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Health: Modernising Medical Careers

Volume 690: debated on Monday 19 March 2007

My Lords, with the leave of the House, I shall repeat a Statement made earlier today by my right honourable friend the Secretary of State for Health. The Statement is as follows:

“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—MMC—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 this year, facilitated by the online Medical Training Application Service—MTAS. That process sets out national recruitment and selection criteria, documentation and standards, replacing the countless local appointment 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 2007 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 consider appointing 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 among 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, 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 immediate action, but 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. In particular, all eligible applicants for level 3 and 4 speciality training—ST—will be guaranteed an interview for their first or second choice of training post; that includes those who have so far been offered only their third or fourth choice. All applicants at ST1 who have not been shortlisted for any interviews will have their application 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 be offered an interview in round 1. Those who are not selected for interview will be offered career guidance and support to enter round 2.

“We expect over 5,000 more doctors to be interviewed in round 1 as a result of these changes. 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 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”.

My Lords, that concludes the Statement.

My Lords, I thank the Minister for repeating the Statement made by the Secretary of State in another place. Knowing what a charming Minister he is, I am sure he will avoid the mistakes of the Secretary of State in her answers to questions. She was asked six times if she would apologise for the shambles that we find ourselves in. Unfortunately, she would not. It was also unfortunate that she started blaming others for the shambles. It was a pity; all she needed to say was, “It is a shambles, we are sorry for the inconvenience and we are going to put it right”. That would have been very acceptable.

To be fair to the Government, MCC has been discussed for three years and the Government have taken notice of what people have been saying. For instance, they agreed with the Royal College of Physicians in its desire to have longer training before entering specialist training, like gastroenterology. The Government agreed that there could be another two years for securing membership of the Royal College of Physicians before entering further specialities. That was good.

There is a very big problem in surgery. As noble Lords are probably aware, there are five or six SHO—senior house officer—posts for every training post in surgery. That is an unfair disadvantage, but it has been so for a long time. Those who were not successful in securing a post could stay in the SHO post until a vacancy occurred. The problem with the arrangement that we have got is that it is like a big bang; it has come in too quickly, whereas the Calman system was phased in gradually—that would have been much better.

As was mentioned in another place, one of the problems has been the scoring arrangements. For instance, if you had a PhD, you got one point. On the other hand, if you wrote a good essay on “How I Deal with Stress”, you got four points. If you produced a poster at a meeting, that would be three points. It takes about an hour to prepare a poster for a meeting; it takes three years to get a PhD and you have a very tough exam at the end of it. There is something radically wrong. Not having the curriculum vitae in front of the examiners is a serious disadvantage indeed.

Another extraordinary thing is that there was no distinction made between an MD of Cambridge and an MD of Harvard or Pisa. Is there a difference? All the difference in the world—they are completely different exams. On average, a Cambridge MD is taken six years after you are qualified, and means that you have worked extremely hard for a long time and produced a thesis, which is no mean accomplishment. Of course candidates in Harvard are of a very high standard but its MD is a qualifying exam. An MD Pisa—well, someone said, “Say no more”. Perhaps I should point out that you can start as a medical student in some Italian universities simply if you want to. To be fair, such students are weeded out later but a very different system is used. The three MDs are totally different.

Another issue that arose in the other place was that the USA has had the system, which we will introduce, for 50 years—but it is not the same system. What happens is that candidates in the United States put their preferences in order and the hospitals and universities to which they are applying put their candidates in order of preference; that is a rather different system. Another point that emerged—we need to nail this one—was that the old system was terrible and was just an old boys’ system. I am afraid that that is not true. Just across the river at St Guy’s Hospital, for 50 years we have had a system whereby the candidates put the jobs that they want in order of preference, and so do the consultants. The junior staff vet the process, and their recommendations go to the consultants, who usually accept them. There is no way in which anyone can fix an appointment.

Finally, I repeat that it is a pity that the Secretary of State did not apologise. I am sure that the Minister will.

My Lords, it is astonishing that an initiative that was welcomed at the outset by all those involved in the process—the deaneries, the junior doctors and employers—could have gone so spectacularly wrong in execution. There was an agreement among most of those involved that it would be preferable to move towards a better technological system. However, it has quickly become apparent that what was going to emerge was nothing like what had been envisaged. The junior doctors’ committee of the BMA has been warning for more than a year that what would emerge from the proposals would not work, would be insufficiently sensitive and would be crude in application. So it has proven to be. That begs the question why the department has taken until the beginning of March to realise the extent of the system’s deficiencies; we know that the application system is due to be completed for posts that are supposed to begin in August.

