Introduction

308. A wide range of organisations share responsibility for the design, regulation and delivery of postgraduate medical training. Although led by the Department of Health, the development and implementation of MMC was undertaken by, and had implications for, many other bodies, including Postgraduate Deaneries, PMETB, Strategic Health Authorities, employers, and numerous medical groups. Many of these organisations were heavily criticised in the wake of the 2007 crisis and the wider shortcomings of the MMC programme. The Secretary of State himself stated:

When you look back at how this was all put together, you had four UK departments of health, you had all the educational bodies, you had the bodies that set standards, you had the regulatory organisations, and all of that put together led to a classic case, I think, of systems failure.[344]

309. We looked in detail in Chapter 7 at the management and leadership of the MMC programme, focussing particularly on the role of the Department of Health and the medical profession. In this chapter we look more widely at the performance of, and distribution of responsibilities between, the main organisations involved with medical training. We examine in turn:

• Postgraduate Deaneries;
• Strategic Health Authorities
• Employers and other training providers;
• PMETB;
• The Royal Colleges and Specialist Societies; and
• The Department of Health.

310. The Tooke Review recommended significant changes to organisational responsibilities for medical education, including the creation of a new over-arching body, NHS Medical Education England (NHS: MEE), to oversee postgraduate training. We examine the case for establishing NHS: MEE at the end of the chapter.

Commissioners and providers of training

POSTGRADUATE DEANERIES

311. As the regional organisers and overseers of training programmes, the 15 Postgraduate Deaneries in England have a critical role to play in the day-to-day provision of medical training. The Deaneries were closely involved with the design and implementation of MMC and MTAS, particularly through the work of the Conference of Postgraduate Medical Deans (COPMeD). The Department of Health explained that COPMeD had specific responsibility for some elements of the national recruitment process:

In August 2005, the Conference of Postgraduate Medical Deans (COPMeD) established a UK Recruitment and Selection Steering Group to develop person specifications, selection criteria and the application form for the specialty selection and recruitment process.[345]

312. Individual Deaneries also had a key role to play, particularly in the implementation of the new recruitment processes. Following a 2004 review of their role, Postgraduate Deans were made accountable to local SHAs for the delivery of training.[346] Some Deaneries were also made coterminous with SHAs following the re-organisation of the NHS in 2006. As a result, many Deaneries were in a state of flux during the planning of the MMC reforms.

313. In spite of this, Deaneries themselves asserted that they were closely involved with the development of MMC. COPMeD stated that "Postgraduate deans and GP directors were engaged in all stages of planning this reform."[347] In this section we look first at the role of COPMeD, and then at that of individual Deaneries.

Criticism of COPMeD

314. COPMeD played a substantial role in the design of MMC and was represented on all of the key groups and Committees which oversaw the programme.[348] COPMeD was also responsible for the design of some elements of the 2007 recruitment process through the COPMeD Recruitment and Selection Steering Group. It is unsurprising, in light of the problems experienced in 2007, that witnesses were often critical of COPMeD's performance. Some argued that COPMeD had failed to provide proper leadership or to take charge of the MMC programme.[349] Others blamed COPMeD for the major flaws in the national recruitment process. RemedyUK argued that COPMeD could and should have prevented the MTAS system from being introduced in 2007:

COPMeD were given operational responsibility for MTAS. As 2007 approached it became apparent that MTAS may not be ready in time for the launch; the 331 Gateway Review gave it a red status. It is unclear why CoPMeD did not call for a delay...[350]

315. Even the Department of Health was implicitly critical of COPMeD's contribution to the design of the new recruitment process, stating that:

Non-Departmental organisations, such as the Conference of Post Graduate Medical Deans of the UK, were responsible for particular parts of the recruitment to specialty training, and these projects lacked a formal project management approach.[351]

Defence of COPMeD

316. The Postgraduate Deans defended the performance of COPMeD. The English Deans group, all members of COPMeD, argued that COPMeD's specific responsibilities were poorly defined and that its views were sidelined:

…there was lack of clarity about what was to be undertaken by the project team and what was expected of Deans. Although COPMeD established a group to lead the implementation of MMC our input seemed to be undervalued.[352]

317. Professor David Sowden, a member of COPMeD and now SRO for MMC at the Department of Health, acknowledged the failure of the 2007 recruitment process. He argued, however, that ultimate responsibility for this lay with the Department of Health rather than COPMeD:

the MTAS process and other aspects of MMC were exceptionally poor. The point is that that was not in the gift or control of COPMeD to any great extent. We and many other parties, including the [Royal] Colleges, were involved in some of the decisions reached, but the process of project management should have rested with the department and it was there where many of the deficiencies became manifest…[353]

