House of Commons Health Committee Modernising Medical Careers Third Report of Session 2007–08 Volume I Report, together with formal minutes Ordered by The House of Commons to be printed 24 April 2008 HC 25-I Published on 8 May 2008 by authority of the House of Commons London: The Stationery Office Limited £0.00 The Health Committee The Health Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Department of Health and its associated bodies. Current membership Rt Hon Kevin Barron MP (Labour, Rother Valley) (Chairman) Charlotte Atkins MP (Labour, Staffordshire Moorlands) Mr Peter Bone MP (Conservative, Wellingborough) Jim Dowd MP (Labour, Lewisham West) Sandra Gidley MP (Liberal Democrat, Romsey) Stephen Hesford MP (Labour, Wirral West) Dr Doug Naysmith MP (Labour, Bristol North West) Mr Lee Scott MP (Conservative, Ilford North) Dr Howard Stoate MP (Labour, Dartford) Mr Robert Syms MP (Conservative, Poole) Dr Richard Taylor MP (Independent, Wyre Forest) Powers The Committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the Internet via www.parliament.uk. Publications The Reports and evidence of the Committee are published by The Stationery Office by Order of the House. All publications of the Committee (including press notices) are on the Internet at www.parliament.uk/healthcom Committee staff The current staff of the Committee are Dr David Harrison (Clerk), Adrian Jenner (Second Clerk), Ralph Coulbeck (Committee Specialist), Laura Daniels (Committee Specialist), Frances Allingham (Committee Assistant), Julie Storey (Secretary) and Jim Hudson (Senior Office Clerk). Contacts All correspondence should be addressed to the Clerk of the Health Committee, House of Commons, 7 Millbank, London SW1P 3JA. The telephone number for general enquiries is 020 7219 6182. The Committee’s email address is [email protected]. Footnotes In the footnotes of this Report, references to oral evidence are indicated by ‘Q’ followed by the question number, and these can be found in HC 25–III. Written evidence is cited by reference in the form ‘Ev’ followed by the page number; Ev x for evidence published in HC 25–II, Session 2007–08, on 14 November 2007, and MMC x for evidence to be published in HC 25–III. Modernising Medical Careers 1 Contents Report Page Summary 5 1 Introduction 9 2 The gathering storm: 2003–2007 12 Rationale for change 13 The Calman training system 13 “Unfinished Business” and the “lost tribe” 13 “Choice and Opportunity” 14 Other influences on training reform 15 Turning principles into practice 16 “MMC: The next steps” 16 The Foundation programme 18 Plans for Specialty and GP training 19 Conclusions 22 3 The 2007 crisis 24 Introduction 25 Causes and triggers 25 The short-listing process 25 BAPIO’s legal challenge 27 “One strike and you’re out” 29 Key events in 2007 30 The crisis erupts 30 The Douglas Review 31 Resignation fever 33 The judicial review 33 The suspension of aspects of the MTAS system 34 The final scramble 35 Conclusions 36 4 2007–08: Fall-out 37 Introduction 37 Aftermath of the 2007 crisis 37 New governance arrangements 37 The status of non-EEA doctors 38 The 2008 recruitment process 40 The Tooke Review 40 The diagnosis 41 The treatment: structural change 42 The treatment: organisational change 43 Responses to the Tooke Review 43 Conclusions 45 2 Modernising Medical Careers 5 The medical workforce 46 Introduction 46 The training system 46 The Foundation Programme 46 Specialty training 50 Academia 54 Recruitment and selection 55 The wider medical workforce 58 Staff Grade and Associate Specialist doctors 59 The consultant grade 63 6 The supply of doctors 67 Introduction 67 The current situation 67 Self-sufficiency and its implications 67 The Government’s efforts to date 70 Future policy options 73 Guidance to employers 73 Changes to immigration legislation 74 Other policy options 76 Conclusions and recommendations 77 7 Managing reform 79 Introduction 79 Policy development 79 Clarity of the overall aims of MMC 80 Realising the principles in practice 81 The development of run-through training 82 Improving policy development 83 Programme governance 84 Over-complex structures 84 Escalation of concerns 85 Improving governance 86 Project management 88 Timescales for change 88 Risk management 90 External communication 91 Improving project management 92 Leadership 93 The Department of Health 93 The medical profession 95 Improving leadership 95 Conclusions and recommendations 96 8 Organisational responsibilities 99 Introduction 99 Commissioners and providers of training 99 Postgraduate Deaneries 99 Modernising Medical Careers 3 Strategic Health Authorities 103 Employers and training providers 106 Regulation and inspection 108 PMETB 