The system’s deficiencies are clear not just in application but in design. The noble Lord, Lord McColl, referred to some of them but there are more. They are at their most deficient in that they give insufficient weight to people’s experience of research in pursuit of academic medicine. We have discussed many times in this House how the NHS has, in view of the access that it gives to large numbers of patients, perhaps the greatest potential in the world for a mix of practical medical care and research. It is only for the want of proper systems that we do not have—although we should have—the best medical and biomedical research system in the world. This application system clearly takes very little into account. That must be wrong and disadvantageous.

Will the Minister comment on reports in the past few days that the new system’s implementation has involved many non-medical staff in the appointment process? That is rather strange. One wonders, given the debacle before us, whether it is another sign of management consultancy in the NHS having gone several steps too far. Will he also explain what is meant by “career guidance”, which he mentioned twice during the Statement? It is a phrase that strikes fear in other walks of life and I wonder whether it does here, too.

We have concentrated mostly on what is an astonishingly bad process, but another matter has lain somewhat hidden behind the headlines. What will happen to the doctors who clearly will not get a post under MMC? The department’s press release issued at the end of last week stated that there will be lots of posts. What sort of posts will they be? Will they be for hospital doctors or GPs? Who will they be going to and how will that be decided?

This has been an amazing process to witness from the outside. It has clearly caused distress to applicants and dissatisfaction to the deaneries, and ultimately it must be a distraction from patient care and research over the next few months. I do not believe that the process can be stopped but can the Minister tell us what, if any, scope there is to reschedule its later stages in the interests of fairness and of ensuring that the best-qualified candidates get the opportunity to apply for the posts for which they are best suited?

My Lords, I am grateful to the noble Lord, Lord McColl, and the noble Baroness, Lady Barker, for their comments and questions on the Statement. I make it clear that we should appoint the best people possible to take on these training posts, as they lead to the most senior medical consultant and general practitioner positions in the country. It is very important not only that we select the right people but that the training that these doctors are then given is up to scratch. I also very much agree with the noble Baroness, Lady Barker, that, as well as ensuring that we have the best possible clinicians, we should never underestimate—I certainly would not do so—the contribution that doctors make more generally to science and to the research base in this country.

I say to the noble Lord, Lord McColl, that the Statement certainly recognises the stress caused to many junior doctors by aspects of the current system. This has always been a competitive process, and I guess that for junior doctors there has always been a high degree of stress. I have already answered this but let me get right to the point: where failings have caused problems for junior doctors, I, as a Minister responsible, must take responsibility. I do take responsibility for it; I would never run away from it. I have already said to junior doctors that, where they have been affected by problems with the system, I am very sorry for what has happened to them.

I say to the noble Baroness, Lady Barker, that, as soon as the problems became known to Ministers, we convened a meeting with representatives of the medical royal colleges. We agreed to a review, and those holding the review have been meeting almost constantly over the past two weeks. The Statement last Friday represented enormous hard work by all concerned, including my officials, the medical royal colleges, representatives of the BMA and NHS employers. Everyone is working as hard as they can to deal with the problems identified. I very much hope that the announcement made on Friday and the Statement by my right honourable friend in another place made it clear that we are in the process of resolving these issues. The review will carry on, and we will look very carefully at its outcome at the end of this month. Of course, we will want to learn the lessons and ensure that, where appropriate, changes are made in the current situation and into the future.

The system has worked well in some places, such as recruitment into GP specialty training. The noble Lord, Lord McColl, identified some of the inevitable challenges in the reform of the training programmes and selection to them.

The noble Baroness, Lady Barker, is right to say that it would not have been sensible to stop the programme in its tracks. Indeed, we did not receive that advice from the review team. It has clearly worked for many people; stopping the process would just cause much greater uncertainty. The noble Baroness asked about rescheduling later rounds in the appointment process. Clearly, many more details need to be worked out. We will be guided by the review team. Of course, there are practical consequences for the health service, and we must remember the time that practising consultants have to spend in short-listing and interview committees. With all those caveats, the answer is yes: rescheduling will be considered. If it is thought to be the right thing to do, we should consider rescheduling.

Career guidance means just that: guidance on the application process itself, with information on where the vacancies are in terms of area and specialty. It also means guidance for those who do not get through the competitive process. We should not run away from the fact that this should be a competition. We want the best doctors to be selected for the specialty training programmes, but that does not mean that those not selected should be lost either to the medical profession or to the NHS. Career guidance may be very helpful.

