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Modernising Medical Careers

Volume 460: debated on Thursday 24 May 2007

I wish to make a statement about modernising medical careers. In my written statement to the House on 15 May 2007, I announced the plans for making offers in the first round and the principle behind the further round of the modernising medical careers specialist recruitment. I welcome yesterday’s decision by the High Court in the judicial review brought by Remedy UK while, of course, acknowledging the criticisms that the judgment contains. I also welcome the decision of Remedy UK not to appeal against the judgment. I will consider the comments of Mr. Justice Goldring on costs.

I well understand the uncertainty that problems with the medical training application system have caused junior doctors and their families. We need to ensure that we learn the lessons from what has happened, which is why I asked Sir John Tooke to establish an independent review. The membership of that review has now been agreed, and I have placed a copy of Sir John’s announcement in the Library.

Following the court’s decision, I am pleased to say that offers for the extended first round of specialist recruitment will start today. Interviews for the current round should be completed by the end of this month and all initial offers for hospital specialties will be made locally by the postgraduate deaneries between now and 7 June.

Successful candidates might receive more than one offer. They will be able to wait until all their offers are received, allowing them to consider their options before making a decision on which to accept. Initial offers must be accepted or declined before midnight on 10 June. Following that deadline, training places that have been declined will be re-offered to the next highest-ranked appointable candidates. Those additional offers will be made from Monday 11 June until Wednesday 20 June.

At its meeting on 9 May, the review group agreed a set of principles upon which the continued recruitment of specialist medical trainees this year would be based. These principles are fully supported by the deaneries, NHS employers—and, of course, the Department of Health—and are set out in a letter of 22 May that was sent to all applicants, a copy of which I have also placed in the Library. That further recruitment round will be locally planned and managed.

Although there will not be a national allocation and matching system for appointments, MTAS will continue to be used by deaneries for administration and monitoring. As in the extended round 1, applicants will be provided with information on the competition ratios for each post to assist them in deciding where to apply. The number of posts available in the further recruitment round will, of course, depend upon the outcome of round 1, but will be substantial.

In particular, the Douglas review group has stressed that there are fewer ST3 posts available at the moment than should be expected for the number of doctors well advanced in their specialist training. Following the review group’s recommendations and with its full agreement, we will be creating 200 additional run-through training programmes for those doctors who have already invested several years in training for their chosen specialty. For example, it is proposed that 20 new posts will be added to the 100 already available this year in cardiology, 19 new posts will be added to the 30 already available in neurology, and so on. We are in discussion with the review group and the appropriate royal colleges to finalise the details, which will take into account the needs of the NHS, as well as junior doctors.

I have already told the House that we will support junior doctors during this further appointment process, including especially those whose current contracts come to an end within it. We are working with strategic health authorities to ensure that all applicants currently in NHS employment will continue to have employment while they progress through the next round. In addition to the extra run-through programmes that I have announced, we have also accepted the recommendation of the review group to create further additional training opportunities for those junior doctors who are appointable to specialist training, but for whom training opportunities may not otherwise be available this year. For those who have successfully completed the MMC foundation training programme and who demonstrate their ability to progress, there will be new training programmes through one-year fixed term appointments. We are asking PMETB to expedite the approval of both the extra fixed-term and run-through programmes. There will also be a range of sponsored training programmes available to enable doctors either to get an additional year’s experience in their chosen specialty or to choose to gain experience in a different specialty, thus giving them all a better chance to apply and secure a training programme next year.

The strategic health authorities will manage the process and work with trusts, deaneries and royal colleges to determine the types of opportunities that they will make available. All those posts will be based on local service requirements and future work force planning needs. Funding to support those training opportunities will come from the Department and SHAs.

At the end of the further recruitment process, there will remain a number of applicants who have been unable to demonstrate this year that they are suitable for the specialist training programmes. Many will remain in their current service posts while others will be able to apply for the non-training service posts vacated by those moving into training posts. SHAs and trusts will work together to match doctors to posts across each region.

