driven it.”

There have therefore been two resignations by people who hold others responsible. Who, then, does the Secretary of State hold responsible?

The way forward this year is still fraught with difficulty. Does the Secretary of State believe that it is sustainable to offer applicants up to four interviews in the first place, but to make them choose only one? She said that the second round will be based on a revised shortlisting and interview process, including a structured CV. Does that mean abandoning the absurd scoring system for shortlisting? Will interviewers in the first round have access to a full CV and references or, as I understand it, will the first interview still be conducted on the same basis as was first proposed, with all the attendant problems?

Will the Secretary of State say how many posts will be available—18,500 have been loaded on MTAS so far, and there were originally 33,000 applications? What are the two respective figures now?

Clearly, there were more applicants than the Department expected. On 19 March, I asked the Secretary of State whether she would create extra training posts by reclassifying trust grade posts. Will she now confirm that her Department has subsequently asked trusts to do as I proposed? And how many such posts is she willing financially to support?

Will the Secretary of State ensure, not least by creating new training posts, that the lost tribe of senior house officers are not forced into a dead end? She must know that they were disadvantaged under the MTAS scoring system, and if they do not gain ST3 posts this year, they will be ineligible in future years. For example, she must know that 1,829 surgeons have been shortlisted for ST3 posts and that only 534 posts are available. Will the Secretary of State promise that they will be able to access training posts this year, even if only on a one-year basis, and that they will be eligible for run-through training posts next year and potentially the year after, so that there is a viable transition for them?

Finally, I welcome Sir John Tooke’s appointment to head a full review, which we also called for. It is time for the medical profession to reassert its responsibility for the education and training of future medics. MMC is needed to reflect a changed world in which trainees are no longer expected substantially to deliver NHS services, but the principle has been undermined by lamentable implementation. The Secretary of State and her Department must accept responsibility for that, and in the light of the appalling shambles that they have made of the situation, will she promise to listen and to let the medical profession give the lead in future?

The hon. Gentleman referred to the recent resignations from the MMC team. My colleagues and I regret the resignations of both Professor Alan Crockard and Professor Shelley Heard. They are both distinguished figures in the field of medical education and training, and I am sure that they will both continue to make a contribution.

The hon. Gentleman referred to the MTAS system and to what he described as the “absurd selection criteria”.

The development of the selection criteria and the scoring system was undertaken by members of the medical profession in consultation with all key stakeholders as well as the Department of Health. That is, of course, being reviewed, which is one of the reasons why we have the review group under Professor Neil Douglas, which is now looking at the details of round 2.

The hon. Gentleman referred to the number of applicants. As I have previously told the House, we received just over 32,000 eligible applications, the great majority of which came from people who are already working within the NHS in one capacity or another. He referred to the number of training posts and, in particular, run-through training posts, and I hope that he agrees that the number of training posts needs to be shaped by the needs of the national health service and future developments in medical technology. As part of the Department’s work with the review group, we asked the service some weeks ago to look at the number of training posts that it was making available in different specialties to see whether it wished to change either the number or the level at which those training posts become available.

The hon. Gentleman asked me to listen to the views of the medical profession and, I hope, the deaneries and others involved in medical education, which is precisely what we have been doing over many years in developing MMC, over the past two years in the successful introduction of the foundation programme and in recent weeks in this difficult transition year and the first year of implementation of full speciality training. I remind him what Dr. Jonathan Fielden, the chairman of the British Medical Association central consultants and specialists committee, has said:

“Having heard the major concerns of the profession and considered all available options we have now produced a practical solution deliverable in England.”

We can now

“move on and appoint the best candidates to the right posts to train and treat patients.”

Dr. Jo Hilborne, chair of the BMA’s junior doctors committee, says:

“We have worked hard to find a practical way forward which treats applicants fairly.”

The training group of the Academy of Medical Royal Colleges says that it has achieved its aim of maximising choice for applicants applying to modernising medical careers without compromising patient safety by overburdening the service.

That is why I said with confidence that the work of the review group and the changes that we have made, on the basis of its work, to this year’s process have the full support of the medical profession.

I congratulate my right hon. Friend, first, on the establishment of the full review and, secondly, on her fulsome apology to those who have been affected. Will she confirm that in addition to the obvious need to get it right for the individuals concerned, it is important that the Department now concentrates on raising the morale of all those affected? Morale in the health service is worth an enormous amount of resource and of those individuals’ personal commitment, and so many of the young people affected feel that they have been neglected and, in some cases, let down by the system.

