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Medical Training Application Service

Volume 692: debated on Wednesday 16 May 2007

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

“Mr Speaker, following the recommendations of the review group chaired by Professor Neil Douglas, an extended round 1 of recruitment to postgraduate medical training is now taking place. As the House knows, every eligible applicant for postgraduate medical training has now been guaranteed at least one interview for their first preference post, regardless of the outcome of the earlier shortlisting process, although many trainees of course will have more than one interview. An additional 15,500 interviews have therefore been arranged as part of round 1, and are now taking place. I am extremely grateful to the consultants who have made themselves available for these additional interviews, and to hospitals for making the time available.

“The review group agreed that offers for the current round will be managed locally by individual deaneries on the basis of published MMC guidance. Subject to the outcome of the current judicial review, the first offers for hospital specialists in England will be made on or after 21 May, with all initial offers made by early June and round 1 completed by late June. Given the continuing concerns of junior doctors about MTAS, the system will not be used for matching candidates to training posts, but will continue to be used by the deaneries.

“As we have stressed before, not all training posts will be filled in round 1, and there will therefore be further substantial opportunities for those who are not successful initially, including the new training posts that are now being agreed by the NHS and the Postgraduate Medical Education and Training Board.

“We have accepted the review group’s recommendation that this further recruitment will be locally planned and managed by the postgraduate deaneries. Because most trainee doctors’ contracts are due to end before the further recruitment has been completed, we will be agreeing with the review group, deaneries and hospitals the necessary measures to ensure that all those trainees are properly supported and that patients continue to be properly cared for.

“Finally, as I told the House yesterday, in relation to the recent security breaches of the online application service, a full security review of the MTAS system has now been completed and validated, and appropriate action taken to deal with the problem. The site was therefore reopened last week, for the use of postgraduate deaneries only, to support the next steps in the recruitment process, including continued monitoring in line with the principles of modernising medical careers. Because the investigation has made it clear that criminal offences may have been committed, the security analysis and report have been given to the police”.

My Lords, that concludes the Statement.

My Lords, I thank the Minister for repeating the Statement. It is almost impossible to exaggerate the extent of the disaster that Ministers in the Department of Health have presided over in relation to postgraduate medical training. The Statement represents a complete abandonment of the system of recruitment that they have been doggedly defending over the past few weeks. Yet in defending MTAS, Ministers have simultaneously left junior doctors bereft of any further information. MTAS itself has been shut down; we have seen important developments leaked to the media without any accompanying government comment. The whole process, over many months, has been characterised by poor planning, insufficient consultation and absolutely catastrophic implementation. Morale among junior doctors has been hit badly and the credibility of Ministers on this issue is now at a nadir.

Nevertheless, we are where we are and Ministers must now sort matters out. It will be helpful if the noble Lord, Lord Hunt, can answer a few central questions. Apart from the failure of MTAS, which has effectively been abandoned, one of the main concerns among junior doctors applying for posts is how round 2 of the recruitment process will work. The concerned voice from many quarters over many months has been that, in planning the number of training posts to be made available, the Government have failed to make allowance for the number of trainees coming through the foundation years in addition to those coming through the senior house officer route and that there will therefore be a bubble of applicants chasing a much smaller number of jobs. How many extra training places will there be and what proportion of the total number of such places is likely to be filled by the end of round 1B? How many training posts filled this year will be temporary or fixed term? And, in passing, why can the Scottish deanery offer four interviews and England only one?

There is an obvious dilemma for doctors who do not get posts in round 1. They need to know what other jobs will be available and where they are, and they will have to apply for these jobs before 1 August. They also need to know what happens if they do not succeed in round 2. Therefore, will these available posts in round 2 be advertised in a timely way, and to what extent will opportunities be available for entry to speciality training next year for those not appointed this year?

Alongside the uncertainty for doctors, what about the uncertainty for NHS trusts? How are trusts supposed to fill their service grade posts between the end of June and 1 August if the available pool of doctors is in the course of applying for postgraduate training posts? What contingency plans are in place to ensure continuity of patient care when the changeover of doctors’ posts occurs on 1 August?

The Minister will be all too aware that a great deal of good will is being drawn on in getting the recruitment process on to some kind of stable basis, not least the extent to which senior doctors who are having to cancel their lists are devoting large amounts of their time to conducting interviews. For their sake, as well as that of junior doctors, I hope that the Minister will appreciate the need to provide full and detailed answers to the many questions that the medical profession as a whole is asking.