Future extent of COPMeD's remit

318. Witnesses also pointed out that COPMeD was not an executive body and could not hold its members directly to account, particularly after individual Deaneries were made accountable to SHAs in 2004. Many saw this as a fundamental weakness of COPMeD, similar to that affecting the Academy of Medical Royal Colleges.[354] The National Association of Clinical Tutors commented that:

COPMED is a conference of Deans with no clear structure or identity and were not able to take the lead in owning this education agenda.[355]

319. COPMeD itself acknowledged this difficulty, commenting that "COPMeD is not an executive body, but it facilitates the deans taking corporate action."[356] Given the problems experienced in 2007 and the formal limitations of COPMeD's remit, there was a clear case for reducing COPMeD's future role in the project management of detailed reforms.

Performance of individual Deaneries

320. In spite of the difficult context in which their work took place, the performance of local Deaneries in implementing the changes to training schemes and recruitment systems was often praised. Witnesses recognised that Deaneries responded well to the chaotic nature of the 2007 recruitment process, particularly after major changes to the selection system were announced at a very late stage. RemedyUK strongly criticised the MTAS process but praised the response of Deaneries to the need to arrange thousands of additional interviews in April and May 2007:

The Deanery HR staff were presented with a Herculean task, which was almost impossible to achieve given the resources made available to them, and they largely coped very well.[357]

321. The scale of the additional work created in 2007 was emphasised by the London Deanery, which stated that its staff had worked a total of 7,500 hours of overtime in 2007. NHS Employers made a similar point:

…deaneries and employers pulled out all the stops, with many people working excessive hours to make sure the recruitment process was completed.[358]

Future role and accountability of individual Deaneries

322. Although Deaneries appear to have coped relatively well with the crisis of 2007, some witnesses nonetheless raised concerns about their future role, questioning in particular whether it was appropriate for Deaneries to remain accountable to SHAs. The Royal College of Physicians called for Deaneries to be directly accountable to the Department of Health. It also pointed out that Deaneries were not seen to have the same level of independence as Royal Colleges:

The relationship between the Deaneries and the NHS trust is very different from the relationship to the colleges and trust. Trainees perceive the Deaneries as less impartial and more focused on maintaining service needs of the trusts than the individual training needs of junior doctors.[359]

323. The Postgraduate Deans defended the current arrangements, citing improved working relationships between Deaneries and SHAs. Professor Elisabeth Paice, Dean Director for the London Deanery, emphasised the advantages of making Deaneries coterminous with SHAs:

The experience of London Deanery working with five SHAs and working with one, NHS London, has been a revelation. It has been infinitely better to work to the same agenda and with the same span, concept and goals. I would not wish to turn back that clock.[360]

324. Despite these assurances, the Tooke Review called for a further review of the role of Deaneries, expressing concerns about the effect of Deaneries' accountability to SHAs on the strength of their relationships with the Royal Colleges and Universities.[361]

STRATEGIC HEALTH AUTHORITIES

325. Strategic Health Authorities (SHAs) hold the budgets for postgraduate medical training and have formal responsibility for commissioning training places, working closely with Postgraduate Deaneries. The recent performance of SHAs and their commitment to education and training have, however, been widely questioned, while the involvement of SHAs with MMC itself was affected by the 2006 re-organisation of the NHS, which reduced the number of SHAs from 28 to 10. In this section we look at past and future SHA involvement with medical training and with MMC.

Lack of SHA input into MMC

326. In general, witnesses agreed that SHAs had had little involvement with the development of MMC, despite their important role as commissioners of postgraduate medical training. COGPED stated that SHAs had shown a general unwillingness to engage with national programmes such as MMC, a point also made by the Royal College of GPs.[362] Anne Rainsberry, Director of Workforce for NHS London, acknowledged this during the Committee's Workforce Planning inquiry. She argued that SHAs had been excluded from the planning of MMC:

…it was a very centrally driven initiative where effectively the department…would say to the Strategic Health Authority, "These are the specialties that are expansion, there are a few that are in reduction, this is the national curriculum and, therefore, please sign here."[363]

327. NHS Employers pointed out that SHAs had been distracted by the 2006 re-organisation, but should nonetheless have done more to take charge of the MMC programme:

SHAs were in the throes of reconfiguration for much of this period and may have been unable to take full account of the significance of the impact of changes to medical training. With the benefit of hindsight it would have been important to have ensured they took a leadership role early on…[364]