My right hon. Friend is absolutely right. There is no doubt that because implementation in this first year of full transition to the new system was not in any way adequate, several of those highly committed junior doctors do indeed feel let down. I, and others, have fully acknowledged that. That is why enormous efforts are being made, particularly by consultants across the service. I am very grateful not only to consultants but to the service as a whole for ensuring that those consultants can be released from their normal commitments for the additional time that will be needed to interview the additional applicants who will now get interviews. That will ensure that all applicants are treated fairly and that the best people are appointed to training programmes and posts within the NHS, which is what all of us would want for the patients whom we all serve.

I thank the Secretary of State for the advance copy of her statement.

The Secretary of State’s apology is welcome, as is the announcement of the wider review, although I think that most people will be confused about how many reviews we how have. Could not this whole debacle, which has so sapped morale in the profession, have been avoided by proper piloting and better engagement with professional groups in listening to concerns that they have been expressing for a very long time?

The statement asserts that there is no problem with the underlying principles, yet goes on to say that the wider review will

“clarify and strengthen the principles”.

Is there a problem with the principles, or not?

Has there been any assessment of the cost of the recovery operation and the impact on patient care of thousands of additional interviews over a six-week period—and, indeed, of whether it is logistically possible?

The Secretary of State highlights the support for the review group’s proposals, but does she accept that many people do not support the plan? Does not Remedy UK have a powerful case in that the process remains deeply flawed, with so-called rescue interviews taking place later and possibly with different panel memberships? That is not a fair interview process. The statement refers to second-round interviews using a

“revised shortlisting and interviewing process”.

When will the details of that be known? Is it not remarkable that no reference is made to the massive mismatch between the numbers of applicants and the numbers of training posts available?

What will happen to those who do not get posts? It is still not clear quite how many there will be; I heard the answer to the previous question. Has not there been a total failure of work force planning whereby thousands of expensively trained dedicated professionals may be left without specialist training posts? Will those issues be part of the wider review? The Secretary of State said that there were likely to be some extra training posts. When will we know whether that is so, and how many there will be?

Will the Secretary of State include in her review a thorough analysis of what went wrong and who is responsible for creating this crisis in the first place?

The hon. Gentleman refers to the two reviews. We established the independent review group under Professor Neil Douglas to deal with the situation that had arisen this year. The absolute priority was to sort out the problems that had arisen with this year’s applications in order that posts could be filled, as they must be, for August, when the current posts, by and large, come to an end. That was what we had to focus on and that is what we have done for several weeks since the scale of the problem became clear.

However, we also need to ensure that we learn broader lessons for the future. As I said, I believe that the principles underlying modernising medical careers are sound, which is precisely what the review group and many others have said. However, particularly in the light of what has happened this year, we need to consider how those principles can be further reinforced and how their implementation can be further strengthened, and we are inviting the second independent review group, under Professor Sir John Tooke, to examine, for instance, some of the specific issues that have been raised about the degree of flexibility in the run-through training programmes provided under MMC.

The hon. Gentleman asks whether the new approach to round 1 interviews would be logistically possible, given the number of additional interviews that will now have to be conducted. The view that the Department, the review group and others take is that it is logistically possible, but only with considerable effort. That is why I referred, in response to the comments from my right hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett), to the fact that the service around the country will in many cases need to release consultants from their planned activities in order to make time available for the additional interviews. That is why we are keeping the timetable under review.

The hon. Member for North Norfolk referred to Remedy UK and those who had suggested that a more radical change should have been made for this year. Let me refer him to what the review group said on Wednesday 4 April:

“Serious consideration has been given to all of the options available, including a full and detailed analysis of pulling out of the current selection process completely. In the end, it was simply not a credible option. It would be impossible to place the best candidates in posts and fulfil the service needs in time for August using the old system of recruitment. We believe we have come up with the best available solution for England.”

That conclusion of the review group, as I said, has been endorsed by the medical royal colleges and by the BMA.

The hon. Gentleman refers to the prospect or the possibility of unemployment among junior doctors. Although he did not fall into this trap, let me take the opportunity to refer to the thoroughly misleading statements made in recent weeks about the prospect of thousands of junior doctors finding themselves without work. That is complete nonsense. As I said in response to points made by the hon. Member for South Cambridgeshire (Mr. Lansley), the great majority of eligible applicants are already working in the service.

Of course, there may be situations in which somebody who has applied for a run-through training programme is not successful in obtaining that and will therefore need to continue in the staff job or, in some cases, to apply for a staff job. The review group is working on the nature of the support that we need to give people in that position and will want to make further announcements.