My Lords, when we discussed this matter two weeks ago, it was commonly recognised that something had gone badly wrong, but quite how seriously was not then obvious; it is becoming so now. Given that, the Minister would do well by the NHS if he were able to provide answers to a number of detailed questions.

The Minister has announced that the system is to be subject to a review led by Sir John Tooke. Can he assure the House that that review will be wholly and thoroughly independent of the Department of Health? Can he explain the extent of the involvement of the Chief Medical Officer in the design of the MTAS system? The Chief Medical Officer is, after all, the doctors’ doctor in government, so there is a serious concern shared by all doctors about the CMO’s role.

In the Statement, the Minister referred to criminal offences. I do not expect him to speak in detail about particular offences, but can he give us the order of seriousness of the offences that have been notified to the police?

What is the cost to the NHS of the MTAS system and the handling of this crisis? The noble Earl, Lord Howe, spoke of consultants being taken away from patient care in order to conduct interviews. Has the Department of Health made an estimate of quite how much this affair has cost the NHS? Further, what is the position of the contractor for MTAS and what is the status of its contract with the department, given the appalling level of service provided?

This year, we are going to subject doctors to a system that is patently unfair. We will have doctors who have been recruited using a system that is now widely recognised as fundamentally flawed. Does the Minister agree that there is a case for making all the appointments to posts this year for one year only, and next year introducing a system that is full, open and fair, and in which all doctors are appointed on an equal footing?

Finally, a problem at the heart of all this, one which has been ignored, is that there are not enough training places. Over 30,000 doctors are chasing 23,000 jobs. In all the four Statements that the Minister in another place has made, she has not addressed that central issue.

My Lords, I say in response to the noble Earl, Lord Howe, that it is clear that there have been visible problems with the MTAS system. But I stress that the Modernising Medical Careers programme came about because doctors and medical bodies found the old system unacceptable. Applicants often had to make dozens of applications, the training was patchy and it had elements of the old-boy network about it. Those very same organisations were all involved in the planning, strategy and development of the new system. It is important to keep in mind that there has always been strong support for the principles behind Modernising Medical Careers.

The noble Earl has asked me some specific questions that I am afraid I am simply not in a position to answer. That is because round 1 has not yet been completed. It is still going on; interviews are still taking place. As was repeated in the Statement, we are very grateful to the NHS trusts and to the senior consultants who have given up time to take part in these further interviews. Only when the first round is fully completed and the offers have been made—as will happen in June—shall we know how many places have been filled and, therefore, how many places will then fall to be filled in the second round.

I understand completely the point that the noble Earl makes about the need for junior doctors to have as much information as possible as early as possible. I absolutely accept that, but we are not in a position to give that information at the moment because it simply is not available. Of course, when the information becomes available, we shall want to ensure that it is put in the public domain and, more specifically, communicated with junior doctors as soon as possible.

Scotland has taken a different approach, but some of the logistics are different. In England, some of the deaneries have a huge number of appointments to deal with. After consideration by the review group, which consists of representatives of very distinguished medical bodies, it was decided to take the approach in England that was considered the most practical. It has ensured that applicants who were not shortlisted at all in round 1A were all given the opportunity to have an interview for at least their first preference in round 1B. We think that that is a pragmatic and sensible solution. It was taken after we had received advice from the review group established under the chairmanship of Professor Douglas.

I fully accept the noble Earl’s point that decisions made in relation to specialty training have a knock-on impact on NHS trusts. Again, I pay tribute to the way in which NHS trusts collaborated with the department and ensured that consultants were released to conduct interviews. He referred to a potential gap as regards some applicants moving to round 2. The relevant interviews will take place and we will set out a timeframe. The noble Earl is concerned that that will lead to uncertainty among NHS trusts. Work is going on with those trusts to ensure that there is continuity of employment and that services do not suffer as a result. That is also my answer in relation to the 1 August date and the issues raised about that.

I say to the noble Baroness, Lady Barker, that I cannot go into the details of the report that is being made to the police. However, the security breaches were very serious indeed and are to be deplored. That is why we took the action that we did. We have now passed that information to the police authorities.