108 Royal Colleges and Specialist Associations 111 The Department of Health 112 NHS: Medical Education England 114 Conclusions and recommendations 119 The 2007 crisis 119 Fall-out: 2007–2008 119 The medical workforce 120 The supply of doctors 123 Managing reform 124 Organisational responsibilities 126 Glossary 130 Formal Minutes 131 Witnesses 132 List of written evidence 134 List of further written evidence 135 Reports from the Health Committee 136 Modernising Medical Careers 5 Summary For many years there have been concerns about the UK medical workforce, in particular the postgraduate medical training system. The most prominent of these centred on the poor training and indifferent career prospects experienced by some doctors at Senior House Officer (SHO) level and by many of those in Staff Grade and Associate Specialist (SAS) posts. The Modernising Medical Careers (MMC) programme of work was established in 2003 to address these difficulties. A new Foundation programme was introduced in 2005, the Specialty Training system was reformed and the SHO grade scrapped in 2007. As a result of inadequate preparation during the implementation of the reforms, in 2007 the MMC programme plunged into crisis. The new centralised recruitment system, the Medical Training Application Service (MTAS), proved highly unpopular with both candidates and assessors. The number of applicants was also much higher than expected, creating fierce competition for posts in many areas and making thousands of doctors deeply anxious about their future prospects. Following intense public pressure and major demonstrations by junior doctors, the Department set up the Douglas Review Group to make changes to the recruitment system. Several senior resignations, a legal challenge, two major security failures and a number of emergency statements by the then Secretary of State followed, however, as the crisis deepened. Elements of the MTAS system were subsequently abandoned and, although most training posts were eventually filled, the events of 2007 proved a disaster both for the Department of Health and for the medical profession itself. The Government acknowledged that its new systems were flawed and apologised on several occasions to the thousands of doctors affected. The Secretary of State commissioned a major inquiry, led by Sir John Tooke, to examine the 2007 crisis. The Tooke Inquiry reported in January 2008 and called both for major changes to the structure of training and for the creation of a new body, NHS Medical Education England, to oversee medical education. The Department deferred decisions on whether to implement the Tooke Inquiry’s most significant proposals. Like the Tooke Review, the Committee’s inquiry exposed serious problems with the management of the MMC reforms, and particularly the introduction of MTAS, by the Department of Health and its partners. A divided and inappropriate governance structure, flawed project and risk management and poor communication with junior doctors were the most serious failings. Co-ordination between the Department of Health and the Home Office on restricting medical migration was also woefully inadequate. These practical shortcomings were responsible for some of the direct causes of the 2007 crisis, including the defective application form and other aspects of the short-listing process, the unsafe computer system and the failure to limit the number of applications from overseas doctors. 6 Modernising Medical Careers Our inquiry also uncovered wider problems with policy development and leadership for MMC. The specific changes introduced by MMC often conflicted with the programme’s stated aims, for instance through the universal introduction of run-through training in 2007, which created a more rigid rather than a more flexible training system. The leadership shown by the Department of Health was totally inadequate. Despite being the architect of the reforms, the Chief Medical Officer chose not to take on a clear leadership role and thus did not accept responsibility for the 2007 crisis. The medical profession was often more concerned by factional interests than by the common good. This confusion and incoherence exacerbated the 2007 crisis and prevented MMC from achieving many of its original aims, most notably increasing flexibility and reforming the SAS grades. We make a number of recommendations for change and improvement in response to the shortcomings which undermined MMC. The Department of Health must address its weaknesses in project and risk management. It should strengthen and increase the independence of the MMC Programme Board and work more effectively with the medical profession on future education policy.