The noble Lord, Lord McColl, referred to the old system. He is very experienced, and this House has great respect for him, so it is fair enough for him to say that in his own hospital things worked well. However, the general consensus is that the old system did not work well. Doctors had to submit many different applications across the country for jobs that might be for only six to 12 months. Often there could be many hundreds of applications for a single job, as short-listing processes were variable. That is why all those concerned—the Government, medical bodies and junior doctors—got together to work through a new process. The noble Baroness, Lady Barker, was right to raise that. Those bodies are now around the table finding answers to some of the issues raised. I am confident that we can ensure that the issues are dealt with. We will have a robust approach to ensuring that the right people are appointed to training posts.

A number of comments were made about the scoring system. The processes were developed after much consideration by all the parties involved. I have taken account of noble Lords’ remarks. It would be fair to say that the system has worked better with candidates who have just come out of the initial training, 84 per cent of whom have been offered interviews. The issue of the points system probably applies more to the more senior applicants. None the less, it is important to learn the lessons. I will listen very carefully to what the review team has to say about that. I have responsibility for research and development and for the pharmaceutical industry, and, as I am sure noble Lords will recognise, I want the best possible research and clinical academic doctors in this country. I want to ensure that the system that we develop gets the best individuals.

The scoring and competency-based approach arose out of discussions and the Chief Medical Officer’s 2002 report which found that, in addition to academic and technical skills, it is necessary to recognise, for example, doctors’ communication skills with patients. We have had many discussions in this House about the need to enhance communication skills. However, I recognise that the scoring system as a whole is subject to comment, and we will listen very carefully to what the review group says.

My Lords, I am grateful to my noble friend for his responses, which were very helpful. This has been an extremely traumatic experience for many young trainee doctors, who feel very frustrated and uncertain about their future. It has left many considering moving abroad.

The application forms made it nearly impossible to judge who should be shortlisted. The forms were anonymous and largely ignored details of applicants’ CVs, previous skills, experience and training. They relied heavily on essay-type questions that anyone with access to the internet and reasonable creative writing skills could answer.

I am not trying to lay blame, because many parties have been involved in getting to this point, but I hope that my noble friend agrees that we should go back to the beginning and look at the application forms to ensure that they include details of what candidates have done and achieved and that they do not get involved in marking that is clearly erroneous.

My Lords, I thank my noble friend. I accept that this has been a difficult time for many junior doctors, and I understand how important being accepted for a specialty training place is for their career in medicine. I am not unmindful of the pressures on those junior doctors, but my understanding and experience is that it has always been a traumatic time for them. The process we now have is more transparent and has been organised on a national basis so, in a sense, that trauma is shared by many more people. We clearly need to do everything we can to make sure that the system is transparent, fair and felt to be fair and that people see the logic behind the application process and the interviews.

I should perhaps have said to the noble Lord, Lord McColl—or perhaps it was the noble Baroness, Lady Barker—that it is critical that doctors are involved in shortlisting and interviewing. I confirm that the key people making decisions are clinicians.

I will listen very carefully to what the review team says about the information in the application form. As a result of the discussions in that review, evidence of excellence in the form of a portfolio or a CV may be presented as part of the selection process. I hope that that meets some of the concerns that my noble friend raised.

My Lords, how much notice is taken of references in selection? Is it not important that the very best doctors are selected for the specialty of their choice so that they have the necessary interest to give full commitment to the post, and to go on learning and improving? Surely, that is a definition of an expert. Is it not a fact that many people are becoming worried by the word “modernisation”?

I hope not, my Lords, because in the health service we are seeing many more doctors being trained and employed—30,000 more than in 1997, I think—and a huge commitment to improving the training of our doctors. That is part of the reform of the National Health Service that noble Lords have wanted and which is being put into action. The programme of training running alongside Modernising Medical Careers is intended to be much more cohesive and appropriate than the rather patchy approach that has existed for many years. However, I accept the comments of the noble Lord, Lord McColl, about his own experience.

It is important that those making the critical decisions of appointing doctors to training posts have relevant information. That is why I said that evidence of excellence in the form of portfolio or CVs may be presented as part of the selection process. However, I believe that there has been some inconsistency between the deaneries responsible for administering the system in different parts of the country. Part of the review process will be to ensure that good practice is made known to all deaneries. I certainly accept the point made by the noble Baroness: we must appoint the right people.

My Lords, the Minister says that a portfolio of experience may be presented. In a process that has taken so long to design, involved so much effort and that is so important to the NHS and to the doctors who have spent years in education, can he explain what he tells his doctors about why the system was designed so that their experience, CVs and references were given so little weight?