My answer on the Tooke review is the same as I gave when the noble Baroness asked me about it two weeks ago. Sir John Tooke is a wholly independent person. The review is entirely in his hands and I am sure that it will be conducted as appropriately as possible. We all want to learn the lessons that need to be learnt to make sure that the system works well in the future. That is in everyone’s interest. Having met Sir John Tooke, I am very confident that he will take a rigorous approach. I also take this opportunity to thank Professor Douglas and his group for the help that they have given in the past few weeks and will give in the weeks to come.

The noble Baroness asked me two questions about costs. I cannot give a figure about the cost to the NHS of releasing consultants. However, under the old system, hospitals had to deal with dozens of applications. Consultants spent time dealing with those. I suspect that it would be impossible to make a comparison between the two systems. It is always part of the duty of consultants and hospitals to take part in recruitment for specialist posts, and it will continue to be so.

The cost of MTAS in 2006-07 was £1.9 million. We reckoned that the five-year cost of the MTAS system was £6.3 million. We will look at the company that we contracted with, and the contract, and keep that under review, in the light of both the experience with the security breach and the future requirements of the system.

The noble Baroness will know that a judicial review hearing is taking place at the moment, and it would not be right for me to comment further on that. It has been suggested that everyone should be offered a one-year post, but that would bring a great deal of uncertainty to many people who have gone through the proper process and the interviews and who would, under our present intentions, be offered run-through training. I do not believe that the suggestion is a panacea. The medical organisations, such as the BMA, that sit round the table in the review group chaired by Professor Douglas are all of the clear view that we must continue with the current process. That is the proper way through, and it is the proper way to ensure that at the end of the day we have the best people in these training posts.

I was asked about additional training places. They are subject to discussions at the moment with the NHS and the Postgraduate Medical Education and Training Board. I am not in a position to give any figures, but when we have the full information we will make it available to the House and to junior doctors.

My Lords, I declare an interest, as my daughter is going through the MTAS system. Can the Minister confirm whether the figure given in the other place is correct and that £1.9 million was spent on IT for this year? By my reckoning, that would cover the cost of about 20,000 junior jobs, which is twice the number of potentially unemployed juniors. What percentage of the posts, which were all educationally approved, are fixed term, and what percentage will be run-through training to allow those doctors to carry on to specialist training? What is being done to increase morale among junior doctors? A paper in the Lancet showed that 95 per cent of juniors are profoundly demoralised and disillusioned with the Department of Health and the way in which this is being handled.

What support will be given to juniors who have to relocate at very short notice when they find that they have a job offer that is outside travelling distance from where they currently live? The lag time to relocate is normally about three months and they will certainly not have that time in hand. Will the Minister confirm that the way in which this is now being run means that those who have had interviews and who have been successful in different disciplines will be given job offers in each of those disciplines and therefore will have an element of choice, rather than finding that they have been shoehorned into one job in one specialty, which is how it started out?

My Lords, I will try to respond to some of those questions. The figure for the cost of MTAS in 2006-07 is correct. I am not sure that it equates to the number of junior doctors that the noble Baroness mentioned; it sounded to me as though the figures did not equate too well, but I am certainly prepared to discuss that with her. The breakdown of the training posts in England, which are the figures that I have, is that 11,943 are for run-through training; for the UK as a whole, that figure is 14,595.

The noble Baroness said that juniors will receive what she described as “short notice” of their new post and will have to consider moving. Of course I understand those issues and the pressure on junior doctors in general, and it is very important to ensure that the right advice and pastoral care is available to help them in that situation; I fully accept that point. There is nothing new about what is happening. This has been an issue for junior doctors for many years. They have applied for specialist training posts; they may have been accepted and they may well have to move to different parts of the country. That is the nature of junior doctors’ training; they have always come under that pressure. I accept that we need to ensure that juniors this year are given as much guidance and advice as possible. We are in close discussion with the postgraduate deaneries to ensure that that happens.

I can confirm that the integrity of round 1A interviews will be maintained. When candidates receive the results of interviews throughout June, some will receive more than one offer.

My Lords, does the Minister accept that in a country which prides itself on its technological expertise, it is extraordinary that a computerised system designed to improve the postgraduate training of doctors has failed so abysmally to satisfy the needs of the health service and of the medical profession—and that at a time when the vastly expensive Connecting for Health system is also struggling to fulfil its objectives? What can be done to ensure that the computerised system will be “fit for purpose”—to use a popular phrase?