Management of training budgets

328. SHAs were also accused of failing to prioritise medical education in their management of the Multi-Professional Education and Training (MPET) Levy which funds the majority of NHS training activities. A number of witnesses accused SHAs of cutting medical training budgets in the 2005-06 and 2006-07 financial years in response to local health service deficits.[365] The Royal College of Surgeons suggested that this practice had impeded the development of MMC:

Strategic Health Authorities were responsible for raiding training budgets during 2006 in order to bring the NHS into financial balance. This shortfall clearly made an impact on decisions made by the Deans.[366]

329. SHAs defended their position, arguing that cuts had not had a major impact on medical education. Anne Rainsberry acknowledged that NHS London had made some reductions to the medical training infrastructure in 2006-07, for example by reducing study leave allocations, but pointed out that such funding had now been restored.[367] She also stressed that the number of medical training places had increased with the introduction of the MMC reforms in 2007.[368] Dr Moira Livingston, Director of Workforce at NHS Northeast, also emphasised her organisation's continuing investment in postgraduate medical training:

…in the north-east there were, in fact, no budget cuts to the deanery. We receive a deanery investment plan every year and we met the requirements of the deanery...since 2005, 2006… there has been an increase in training numbers, overall 58%, and if we look at the specialty training, training numbers, they went up by 71%, with general practice being less, at 22%. So that commitment to training, in terms of the number of trainees in the system, I think, is evident.[369]

Increasing SHA engagement with education

330. Despite these reassurances, a number of witnesses called for changes to increase the involvement of SHAs in medical education and improve their commissioning performance. The Tooke Review called for SHAs to improve partnerships with local education providers and to take a closer interest in medical training issues:

At a local level Trusts, Universities and the SHA should forge functional links to optimise the health:education sector partnership. As key budget holders SHA Chief Executives should have the creation of collaborative links between local Health and Education providers as one of their key annual appraisal targets.[370]

331. Professor Sir Nick Wright expressed a similar view, and was specifically critical of the decision not to require SHAs to have a higher education representative at board level. He asserted that only three of the ten SHA boards have a member from a higher education background, commenting that:

It has always been the tradition in this country. The Strategic Health Authorities, the teaching hospital Trusts always had a non-executive director who is an academic. That has been lost.[371]

332. Some argued, however, that improvements had already been made. The English Deans and the London Deanery both described improved working relationships between SHAs and Deaneries,[372] while representatives from NHS London and NHS Northeast pointed out that their organisations had representatives of the education sector at board level.[373] And the English Deans commented on a general improvement in SHA engagement since the 2006 reorganisation:

The new SHAs are demonstrating a far greater engagement with the medical education agenda than their predecessor organisations…[374]

Oversight and performance management of SHAs

333. Witnesses also called for tougher performance management by the Department of Health to ensure that SHAs were held to account for the use of education and training funding. Service Level Agreements between SHAs and the Department were introduced in 2007/08, with the aim of improving the oversight of education spending. The Tooke Review, however, expressed doubts about the effectiveness of these arrangements and called for the system to be reviewed:

A formal review of the compliance with Service Level Agreements between DH and the SHAs relating to commissioning training and the functionality of the arrangement should be undertaken in 2008/9.[375]

334. SHA representatives agreed that improving oversight was an important goal, but argued that the introduction of Service Level Agreements had proved effective. Dr Moira Livingston described the benefits from the new arrangements:

…within SHAs we are all required, through a service-level agreement with the Department of Health, to have a learning development agreement and that has provided us with a tremendous lever. In the north-east we have all bar one trust as a foundation trust in terms of acute secondary care providers, and having a lever such as that allows to us to go in and discuss funding, directing the funding and driving up the quality of training.[376]

335. The Department of Health also defended the new performance management regime, stating that SHAs had generally performed well against the new Service Level Agreements:

In 2007/08, a range of Key Performance Indicators (KPIs) for the MPET allocation were agreed with SHAs. Performance against these indicators was first assessed in summer 2007. A further review is under way. There is good evidence about the effectiveness of the arrangements for 2008. Most SHAs have achieved most of their KPIs or are on track to do so by 31 March…[377]

EMPLOYERS AND TRAINING PROVIDERS

336. The many hospitals, GP practices and other care providers that employ doctors during their training are central to the medical education system. Employers provide the bulk of training which doctors receive and in turn rely on training doctors to provide a large proportion of patient care. In this section we look at the role of employers, and their representative organisation NHS Employers, in the MMC programme.