Last Friday, I met a senior house doctor who was speaking on behalf of a number of his colleagues from a variety of professions in the NHS. He said that, as far as Scotland was concerned, much ground had been recovered but that it was vital for all concerned that UK-wide progress could be made. Can my right hon. Friend assure me that ongoing efforts will be made to ensure that the progress that has been made in Scotland will be mirrored right across the country?

I can certainly give my hon. Friend that assurance. Obviously, we are dealing with far larger numbers of applicants in England than the NHS is in Scotland, but that is why we have established the review group and why we are so determined to ensure that we implement its proposals in a way that is fair to junior doctors and other applicants and that reassures them after the anxiety and distress that have been caused. My hon. Friend referred to senior house officers, and it is worth recalling the enormous difficulties that the old training system caused, particularly for SHOs, who, on various occasions, have notoriously been described as a “lost tribe” and who often had to apply for a new job every six months without knowing whether they would be able to continue their training in their chosen specialty.

In today’s post, I received three glossy brochures about different parts of the NHS and a letter about PCT reorganisation, which reminded me that the strategic health authority in my part of the country takes 10 per cent. of the money that goes to the hospitals and the SHA together. Is not the truth behind this crisis that there is not enough money to appoint decent doctors with appropriate experience and training because the Secretary of State’s priority is to have an NHS suitable for the glossy brochure industry and for all these reorganisations?

That comment is not at all worthy of the right hon. Gentleman. It is a bit much for him to allege a lack of funding for the training and employment of doctors when the Government of whom he was a part starved the NHS of funds for nearly two decades and when we are training and employing more doctors, nurses and other health care professionals than the NHS has ever had before.

When I saw the leader of Stafford’s junior doctors last week, she said that there was broad support for the standardisation that this system brings, and for it being an online system. Sadly, however, she also told me of the all too many instances of great distress being caused by the system. These included stories of people having their choices, and their family ties and personal circumstances, ignored, and of people who felt so disillusioned that they did not even believe that their applications had been properly read before a decision was made. Should not such situations be ironed out of the system? Should not the Secretary of State give an assurance that, in the second round and beyond, there will be greater respect for the individual circumstances of every applicant?

The cases to which my hon. Friend refers are exactly what led us to establish the review group and to change the process for this year’s recruitment and training programmes. A critical aspect of the way in which we are now moving forward is that every applicant will be guaranteed an interview for their first preference post. I have no doubt that, when applicants decide their preferences, they take into account the location of the various posts available as well as the specialty within which the post is offered. Similarly, when the service makes decisions on job offers, they will be matched—as far as possible—to the first preferences that have been indicated by all junior doctor applicants.

Remedy UK and Mums 4 Medics have done valiant work to try to bring together the concerns of doctors in training and their seniors. Will the Secretary of State, either now or very shortly, announce the e-mail address to which people can send their concerns, including the possibility—or, in some cases, the certainty—that some doctors have had their answers dissociated from their own application and were considered on the basis of answers given by other people? That is one of the real worries that has not yet had the attention that it deserves. Doctors should be judged on their own applications and CVs, not on those of others.

Various allegations about applications being wiped from the system have been investigated and found not to be true. For instance, the allegation that 1,300 or 1,500 applications had been lost turned out to refer to the number of applications from people who were ineligible for training programmes; applications from eligible applicants had not been lost from the system. I have not heard any accounts of people who believe that their details have been lost from their application and someone else’s details substituted. If the hon. Gentleman gives me the details of those cases, I will ensure that they are properly investigated.

Last autumn, I wrote to the Secretary of State expressing concerns about this year’s implementation. The reply from the then Health Minister, Lord Warner, indicated that my concerns were misplaced, so several weeks ago I wrote back to the Secretary of State’s ministerial team pointing out that the implementation was not going well, to say the least, and asking whether anyone responsible had been disciplined as a consequence. I have not received a reply to that question.

I do not wish to know names. I do not wish to hear that the Department does not believe in a blame culture, because that would be avoiding responsibility. I do not wish to hear that it is time to move on. What I would like to know from the Secretary of State is whether any disciplinary proceedings are in train or concluded against anyone whatsoever for these problems; if so, how many; and if not, why not.

As I said earlier, once the problems became apparent our absolute focus was on sorting them out. That has been and remains the priority. But as I also said earlier, of course there are lessons that we need to learn from what has gone wrong this year, and that will be a matter for the independent review group. As far as I am aware, no disciplinary or performance management steps are being taken in the Department, but no doubt that can be considered as appropriate.

As one who is currently undergoing treatment in the NHS, I pay tribute to the medical care that I have received. However, I also wish to convey the anger that a number of junior doctors whom I have seen when I have been in hospital—not just my constituents—have expressed to me about the way in which the whole debacle has arisen, and the fact that so many of them are now considering taking their careers abroad.