Bearing in mind the point made by the noble Baroness, Lady Barker, is the Minister satisfied that there really are enough training posts to be occupied by all of those coming out of the foundation programmes? Is he aware of press publicity concerning demoralised doctors being invited in considerable numbers to go to Australia, for example? Those doctors have been trained at great public expense in the UK and are much needed by the National Health Service. It is a very serious situation and it is good to know that the MTAS programme has been put on hold in favour of the old-fashioned system that had its defects, but at least gave doctors adequate notice before they took up new appointments.

My Lords, I want to draw a distinction between the Modernising Medical Careers programme and MTAS, which is a technical system by which applicants made their preferences known, through which their interviews were arranged and which informed them of their success or otherwise. The principles of Modernising Medical Careers hold good and are widely supported by the profession, which made a considerable contribution to their development.

It is clear that there have been issues and problems with the MTAS system and that is why in the next stage we will look to local deaneries to do the work required in matching applicants to available posts. There are lessons to be learnt and that is why we have established Sir John Tooke’s review.

I have already told the House that we are working with the Postgraduate Medical Education and Training Board to establish whether more training posts—and how many—could be created. However, I caution the House that it would be wrong suddenly to create a huge number of extra training posts if, at the end of the training programme, the consultant or GP jobs were not available. It is important that we keep in balance the workforce requirements of the NHS and the number of training places.

Yes, there are over 30,000 applicants and the number of training places is about 22,000 to 23,000; but there has always been an oversupply of candidates for training posts. There has been a bulge this year, because there have been applications from many candidates who have been working in the NHS for several years and who have always been looking for further training opportunities. However, most of the applicants work in the NHS and will continue to work in it, but some will not be successful in getting on these training programmes. That is no different from what happened in previous years.

My Lords, does the Minister accept that what has happened has not only damaged people’s confidence in the system but, in a number of cases, has also damaged individual applicants’ confidence in their own sense of vocation? What plans do the Government have to seek to restore that sense of vocation in these young doctors and in the profession generally, which is so important to the well-being of our society?

My Lords, I thank the right reverend Prelate for that question. I have no doubt that the events of the past few weeks and months have caused a great deal of anxiety to junior doctors applying for specialty training posts. There is no doubt about that; nor is there any doubt that they are dedicated people who have a vocation to help people and to work in the National Health Service. I fully accept the right reverend Prelate’s challenge: we have to ensure that this system works and that the value of our junior doctors is fully recognised. In a sense, the response that I gave to the noble Baroness, Lady Finlay, about pastoral care applies to junior doctors generally. It will be very important for all of us in the National Health Service to ensure that those doctors understand that we greatly value the work that they do and the contribution that they can make in the future.

My Lords, does my noble friend accept that when the noble Earl, Lord Howe, referred to the disaster that Ministers have presided over, it would have been an even greater disaster for patients if we had kept the number of training places for doctors at the level that it was at when this Government came into power? We are now dealing with problems of success in doctor training, not problems of failure. Will the Minister accept that I regard it as a sign of strength in politicians when they change their mind on the basis of empirical evidence? I do not regard it as a weakness, and I commend my noble friend for repeating the Statement, which reflects that change of mind.

We should not allow the bad news—and it is bad news—about the need for training places for doctors to overshadow other news about the National Health Service that has come out today; for example, the report of the Healthcare Commission.

My Lords, does my noble friend recognise that, in this context, the report shows that overall the National Health Service is doing a good job? Patients gave a vote of confidence in the overall level of care. I remind him that Anna Walker, chief executive of the Healthcare Commission, said:

“We hear a lot of negative comment about the NHS, but we must never forget that most patients have consistently rated the [National Health Service] as good or excellent”.

My Lords, my noble friend has raised some very relevant questions. It is worth making the point that the Healthcare Commission’s report showed an ever-higher degree of satisfaction with the NHS among patients. My noble friend is right that one reason why we need to reform medical training is that we now have many more doctors. We increased the number of training places and there are 30,000 extra doctors in the health service. That is why waiting times have come down and why we have opened new facilities, and it is why we have to ensure that our doctors of the future are given the best possible training. That is what Modernising Medical Careers is about: it is about getting rid of the old, inconsistent, patchy approach to training. I am absolutely convinced that the outcome, as we have seen from the foundation course for very junior doctors, is that we will get better doctors and higher-quality patient services.