I believe we now have the right way forward both to give junior doctors the support and opportunities they need, and to ensure that the NHS has the right doctors in place to continue providing excellent care to patients. The result is that there will be more junior doctors in specialty and GP training than ever before. I am extremely grateful to Professor Douglas, the medical royal colleges, the BMA and other members of the review group for their help and support in resolving this difficult situation.

I am grateful to the Secretary of State for advance sight of the statement and for coming to make a further statement on those matters. The Secretary of State said that she welcomed the High Court judgment and acknowledged the criticisms made by Mr. Justice Goldring. At the very least, she might have had the good grace to accept them. He said, for example, that

“the fact the claimant”—

Legal Remedy UK—

“has failed in what was accepted to be an unprecedented application so far as the law is concerned does not mean that many junior doctors do not have an entirely justifiable sense of grievance.”

They certainly do. He continued:

“The premature introduction of MTAS has had disastrous consequences. It was a flawed system”.

He also says that

“the shortlisting process was flawed. The application form was unreliable as a measure of ability…the algorithm needed to govern the allocation process under MTAS did not work”.

Not least as a result of the judgment, the Secretary of State has had to accept many of the criticisms that the Opposition have made over the past two months. She will also have to accept—not least because Professor Douglas and his review group have recommended them—some of the remedies that we called for. For example, in the statement she essentially said that additional training posts would be available. She will recall that that is precisely what I called for from the Dispatch Box on 19 March. The Secretary of State and her colleagues disparaged that call. Time has been lost and that is a lamentable further failing after the original failings of the MTAS scheme.

I wish to ask the Secretary of State some further important questions. Can she confirm that it is not her intention to seek costs from Legal Remedy UK? That would be a deplorable act after all that it has gone through. Secondly, she has announced how many additional run-through training posts are to be made, but she will know that what is even more significant is how many temporary training posts are able to be added. How many posts will be in round 2? She says that the number will be substantial. The word “substantial” is often used and Mr. Justice Goldring was right yesterday when he said that—as the Secretary of State said on 13 March—it is very important that a “significant” number of posts are available in round 2. In the Department’s evidence to the High Court it was said that there would be unfilled posts from round 1, posts that were held back from round 1, and new posts. Can the Secretary of State tell us how many new posts there will be in round 2 and how many posts have been held back from round 1? I know that she will not be able to tell us how many unfilled posts there will be from round 1, but can she explain why, both in her evidence to the High Court and in the letter to applicants sent out yesterday, it continues to be the Department’s view that the offer and re-offer process will enable the units of application—the deaneries—to fill as many training posts as possible? Surely the objective of round 1 is not to fill as many training posts as possible, but—as she said on 13 March—to fill training posts wherever the interviewers are satisfied that they have an eminently qualified candidate; otherwise, round 2 will not have as many posts as it should.

Back in late April, the Department appeared to believe that there were between 500 and 1,300 foundation programme graduates who were at risk of not attracting either specialist training one posts or fixed-term specialist training posts. Do I gather from the Secretary of State’s statement that it is now her intention to ensure that every suitably qualified foundation programme graduate, which I hope is virtually all of them, will find a training post, and that the numbers will be brought down virtually to zero?

Can the Secretary of State tell us what she might further do to help hospitals with their problems at the beginning of August? It is virtually impossible for many hospitals to advertise and attract candidates for service posts starting on 1 August in circumstances in which so many junior doctors have no idea whether they will get training posts. Round 2 will extend beyond August, perhaps all the way to November. It is therefore vital that as many as possible of those posts be converted to training posts, even if they are temporary training posts or, as the letter to applicants says, a process will follow in which PMETB tries to progress the posts into ones that it recognises for training purposes. What will the Secretary of State do to try to help trusts to fill posts in circumstances that are becoming increasingly difficult?