The role of employers to date

337. Witnesses consistently argued that employing organisations had had too little involvement with the design and implementation of MMC. Sir Jonathan Michael pointed out the critical role of employers and argued that they had not been sufficiently engaged with the reform programme:

…the role of employers and their engagement has been sub-optimal. Clearly, employers have accountabilities as employers and therefore they need to be engaged not only in employment issues but they have a responsibility to their employees to make sure they are properly trained…They also have a responsibility in terms of engagement in workforce planning because the needs of individual employers must be part of the overall picture.[378]

338. Sian Thomas, Deputy Director of NHS Employers, confirmed that employing organisations had not been closely involved with the development of the MMC reforms:

Before February 2007 we had a very peripheral role. We were probably regarded as a peripheral stakeholder in the process and, therefore, our influence was limited. We had no role on governance and had very limited engagement in implementation and design. In fact, I would say a great majority of the design decisions were made without employer input.[379]

339. This view was supported by the Tooke Review's analysis of the MMC governance system. Aspiring to Excellence demonstrated that NHS Employers was not represented on any of the key decision-making bodies during the development of MMC. The Association of UK University Hospitals was represented on the MMC Advisory Board, but there was no other formal involvement for employers prior to 2007.

340. Sian Thomas did point out, however, that the role of employers, and of NHS Employers itself, had considerably increased in response to the 2007 crisis:

…at the beginning of March we realised there were grave problems, and that was when our active and full participation began through membership of the review group, and I would have to say since that date we are more engaged.[380]

Employers' future role

341. In general, witnesses argued that employers should continue to have a more active role in the management and reform of postgraduate medical training. The NHS Workforce Review Team, NHS Employers and the Tooke Review all expressed this view.[381] More specifically, Sian Thomas argued that employers should be involved in debates about the future role of consultants and other medical staff:

…to determine what we want doctors to do in the future: what is their role in the healthcare team and what will the career structure look like? Employers will determine that, and they may actually not all determine the same thing and may want to do different things, which is obviously, in an autonomous employer situation, what they are entirely able to do.[382]

342. She also argued that employers should be more closely involved in the future design of recruitment process:

…more employer views need to be taken into account in the design especially of the recruitment processes, because at the end of the day these are our employees who we will be employing for 30, 40 years and the end product of this process is important to employers on the ground.[383]

343. The arrangements for the new MMC Programme Board do appear to give employers a more prominent role. As well as a representative from NHS Employers, the new Board includes the heads of two major acute hospitals.[384]

Conclusions and recommendations

344. There are a number of organisations involved in the design and delivery of medical training at local and national level. Although led by the Department of Health, the MMC programme placed an onus on all of these groups to work coherently and constructively. The causes of and responses to the crisis of 2007 provide clear evidence of widespread failure to co-ordinate thought and action. The Secretary of State attributed the breakdown of the MMC programme to a "systems failure". We agree.

345. A number of measures are required to strengthen individual organisations, realign responsibilities and improve co-ordination. To this end, we recommend:

• In the future, the Department recognise that COPMeD is not an appropriate body to implement reforms. The Department of Health relied far too heavily on COPMeD, a body with limited authority and resources, during the development of the 2007 recruitment process.
• Postgraduate Deaneries engage their local Strategic Health Authorities (SHAs) to ensure that these are closely engaged with the delivery of medical education. Improving the quality of education should be a specific objective for SHA Chief Executives.
• The Department of Health strengthen its performance management of SHAs, holding SHAs to account in particular for improving the quality of partnerships with the education sector and for effective commissioning of medical education and training.
• SHAs improve their wider links with the education sector, and in particular with Universities and further education providers, whom they should regard as key strategic partners. Postgraduate Deans should be closely involved with this work, providing a link between the education sector and the NHS. This work should be replicated at a national level by the Department of Health.
• Employers continue to be given a much more prominent role in the design and implementation of changes to medical training, through NHS Employers at a national and through NHS Trusts and Foundation Trusts at a local level. In particular, employers should be closely involved with future changes to recruitment and selection.
• NHS Trusts and Foundation Trusts ensure that responsibility for medical education is overseen by a Board level Director, typically the organisation's Medical Director. Wider education and training provision should also be overseen by at least one non-executive director.

Regulation and inspection

PMETB

346. The Postgraduate Medical Education and Training Board (PMETB) was established in 2003 as part of the wider reform of the regulation of the medical profession which followed the Shipman Inquiry.[385] The Board's main role was to provide regulation and quality assurance for postgraduate training. Although its creation was not connected with MMC, PMETB was immediately charged with overseeing the reform of the 59 specialty training curricula in support of the MMC programme. The Board also took over responsibility for directly inspecting training providers, a task previously carried out by the Royal Colleges. The role of PMETB has been widely debated in the wake of the 2007 crisis.