My Lords, I am one of those who have nothing but praise for the current state of patient treatment in the NHS, particularly in London, where my family has been very blessed in having had remarkably good treatment. However, will the Minister acknowledge that the anxieties, the impression of disorder and the poor arrangements surrounding the promotion of junior doctors onwards will have a knock-on effect on those who may still be at school but are thinking of entering the profession? What will the Government do to try to reassure these young people who are taking A-levels, which will take them on to medical school, that, by the time they reach the same position as those who are being examined at the moment, they will not be subjected to the same sort of chaos?

My Lords, there is nothing fundamentally wrong with the modernised medical careers programme. We have dealt with the issues as they have arisen, such as the problems with MTAS. That is why we set up the review group and accepted its advice to place responsibility in the local deaneries for the next part of the MTAS process. The quality of candidates coming through into medical schools is of a very high order, and information is beginning to reach us suggesting that many of the candidates who have been interviewed for the specialty training posts are first rate. It is no coincidence that one of the reasons why we have such a strong research-based pharmaceutical industry is the quality of our clinical staff, and the quality of our science base. I assure the noble Baroness that we shall do everything we can to enhance that reputation.

My Lords, the question of how morale can be restored has been asked. When the Secretary of State in another place was asked to apologise six times during the discussions, she refused, but the good news is that our Minister here, the noble Lord, Lord Hunt, has apologised. That was very much appreciated. There is no doubt that when the Government make mistakes, they should apologise and avoid attacking the medical profession and accusing it of making mistakes. A lot of remarks have been made about the old-boy network—the Minister used those words himself. Many hospitals have tried very hard over many years to make a serious attempt always to appoint the best candidates. When I mentioned that in a previous discussion, the Minister dismissed it as a one-off.

Let me explain that if you put, say, 100 applications in order of merit on the basis of previous exam results, clinical assessments, and so on, then give that list to another group of people—perhaps the consultants—to see whether they agree, you end up with a list in order of merit. A secretary then gives the top one their choice and so on all the way down. There is no way that you can have an old-boy network as you cannot fix a job at all. Many centres in the country tried and established that system, and the old-boy network was precluded in many places.

On the business of trying to avoid mistakes in the future, have we in place a system that will avoid awarding one point to a candidate with a PhD, and four points to a candidate who writes rather a good essay on how to manage stress?

My Lords, I hold the noble Lord in high regard. He is a brilliant doctor and has done sterling work in the health service over many years. I would never accuse him of being part of the old-boy network, but there have been strong criticisms about the traditional approach. I take the noble Lord’s point about working with doctors and medical bodies, which I have always sought to do because I think that that is the only way to achieve success in the health service. However, I was making the point that they were all involved in the discussion on the principles of changing the approach to training. They gave broad acceptance because of the concerns expressed about the previous system.

Finally, I believe that the points system should be looked at by Sir John Tooke in his independent review. I am sure that we shall take careful account of what he has to say.

My Lords, I apologise to the House. I made an error with my sums and the Minister was correct, which shows that medical errors occur when you are stressed.

My Lords, I accept absolutely what my noble friend Lord McColl said about how much we appreciate the Minister apologising for what has happened; it made a difference. However, I find it difficult to understand that, in the course of a very short, compact Statement on a longstanding problem, the Minister said, “Of course, we will learn lessons”. He repeated that in an answer. Will there be a time when we have learnt the lessons? We are hearing about this problem rather too much.

The noble Lord, Lord Tomlinson, may well laugh at that, but the other report he mentioned as being published today, although irrelevant to the subject of this Statement, is perhaps relevant in another way. The Government always seem to bury bad news when they have some good news to put out, which is why, if I may say so, we have ended up with such a tiny Statement.

My Lords, the noble Baroness is being a little unfair. The Statement reflects two things. First, on the basis of the report on security, we have referred that matter to the police, so there is little I can add. The second part of the Statement related to the work of the review body, and encapsulated its discussions at its previous meeting. In addition to a number of oral Statements, we have issued regular Written Ministerial Statements and will continue to do so. The review group meets on a regular basis, at times weekly, and deals with specific issues. The Statement today was about a specific issue.

Moving from the old system to the new one was a huge challenge; there is no question about that. The foundation programme has worked very well. Indications are that the recruitment and interview process for GPs has worked well. We should not allow the immediate issues and problems which have been identified to undermine this whole process. At the end of the day, it is about a better training programme for the doctors, which means that we will ultimately get better, high quality, care. We must focus on that.