How can all this be achieved in circumstances in which, in several regions, the MPET budgets, which were cut last year, also face cuts this year? We know from SHA board papers that £136 million will be cut from MPET budgets. Surely that was always intended to be a one-year cut in the education and training budget. If it carries on, it will prejudice the delivery of all of those objectives.

We have arrived at the point at which the Secretary of State comes to the House to report what Professor Douglas tells her should happen this year and, for the future, what Professor Sir John Tooke and his review tell her will happen. To all intents and purposes, the Secretary of State is now merely a cipher for the profession. Frankly speaking, that is a better solution than has been the case in the past, because the Secretary of State has so completely failed. If she would only admit that, as Mr. Justice Goldring said yesterday, the process has been a disaster, that would serve her rather better.

I have learned never to be surprised by the hon. Gentleman’s inability to welcome developments—in this case a very good package of support for junior doctors. Of course, it would have been much better if it had been in place from the beginning, but it gives junior doctors better support than the NHS has provided in the past.

On the issue of costs for yesterday’s judicial review, of course I will consider that with sympathy. [Interruption.] I do not know whether the hon. Gentleman wants to hear my answers to the specific points that he raised. Public funds are involved, and I am not going to make a snap decision.

The hon. Gentleman asked how many round 2 posts there will be. He also acknowledged that we do not yet know how many posts will be filled in round 1, so the final total number of posts available in round 2 will depend on how many are filled by well qualified candidates in round 1, following the decisions of the deaneries and the interview panels. However, the round 2 posts will also include the 200 new run-through posts for the more senior junior doctors recommended by the review group and specifically welcomed by Professor Douglas.

On the issue of those graduating from the two-year foundation programme, any graduate from that programme who is ready to progress with their training will certainly have a training opportunity.

The hon. Gentleman asked what will happen in August. There are a number of options for hospitals to ensure that they have the right number of doctors continuing in post to support the care of patients. The detailed plans are being worked on by the hospital trusts with the support of the strategic health authorities.

On MPET, I remind the hon. Gentleman that there is more than £8 billion of additional growth money for the NHS this year, some of which is going into the training budgets that are now the responsibility of the NHS within each region. It is for the strategic health authority in each region to manage that budget, taking into account the fact that in many regions, including my own, the east midlands, there have not been particular difficulties with the recruitment round this year. There have been substantial difficulties in some parts of the country, but the picture is not uniform, so the management of the budget and the answers to any problems are much better worked out at regional and local level.

The Secretary of State told the House a moment or two ago that she wanted to support through the further appointment process those junior doctors who were most vulnerable—those whose current contracts come to an end during that process. How many such people are there?

The Secretary of State said that a number of applicants will have been unable to demonstrate that they are suitable for this year’s programme, and they will remain in current service posts. Does she fear that if the MTAS merry-go-round cranks up again in 2008, some of the people in those service posts will act as a logjam, blocking next year’s would-be trainee consultants?

My hon. Friend raises two important points. On the first issue, of supporting junior doctors who continue to apply through the second recruitment round, we will, as I have said, ensure that those who are currently in NHS employment and whose contracts come to an end will be able to continue in NHS employment.

On the second issue, of those who at the end of this year’s process have been unable to demonstrate that they are suitable for specialist or GP training posts, it is important to remember that through the service posts—the non-training posts—doctors continue to make an invaluable contribution to the NHS. Securing a training programme that may lead to employment either as a consultant or a GP is not the only way for a doctor to have a valuable and fulfilling career in the NHS, and we welcome the contribution of those doctors in the service posts as well as those who proceed through their training to become consultants and GPs.

I, too, am grateful to the Secretary of State for advance sight of the statement. I am sure that she acknowledges that yesterday was something of a hollow victory and I trust that she is not feeling triumphant about the outcome of the case, particularly in light of the judge’s criticisms of what has happened to date. I shall have another go: the right hon. Lady said in her statement that she acknowledges the criticisms, but does she accept them?