Criticism of PMETB

347. A number of witnesses, particularly from within the medical profession, were critical of PMETB's performance to date. The Yorkshire Deanery argued that PMETB had contributed to the rigidity of the MMC training structure by taking a "harsh line" on whether to recognise experience gained outside the UK training system.[386] The Royal College of Surgeons also criticised the "rigidity" of PMETB's approach to developing the new curricula to support MMC.[387]

348. Other witnesses criticised the role of PMETB in inspecting training programmes. The Royal College of Psychiatrists argued that the quality of inspection had declined since PMETB took over this responsibility.[388] Fidelio went further, describing the transfer of this responsibility to PMETB as "a direct attack upon the medical profession, and in particular its Royal Colleges."[389] The Royal College of Physicians called for PMETB to scale back its inspection activities, proposing "maximum delegation" of responsibility to the Royal Colleges.[390]

349. Finally, witnesses argued that PMETB had failed to accept responsibility for problems with curriculum development and the wider MMC reforms. The Royal College of Surgeons expressed disappointment at PMETB's unwillingness to accept criticism of its role,[391] while the Royal College of Psychiatrists accused PMETB of avoiding its operational responsibilities:

High-sounding strategic statements are followed, if at all, by evasion of the reality of daily operation.[392]

Defence of PMETB

350. PMETB defended its own performance, pointing out that it had completed the revision of all 59 specialty training curricula in time for the introduction of the 2007 reforms as well as creating the new CESR route to specialty registration.[393] The Board argued that its work had attracted unfair criticism because its role was confused with that of the MMC programme:

There has been a good deal of confusion about the respective roles of PMETB and MMC, not least because they were established at much the same time. However, PMETB and MMC are quite different…PMETB played no part in the design or implementation of the MMC career structure beyond offering guidance on how the proposed model would relate to our standards and principles.[394]

351. The Secretary of State also defended PMETB's achievements in his response to the Tooke Review. He commented that:

I am very conscious of the progress PMETB has made and the significant contribution they have made to postgraduate medical education. They have put in place a much-needed and valued programme of work. Their work on the quality framework and their toolkit in particular are excellent achievements.[395]

The case for streamlining regulation

352. The Tooke Review offered a balanced assessment of PMETB's progress to date, acknowledging that it had made some achievements after a "slow start". Aspiring to Excellence recommended, however, that PMETB be absorbed by the General Medical Council (GMC) to create an integrated regulatory body:

PMETB should be assimilated in a regulatory structure within GMC that oversees the continuum of undergraduate and postgraduate medical education and training, continuing professional development, quality assurance and enhancement. The greater resources of the GMC would ensure that the improvements that are needed in postgraduate medical education will be achieved more swiftly and efficiently. To this end the assimilation should occur as quickly as possible.[396]

353. Witnesses generally expressed support for this proposal. The Royal College of Physicians and Royal College of Surgeons both agreed that PMETB should be assimilated by the GMC.[397] Professor Sir Nick Wright pointed out that such an arrangement would make the regulation of postgraduate training more independent and expressed support for the GMC:

Moving this to the General Medical Council would show that there is independence in regulation outwith the secretary of state's purview… I have every confidence the GMC could produce the goods.[398]

354. The Chief Medical Officer also expressed supported for the idea of streamlining the two regulators:

When we had the response to consultation on medical regulation, it was clear that some very strong arguments were mounted for merging the PMETB into the GMC, and that became my position and I would agree with Sir John Tooke that that would be a good thing to do.[399]

PMETB's and the Government's response

355. The only opposition to the idea of a merger came from PMETB itself, which argued that the responsibilities of the regulators should not be changed until a planned review had been carried out in 2011.[400] Professor Peter Rubin, PMETB's Chair, argued that reorganising PMETB and the GMC would disrupt the implementation of other changes to medical training:

If some or all of Professor Tooke's recommendations or recommendations that you make are implemented to postgraduate medical education, then an effective regulator will be very important, and so that would be the worst time to shut down the regulator that deals with postgraduate medical education…[401]

356. In spite of this, the Secretary of State agreed in his response to the Tooke Review that PMETB and the GMC should be merged. He did not, however, agree to make the change "as quickly as possible", as Aspiring to Excellence had recommended. Instead, the response stated that the merger would not take place for at least two years:

I have accepted the Inquiry's recommendation to merge PMETB with the GMC… The legislative process means that this will not be before 2010. We will publish a timetable for doing so once a plan has been worked through.[402]

ROYAL COLLEGES AND SPECIALIST ASSOCIATIONS

357. The numerous Royal Colleges and Specialist Associations play an important role in the medical training system, setting standards and assuring the quality of training across their individual disciplines. Significant elements of the Royal Colleges' role in MMC are considered in Chapter 7 where we make recommendations about the leadership of the medical profession and the role of the AMRC. In addition, witnesses made a number of suggestions for adjusting and improving the Royal Colleges' contribution to MMC and the wider medical training system:

• Several Royal Colleges suggested that they should take back responsibility for directly inspecting training providers from PMETB;[403] although Deaneries felt that the inspection process had improved under PMETB.[404]
• The Association of Surgeons pointed out the specific value of Specialist Associations and argued that they should be given a bigger role in decision-making in future.[405]
• Other witnesses called for the Royal Colleges to be more prepared to challenge the direction of reform. Fidelio described the response of the Royal Colleges to the 2007 crisis as "very disappointing" and called on the leaders of the Colleges to "stiffen the spines" when dealing with the Department of Health.[406]

Conclusions and recommendations

358. In order to improve the regulation and inspection of postgraduate training, we recommend that:

• The amalgamation of the Postgraduate Medical Education and Training Board (PMETB) with the GMC be carried out in 2010 as planned. We advise the Department to proceed carefully with this reform and to recognise that merging the two regulators is a substantial and complex task which, if mishandled, could further destabilise the training system.
• The relevant Royal Colleges and Specialist Associations be more closely involved in the quality assurance of the training system, drawing on their knowledge and experience in this area. Royal Colleges should work with PMETB, and subsequently the GMC, at a national level, and with Postgraduate Deaneries at a local level.

The Department of Health

359. The Department of Health played a fundamental role as the instigator and leader of the MMC reform programme. We discussed many aspects of the Department's performance, including leadership, policy development and project management, in Chapter 7, making a number of recommendations for future improvements. We look briefly here at other elements of the Department's role.

Attitude and working relationships

360. Witnesses were critical of the overall attitude of the Department of Health towards the MMC programme and the medical profession, calling for it to be more constructive and approachable in future. We saw in Chapters 2 and 3 that the Department ignored warnings from the medical profession about potential problems with the 2007 reforms, and that it did not heed the BMA's "Call for Delay" in 2006. Professor Stephen O'Rahilly of Fidelio was highly critical of the Department's general approach to dealing with the profession:

To date, there has been a rather lethal brew of high-handedness and incompetence and one hopes that will be fixed. I fear there is a fundamental distaste for the medical profession in the centre of the Department of Health…[407]

361. RemedyUK expressed a similar view, stating that the Department "did not listen to anyone" during the development of MMC.[408] Dr Ian Wilson of the BMA also condemned the Department's attitude to the profession in recent years, but pointed out that things had improved in the wake of the 2007 crisis:

I will use the words fickle and contemptuous…That is the way that the Department of Health has responded to the medical profession over a number of years of late, but we have been working increasingly well with them more recently and have much better communications with them than we ever did, so it would not be fair to describe them in that way now.[409]

362. The Chief Medical Officer defended the Department's approach, pointing out that the medical profession was heavily involved with the MMC programme. He argued that it was not possible for the Department to satisfy the demands of all the different groups within the profession:

In any programme of implementation there will be many, many different views expressed. It is very easy with hindsight to pick out one and say. "That was the shining torch we should have followed," but at the time many, many different voices were involved…[410]

Extent of remit for medical training

363. Questions were also raised about the extent of the Department's involvement with the detailed implementation of MMC. The Department established a highly complex governance structure for MMC and was involved in a number of different elements of the programme.[411] The overall direction for MMC was set by the Department's UK Strategy Group which reported directly to the Chief Medical Officer. Operational matters were dealt with by MMC's Programme Delivery Board, which reported jointly to the CMO and the Director of Workforce. Meanwhile elements of the detailed design of the reforms, including the 2007 recruitment process, were undertaken by the Department's Workforce Directorate.[412]

364. The Tooke Review raised concerns about whether the Department should have involved itself in the detailed implementation of MMC. Sir John Tooke told the Committee that while the Department should have responsible for defining policy, it should not take on responsibility for implementation as well:

…the department in conjunction with professional stakeholders has the key role in determining policy…but at least for the panel there is an open question as to whether the Department of Health has the resources and professional skills to implement something of this nature. My personal view is that for something like this it is probably better conducted by an accountable arm's length body…[413]

365. Sir John Tooke went on to argue that the Department should reduce its involvement in the implementation of major programmes such as MMC, calling for "policy and implementation separation" at a national level. Fidelio made a similar point, arguing that the Department's overall involvement with MMC should be reduced:

If no one at the Department of Health accepts responsibility for this year's disaster, no future modification is safe in their hands.[414]

366. Many witnesses supported the Tooke Review's recommendation that elements of the Department's role in MMC should be taken over by a new national body. We consider this debate in more detail below.