My Lords, selection into each specialty was based on person specifications that were agreed with the Postgraduate Medical Education and Training Board and the royal colleges. Attributes that the doctor should have for that specialty are described there, becoming more specific as the level applied for in a training programme increases. The selection processes were devised with the input of stakeholders, including postgraduate deans, the medical royal colleges and trainees. The Academy of Medical Royal Colleges and junior doctors from the BMA were part of the stakeholder group responsible for developing the recruitment and selection processes. The application form asked applicants to provide evidence of their skills, experience and commitment—and, where appropriate, of their achievements in the specialty. Eligible applicants were considered for shortlisting by senior doctors in the specialty who were trained in the process.

The principles that I have just described to the noble Lord were agreed by all the stakeholders. It is quite clear that some shortcomings, as noble Lords have mentioned, have been identified. Some of those may be due to a variation in practice from deanery to deanery; others because they have been identified as the system has come to work in practice. As I have said, the review team continues to meet and there are still more details that need to be agreed. We await its final report at the end of this month; that will inform how the process will proceed. Where problems have been identified, I am keen that we put them right.

My Lords, I think that we are very grateful to the Minister for his apology about what has happened. We all recognise that he has been one of the most popular Ministers with the medical profession in the health service for the good that he has done, for which we are very grateful. Frankly, however, this situation has been a bit of a disaster. I suspect that it is not really the current Minister’s doing; none the less, it needs to be put right urgently.

Unfortunately, we are still hearing one or two buzzwords that I would rather not hear. The Minister used the word “transparent”. I do not believe that this process is truly transparent. There has always been competition for jobs, and it is right that there should be, because competition should ensure that the best people for the job get it. However, the current competition certainly does not allow for that; nor is it fair or logical. Of course every patient wants communication, but ultimately what they want above all from their doctor is competence. This method of application does not allow for competence, because it is purely subjective. The whole form is badly designed.

I speak as someone who has a conflict of interests. I have a son who has just gone through this process. His PhD yielded 11 publications in good peer-review journals. None of that could be shown on the form; nor could someone who has worked with him give him a reference. A young woman who works in my laboratory started as a science graduate and gave up every summer and winter holiday to work in the laboratory voluntarily. She managed to raise funds to maintain the research that she was doing and got her trips to California paid for three times. She went through medical school at my suggestion and has been absolutely assiduous at every stage. However, the trouble is that, although she has given up every holiday, she is now in this system and I cannot give her a reference, even though she is absolutely outstanding. That is quite shocking because the quality of the reference is very important, and we must accept that it is the only way in which you can judge someone’s initial competence when they apply for a job. I therefore hope that the Minister will review this whole method of application very carefully after the initial impact has been dealt with.

My Lords, I am grateful to my noble friend. I am sure he will accept that it was better to convene this review group to deal with the immediate issues that have been raised and to allow round 1 to continue, and then to listen further to the review team to see what further changes might be made in round 2 and to learn further lessons about how such a process can be implemented in future years. I give that commitment to my noble friend. It is fair to say that the application form is not about testing clinical skills; it cannot do that. Its purpose is to choose people for interview, where evidence of their competence in given areas can be further assessed. The questions were designed in partnership with the Academy of Medical Royal Colleges, training representatives and other stakeholders. I fully accept that it is important that all those stakeholders, particularly the junior doctors who are applying for specialist training programmes, need to have confidence in the process. I am committed to doing that, to listening very carefully to the review group and to making necessary changes. I shall take very careful note of what my noble friend has said.

My Lords, I, too, declare an interest in that my son is also going through this process. I am also grateful for the Minister’s apology. I take it from his apology that he is aware of the devastating morale implications of how this process has panned out and the changes that have taken place because of the difficulties that arose and the consequences that have resulted. For example, people have to scurry around at short notice in the midst of differing shift patterns to get references, which are now being accepted and have to be signed in person.

I have a question about the process of short-listing and the task of the consultants and those who have to do it. I am aware that any process designed by a committee is going to be much better than one designed by an individual—that necessarily follows. However, this process requires people to consider a series of 150-word statements, many of which will be similar in tone and nature, if not identical in wording, and to look at many dozen—and in some instances several hundred—such applications in a short period. I wonder whether those who advised on this system had thought about the practicalities. Many of us who have been involved in other forms of selection processes recognise how difficult it is to look at what are essentially standard statements and distinguish between them. I wonder how sensible it was, and how much this was reviewed by those who are experienced in this sort of selection process.