The Secretary of State said that she would consider further the question of costs, and I am grateful for that. Will she give a time scale for that? Obviously, junior doctors are concerned that they may face a substantial bill. When are they likely to know? I urge her not to pursue costs against them.

Today, I have written to the National Audit Office to ask it to investigate the cost-effectiveness of MTAS and the costs incurred in the Remedy programme. Does the right hon. Lady support that proposal? It seems to me to be entirely appropriate. Does she agree with the suggestion that Professor Tooke’s review group should work closely with the NAO? Will she ensure that Professor Tooke’s review and all the relevant documents are published?

The Secretary of State referred to the fact that there appears to be a breach of contract on the part of the contractors. Is she considering legal action against them and termination of the contract? She said that MTAS will continue to be used for monitoring and administration. Will she explain what that means and how it will continue to be used by the deaneries?

The judge referred to the fact that there were possible individual employment law claims. What assessment has been made of the risks of that and how we can ensure that there are not claims? Obviously, we want to try to avoid unfairness as far as possible.

Time will be tight between offers being made and accepted. What practical help is being given to applicants and deaneries to ensure that they can handle the potentially huge number of inquiries during that tight time scale? Can the Secretary of State give any update on the time scale for round 2? We have heard that it could drag on until November. Does she expect that to happen?

The right hon. Lady referred to the 200 additional run-through training posts. Is that it, or could there be more? She did not give a number for the one-year fixed-term specialist training appointments. Can she give any indication of the likely number of those additional appointments? Will she also reflect on the fact that this may simply be postponing the problem? If there are not sufficient consultant posts at the end of the process, will we not have a crisis further down the track? What is the latest assessment of how many junior doctors will be unemployed this summer? There has been a clear acknowledgement that there could be some.

This experience has been a horror for junior doctors, and I am sure that the Secretary of State has not particularly enjoyed it either, but it is important that everyone now works together to achieve the best possible outcome. Is she willing to meet Remedy UK to try to start building bridges, get it on board and find a unified way forward?

The hon. Gentleman has asked a number of questions; let me deal with them all in turn. I have always accepted that the implementation of this move to the new specialty training system has been inadequate in many respects and has caused needless distress and anxiety to junior doctors, for which I have apologised on a number of occasions.

I will make a decision on costs as quickly as possible, but, as I said, public funds are involved and I need to consult on that issue before making a decision.

The hon. Gentleman asked about a possible NAO review of MTAS. That is a matter for the NAO itself. Sir John Tooke will make his own decisions because he is leading an independent review, but I have placed in the Library a copy of his statement about how he will work.

What I have also done, as I mentioned to the House on an earlier occasion, is ask the Cabinet Office and the Office of Government Commerce to conduct a separate review of the MTAS procurement process. Once we have that report, we will be able to make further decisions as needed about the contract. I will take a view on that when we see the report, which may include commercially confidential information.

As for the way in which MTAS will be used, as I said, the postgraduate deaneries want to be able to continue to use MTAS, including for monitoring purposes. For instance, it is important, given many of the criticisms made of the original shortlisting process, that we are able to track the success rate in securing training offers and appointments for those who were shortlisted and interviewed in round 1a, and those who were not shortlisted but were guaranteed an interview in the remainder of the extended round 1. The initial indications—and that is all they are, as we said in our evidence to the court—are that the overall quality of candidates in the first round was extremely high. However, the deaneries will want to track and monitor that through MTAS.

The hon. Gentleman asked about employment law claims, and he raised, too, the important issue of junior doctors’ fears of unemployment. The best way to deal with those fears and avoid employment law claims is to ensure that we make the job offers—as I said, those will start today—enable doctors who receive offers to decide which ones they want to accept, and then ensure that those who progress to round 2 and are in NHS employment continue in such employment. The hon. Gentleman asked about the time scale for round 2. As we have already told applicants—and this is very much at the request of the deaneries and the hospital trusts—that will start in June, immediately after the end of round 1, but it will continue, if necessary, through November, because it will vary in different specialties and different parts of the country.