The Secretary of State’s earlier answer to a question about possible unemployment was slightly disingenuous. It may be true that nearly all those involved are currently employed in the NHS, but if they cannot see their careers advancing in the NHS, they will take their valuable skills abroad—skills that we have paid to give them.

There are now two groups of people: those who have already been interviewed for their first choice and those whose applications for interviews for their first choice were originally rejected, and who will quite rightly be given them after the Secretary of State’s review. There is concern in both groups about whether the interviews will take place on an equal basis. Can the Secretary of State assure us that those who were originally refused interviews and who will be given them now will be interviewed on exactly the same basis, and against the same criteria, as those who were interviewed on the first occasion?

There are more training places for junior doctors now than ever before. As for the important issue of applicants who were not given interviews during the initial shortlisting process and who will be given them now, of course I can assure the hon. Gentleman that all applicants will be treated fairly and equally. I am sure that the House would expect nothing less of the interviewing panels.

Let me also take this opportunity to wish the hon. Gentleman a speedy recovery.

I understand the Secretary of State’s problems. She has to accept the opinions of the sources that feed information to her. However, I want to make her aware of the grass-roots feeling of senior consultants in the NHS who oppose the views of the Academy of Medical Royal Colleges.

I have received no fewer than 40 letters in the last four or five days from senior consultants involved in medical training, and with only one exception they have said three things: that the national selection process has failed, that despite the review the morale of the juniors is still at rock bottom, and that the only answer is to scrap the medical training application service. Some have suggested ways of filling the posts by 1 August even if MTAS is scrapped.

I always listen carefully to the hon. Gentleman’s views on these matters, but I must stress to him that the review group, which includes some rather distinguished members of the medical profession, has looked very carefully at proposals from various quarters for scrapping this year’s system and returning to the old system, or doing something else in order to fill the posts by August. As I said when I quoted from the group’s statement of 4 April, it concluded that that was simply not credible or possible. On that basis, we need to move forward and I hope that all consultants involved in education and, in particular, interviewing for training places will, despite the difficulties, be able to make the necessary time available to ensure that candidates are treated fairly and that the NHS can appoint the best people.

We have heard evidence from Government Members this afternoon of a great deal of complacency about how this whole situation occurred. May I ask the Secretary of State about the scoring system? The right hon. Lady said in her statement that it was created in conjunction with the medical bodies, but those bodies have indicated that it was imposed on them. Who will bear the cost of this debacle? I hope that it will not be the professional bodies. Will she let us know how much this has all cost?

I am advised that the scoring system was devised with the full involvement of the medical profession and others. No doubt that is one of the issues at which the wider review that I have announced today can look. Clearly, regardless of how it came about, the system needs to be looked at for the future, since so many objections have been made to it now.

At this stage I do not know the additional costs of the changes that need to be made for this year. I have said that there will be some practical problems for the service in making consultants available and freeing them from their normal duties so that they can take part in the additional interviews. We will need to see what the additional costs will be, and in conjunction with the review group we are doing everything possible to keep them to a minimum.

May I ask the Secretary of State about nurses? There are currently nearly 75,000 students training on nursing courses who will graduate over the next three years. What assurances can she give the House that when they finish their courses in the summer they will not find themselves in a similar position to the many doctors about whom we have heard today?

Modernising medical careers obviously does not affect nurses. It is perfectly true that some newly qualified nurses and other health care professionals have found it extremely difficult to get posts in the current year, given the financial difficulties that the NHS has had to grapple with over the past 12 months, but we do not expect those problems to continue—certainly not on that scale—in future years. We are working with the newly strengthened social partnership forum to see, for instance, whether it might be possible to offer guaranteed employment in some cases to newly qualified health professionals.

As I understand it, they were from people who either did not have the necessary permission to work in this country or simply did not meet the basic educational and qualification criteria for the post.

I have yet to receive a satisfactory reply to this narrow point, which I have raised with the Secretary of State before. It will not be quite such a narrow point if one needs hospital care on 1, 2 or 3 August, when every junior doctor will be either moving or undertaking induction training at their hospital. What arrangements have been put in place to ensure that there is satisfactory doctor cover in our hospitals between 1 and 3 August?

Each hospital must ensure that it has the staff available to meet the needs of patients coming in for planned care and of those who may well arrive as emergencies. In the light of the question that the hon. Gentleman asked me on a previous occasion in this House, I have asked for a full briefing on that subject and I shall be happy to write to him when I have more information.