My Lords, my noble friend raises an interesting point. I fully understand the difficult time that this has inevitably caused for junior doctors. However, whatever system had been adopted, choosing junior doctors to go on to specialty training courses will inevitably, like other tough selection procedures, prove a stressful time. But of course we need to make sure that those junior doctors have confidence in the processes and procedures they go through. That is the importance of the work of the review team, to which we will listen carefully.

Let me make it clear that applications were scored only by doctors. Preparatory work was done by the individual deaneries, which were responsible for the administration of this system, to help doctors in the most effective way possible. Again, I will want to listen to the feedback from doctors involved in both the short-listing and the interview process to see if there are areas where improvement can be made. That is the whole purpose of the review team. I offer enormous thanks for the time the doctors involved have given up so far and will give up in the future. However, it would not be fair to say that they were not given appropriate guidance and support, and I am keen to learn any lessons that have come as a result of their experience.

My Lords, the numbers in the dental profession are much smaller, but is the Minister aware of any plans to expand this recruitment and selection process to specialisms in dentistry?

My Lords, it is perfectly clear that a number of candidates of very high calibre have been missed and not offered interviews. Perhaps this is a question for Professor Douglas’s review group, but does this not have a knock-on effect in that those who have already received interviews may be some of those who are perhaps not of such high calibre? There is a limited number of posts and some of the people who are perhaps not the crème de la crème may already have been recommended for them—or if not appointed. Is this not going to somewhat queer the pitch even if all those doctors who have been refused interviews eventually get one?

My Lords, I can tell my noble friend that my officials have taken careful advice on the appropriateness of the procedures that are now going to be adopted. No appointments have been made in round 1. I can also tell him that the initial feedback from those doctors who have already undertaken interviews is that a very high standard of candidate has been short-listed. But the importance of the Statement last Friday is that it enables us to strengthen the process in round 1. It means that all applicants at ST1—the first level of the specialty training—who have not been short-listed for any interviews will have their application reviewed and may be offered an interview in round one. That is the most appropriate way to try to deal with the issues immediately, but as I have said to my noble friend, we have sought advice and we are confident that this is the correct way to proceed.

My Lords, I would like to pick up on the point made by the noble Baroness, Lady Barker. When everyone embarked on this journey we were in general agreement that there was a case for change; that life was not perfect under the old regime. First, I would like to know when these discussions commenced. Secondly, could the Minister indicate at which point, in his opinion, things started to go wrong? Thirdly, I would like to address a question to some of my colleagues here. How do we know that these people who have not been selected are of high calibre? Who is making the judgment about this?

I was in one of our famous hospitals on Friday afternoon, being tended to by a young junior doctor who told me that she was generally in favour of the changes being proposed. She was of Asian extraction. She said she believed that under the system she would have a much better chance of being able to compete for the better posts that were to be filled. She was generally in favour, but she believed that there would be strong resistance—as there always is, in her opinion—to any change, particularly from consultants and from people of the old school, as she described it. She says there is still an old-boys system operating which she found quite unacceptable—I raised this with the noble Lord, Lord McColl, at lunchtime. There will be a whole range of different views on this, but when does the Minister believe that the situation will be resolved to, as is hoped, everyone’s satisfaction? Those of us who do not have a vested interest other than simply being patients in the NHS want to ensure that, as the Government proceed with their programme of modernisation, there is a direct link between delivering the agreements reached by the stakeholders and the way in which those stakeholders are subsequently rewarded with the taxpayers’ money, to which we all subscribe.

My Lords, I understand that there have been intensive discussions about the new system among all the stakeholders I have mentioned over the past four years. My noble friend then referred to the old system. Of course, one of the problems that has always been perceived within it has been the question of whether there was an old-boy network. There has been some evidence of that. But there were also concerns that junior doctors went from job to job without properly focused training. As I have said already, junior doctors often applied to many different institutions. Often hundreds of applications were received for one post. The whole system was completely unsatisfactory. That is why the stakeholders got round the table to devise a new system. I have no doubt whatever that coming out of this will be a fairer, better approach to the selection and training of doctors to go on these important, specialty training programmes.

Equally, it has been clear that there have been some practical teething problems with some of the deaneries and the way the process has been approached. The purpose of the review team is to learn those lessons and put things right that need to be put right and then to proceed with the general principles of a fair process designed to ensure that the best possible doctors are selected for specialty training programmes to the benefit of the National Health Service and the people of this country.