The hon. Gentleman asked for the number of additional training opportunities over and above the 200 run-through posts that I have just announced. It will depend on how many junior doctors emerge at the end of the process, having been found fit to progress with specialty training but without a training opportunity this year. There will be as many as are needed for that group, funded in the way that I have already described.

The hon. Gentleman asked what will happen next year, and whether there will be sufficient consultant posts. We have already seen over the past 12 months an increase of about 3,500 doctors employed in the NHS, so there has been a further increase in the number of doctors in that period. The number of consultant posts will depend on what the service needs to care for patients. There has always been stiff competition for consultant posts, particularly in the most popular specialties, and it is absolutely right that that should continue so that the NHS can appoint the best people to those immensely important leadership posts.

The hon. Gentleman ended by saying that it is essential that everyone work together to ensure that the solution that has now been put in place is properly implemented. There was a meeting with representatives of Remedy UK before the application for judicial review, and the Department is now seeking an early meeting with the Academy of Medical Royal Colleges, the British Medical Association and Remedy UK. I am meeting the BMA myself this afternoon.

Now that the dust has settled, does my right hon. Friend agree that the focus should be on ensuring that the original principles of the new system of modernising medical careers can give us all confidence that the very best in the NHS will get the jobs that they deserve? We should bear that very much in mind as we go forward, to make sure that it is a successful scheme which gives the public confidence that there are no shenanigans in the background giving people jobs that they do not deserve—and this is the way to do it.

My hon. Friend makes an extremely important point, and I entirely agree that we now need to ensure that the principles of modernising medical careers are effectively implemented. Those principles include open, transparent competition for training opportunities with agreed national standards. Thanks to the work done on modernising medical careers, we have a system that will be fair to junior doctors, but that will ensure, too, that the NHS can get the right doctors and the best people in the right jobs to go on giving the best possible care to patients.

May I thank the Secretary of State and the Department for helping the judicial review to be heard without delay? It was held with unprecedented speed, and the Department played a part in that. May I ask her to try to arrange for both the claim and the submissions by director Nicholas Greenfield to be posted on the Department’s website or on some other one, so that those with an interest can see the arguments, together with the judgment?

The Secretary of State spoke about the attention that she will give to the judge’s remarks, so I will not go over them now. However, will she give some indication of how many posts are likely to be available in round 2, especially in the less popular specialties and areas of the country? What estimate can be made, either now or in the run-up to 1 August, of how many essential posts in hospitals are unlikely to be filled, and whether there will be a great informal hiring system to try to make sure that patients do not suffer?

Finally, since last year, Dr. Gordon Caldwell of Worthing and others, including Richard Marks, the London anaesthetist, have tried to engage with the problems, which are now accepted by the Department. People involved in the process, whether they said that it could be improved or that there were dangers, or whether they helped to run it—I pay tribute to them for their diligence and dedication—ought to get together. Will the Minister meet Dr. Gordon Caldwell, perhaps his father, Bob Caldwell, who is rather good at algorithms, and Richard Marks? I am not sure whether John Marks is still alive—

Order. I think that the House has enough questions to work on for the time being.

Thank you, Mr. Deputy Speaker. I am grateful to the hon. Gentleman for his comments, as he has taken a very close interest in this matter. I should like to place on record my appreciation of my officials, who worked exceptionally hard to ensure that the evidence was put before the court so that the judicial review hearing could be expedited. I will look specifically at the hon. Gentleman’s point about making all the submissions available.

I have already dealt with the issue of the number of jobs in round 2. There is real confidence among the postgraduate deaneries that, as I said, a substantial number of posts, including those 200 very good new run-through posts, particularly in the most popular specialties, will be available in round 2.

On the issue of hospital staffing in August—again, we have discussed that on other occasions—hospitals are used to planning for the normal changeover of junior doctor rotation in August. Obviously, they have to step up those plans this year, but they are doing so with the support of the strategic health authorities. We expect hospitals—and the chief executive, David Nicholson has made it clear that he does so, too—to ensure that patients continue to be cared for properly and safely. As part of the process of learning lessons from what has happened and ensuring that the whole system works properly in future, we will engage with as many people as possible and ensure that those lessons are learned. As I have said to the hon. Gentleman before, if he gives me details of particular individuals who would like to contribute, we can ensure that the review group or officials meet them.

We are shortly to have a statement about how the Government want to charge people according to how much rubbish they put out. I suspect that the Department of Health will face a hefty bill, judging by the rubbish that has come from it in recent months. Why has this shambles been allowed to drag on for so long? What time scale has the Secretary of State given herself to look at whether Remedy UK will face a legal bill, and what time scale does she think Sir John Tooke requires to publish his report?

I have already dealt with most of those points. As for the Tooke review, Sir John said that he will publish an interim report in September that will be subject to widespread consultation, but it will be up to him to decide when he publishes his final report.

A junior doctor in my constituency told me that the chaos of U-turns and compromises announced by the Government has left him facing a brief interview, which, he says, gives him 30 minutes to save his career. Does the Secretary of State accept that that is no reassurance that he and thousands of others have a future in the NHS?

The interview that was guaranteed to every candidate, including those who had not been shortlisted in the initial round 1, gives everybody the opportunity to be interviewed for their first-preference job, but that is not the end of the matter. Phrases such as “one opportunity to save my career” and “make or break” simply do not reflect reality—

The point that I want to make to the hon. Gentleman, and through him to his constituent, is that any applicant who does not secure a training post in round 1 will be able to make as many applications as they want for the substantial number of posts that will be made available through round 2. As I have said, we are taking steps to ensure that applicants in NHS employment whose contracts come to an end during round 2 will be able to continue in NHS employment while they try to secure a training opportunity in round 2. I have already dealt with what happens to people at the end of round 2.

It is right that there should be an increased number of training posts, but they will be run-through posts to nowhere if there is no expansion in the number of consultant posts in order that those who are being trained can be provided with jobs at the end of the process. It is not only service that dictates the number of consultants, but policy—national policy to provide trainers for those extra people, the European working time directive and the consultant-led service. Will the Secretary of State undertake to get a national grip on the increased number of consultant posts needed to provide those policy outcomes and careers for all the junior doctors who are dedicating themselves to training?

The hon. Gentleman raises an important point, but he is in a little danger of turning the situation on its head. The number of consultancy posts depends on the needs of the service, although of course that is in the context of the working time directive, national service frameworks, National Institute for Health and Clinical Excellence guidelines, and so on. It also depends on what individual hospitals judge they require and what the specialist royal colleges and associations recommend. All those factors have to be taken into account to ensure that in every part of the country the NHS gives patients the best possible care. That will determine the number of consultant posts and the number of training opportunities and non-training junior doctor posts, which will continue to make a valuable contribution to the NHS. As I said earlier, there will continue to be stiff competition for consultant posts, which is how it should be.

I am sure that many of the junior doctors in my constituency who contacted me because they are concerned about this whole process will welcome the announcement of additional training posts. Will the Secretary of State clarify where the funding of those training posts will come from? She said that it would come from the Department and SHAs, but will it be from existing budgets or will additional funding be found for those posts? What is her estimate of the total cost of funding those additional training posts?

I am grateful to the hon. Lady for welcoming the announcements that I have made. The funding will come from the existing budgets of SHAs and the Department. I am not making a claim on the reserves. I always find it entertaining when Opposition Members who voted against extra funding for the NHS ask for extra funding for something else. I stress this point to her: because of the difficult decisions we have taken over the past 12 months, the NHS as a whole is not only back in financial balance but will have a surplus in the financial year that has just ended, putting it into a much better position to deal with those extra funding needs. We shall not know what the cost will be until we know the number of applicants who have been assessed as ready to progress to further training but for whom training opportunities are not currently available. What I have indicated is that there will be funding for the number of additional opportunities required for those candidates.