Conclusions and recommendations

367. Significant reform of the Department of Health's relationship with the medical training system is required. The Department became too involved in detailed implementation of MMC, and particularly of the MTAS recruitment system, losing sight in the process of the programme's strategic aims. Despite consulting frequently with medical groups, the Department also failed to adequately reflect the wishes of the profession in its plans, leading to a breakdown in this key relationship. We therefore recommend that the Department:

• Establish a clear distinction between its policy-making activities and its support for the detailed implementation of policy;
• Ensure that the MMC Programme Board, with representation from across the medical profession, remains the main forum for policy development and for approving plans for future changes to medical training;
• Ensure that future consultation with the medical profession is more than a superficial exercise, that differences of opinion among consultees are reconciled where possible, and that the outcomes of consultation are clearly recorded; and
• Reduce its direct involvement with policy implementation, ceding control to Postgraduate Deaneries, Royal Colleges and employers.

NHS: Medical Education England

368. As outlined in Chapter 4, the Tooke Inquiry recommended the creation of a new national body, NHS: MEE, to oversee medical education and training. Aspiring to Excellence proposed that the new organisation take over responsibility for defining the principles for postgraduate training from the Department of Health. It also recommended that NHS: MEE be made responsible for a ring-fenced budget for medical education, removing this responsibility from SHAs. In addition, NHS: MEE would take over from the MMC Programme Board as the main forum for interaction between the Department of Health and the medical profession.[415]

369. The decision about whether to set up a new national body therefore has significant implications for the future both of the other organisations involved in postgraduate training and of the training system itself. In this section, we consider the arguments for and against the creation of NHS: MEE.

Arguments in support of NHS: MEE

370. Sir John Tooke set out the case for establishing a new body to oversee medical training in a letter to the Committee in February 2008. He argued that neither the Department of Health nor SHAs were capable of overseeing the reform of medical training, creating the need for a new and dedicated organisation to do this:

Our belief that such a body is necessary stems from a fundamental lack of confidence by the medical profession in the Department of Health's ability to manage the implementation of changes in PGMET, and the clear need to separate policy from implementation. Devolution of complete responsibility to SHA level engenders even less confidence, given the current lack of workforce planning and commissioning capacity, the lack of labour market intelligence and the very recent history of education and training budgets being raided to meet service pressures.[416]

371. Several witnesses, particularly from within the medical profession, expressed strong support for the creation of NHS: MEE. Professor Peter Rubin stated that:

…the establishment of NHS: MEE, with a ring-fenced budget for medical education… would by itself go a long way to ensure that we do not have a repeat in the future of the MTAS/MMC problems. That is a view that is shared not just by the regulators but by the Academy of Medical Sciences, by the Medical Schools Council, by the Academy of the Royal Colleges.[417]

372. A similar view was expressed by Professor Neil Douglas, vice-chair of the AMRC and a member of the MMC Programme Board. He drew attention to the effectiveness of NHS Education Scotland, a body with responsibility for overseeing education for all staff groups within the Scottish NHS. He argued that the recommendation to create NHS: MEE was central to the changes proposed by the Tooke Review:

…recommendation 47 is the key one in the new version of Tooke. I work very closely with NHS Education Scotland in Edinburgh. They are an extremely effective organisation, controlling of the funds is critical to properly planning the training for the juniors. If anything gets enacted, it has to be recommendation 47.[418]

373. Others witnesses emphasised the risks involved with devolving responsibility for medical education directly to SHAs, one of the perceived alternatives to creating NHS: MEE. Dr Bill Reith argued that SHAs would struggle to prioritise medical education, given the scale of their other responsibilities:

There are so many things for SHAs to be doing that, frankly, it seems that for some education does not have the priority that it merits, so we certainly support an independent special health authority of some kind.[419]

Arguments against NHS: MEE

374. Other witnesses, however, raised concerns about the prospect of setting up NHS: MEE and argued that a new organisation was not desirable or necessary. Representatives from SHAs, Deaneries and employers consistently expressed this view. Professor Elisabeth Paice of the London Deanery argued that creating an organisation dedicated specifically to medical education would make it more difficult to integrate planning and would isolate decisions about the medical workforce from their wider context:

I would hate to see medical isolationism as the outcome of this and a step backwards from the integration of service strategy and financial planning, using medical education, if you like, as an enabler for service change and reform.[420]

375. Anne Rainsberry, Director of Workforce at NHS London, agreed, pointing out that NHS: MEE would prevent SHAs from integrating service planning with workforce and education planning:

I think that it fractures the relationship between service and education…strategic health authorities are the only part in the system where the balancing of service, long-term strategic planning and education align, and I think, by taking medical education off-line in that way, it would fracture that relationship…[421]

376. NHS Employers expressed a number of concerns about the proposal, arguing that creating a national body would contradict the policy of devolving decision-making within the NHS. NHS Employers also opposed the ring-fencing of education budgets and pointed out that the creation of NHS: MEE would make implementation of other changes called for by the Tooke Review more difficult:

…the proposal does not seem to support the desirable intention, set out clearly in the Tooke Report, of getting those involved in the policy and commissioning of education for doctors closer both to undergraduate medical schools and to the service.[422]

377. Anne Rainsberry pointed out that the success of NHS Education Scotland was not directly relevant to the debate about NHS: MEE, largely because of the smaller scale of the Scottish health service:

It does work well in Scotland, I would agree with that, but the number of their trainees is similar to one of our medium-size deaneries…[423]

378. Witnesses also pointed out that the remit of NHS Education Scotland covers all staff groups, rather than just medicine. NHS Employers argued that if a new organisation were created then it should be responsible for overseeing all training and education, describing the idea of a separate organisation for medical education as "not helpful". In a subsequent letter to the Committee, Sir John Tooke acknowledged that an organisation dedicated specifically to medical education was not necessarily required:

Whereas the Final Report proposed the creation of NHS:MEE (reflecting the fact that our remit was medicine) the Panel supports the concept of NHS Education England, embracing the needs of the various professional clusters.[424]

The Department of Health's position

379. The Secretary of State was guarded when questioned about NHS: MEE and did not state whether the Tooke Review's recommendation would be accepted. He acknowledged the differences in opinion regarding the proposed national body, but particularly emphasised the opposition of some interested parties:

This thought of putting one organisation in charge of that has got its advocates and its detractors. Since Tooke's Report was published I have had many people saying to me that they do not agree with that recommendation. The deaneries have put on record their concerns about that recommendation. Given that is the case, we need to consider it and we need to consult…[425]

380. The Department's formal response to the Tooke Review was similarly cautious, deferring the decision about whether to set up NHS: MEE until the publication of the NHS Next Stage Review:

The Workforce Planning, Education and Training (WPET) work, which is part of the NSR, is addressing many of the substantial issues raised by this Inquiry recommendation… The proposal for an NHS:MEE needs to be considered alongside this work. The NSR is due to report by the end of June.[426]

Conclusions and recommendations

381. The Tooke Review's proposal to create a new arms-length body, NHS: MEE, to oversee medical training was strongly supported by the medical profession, but opposed by other key groups including Deaneries, SHAs and employers. NHS: MEE offers a number of potential benefits. First, a new body would provide a dedicated forum for improving medical training, free from external pressures and influences. Secondly, NHS: MEE would be able to work specifically on implementing many of the Tooke Review's other proposals. Thirdly, a ring-fenced budget would ensure that funding for medical training could not be used for other purposes. And finally, neither the Department of Health nor Strategic Health Authorities have proved themselves capable of leading the reform of the medical education system, as witnessed by the debacle of 2007.

382. The creation of NHS: MEE would also have a number of potential risks and disadvantages, however. Chief among these is that a body dedicated to medical education alone would cause medical workforce planning to become further isolated from wider health service planning. In addition, there are already numerous organisations involved with medical training, and it seems unlikely that creating another one would improve the coherence of the reform programme. Equally, if the Department is serious about devolving more responsibility to local organisations, then creating another national body would run counter to this ambition, as well as contradicting the Department's recent efforts to reduce the number of arm's-length bodies. Establishing a new organisation would be expensive and time-consuming and would potentially disrupt the implementation of future change. Finally, the theoretical independence of arm's-length bodies has often proved illusory in practice, at times allowing responsible Departments to abrogate responsibility for key issues without relinquishing ultimate control of policy.

383. In view of the scale of the 2007 crisis and the "systems failure" identified by the Secretary of State, there is a clear need for strong central co-ordination of future changes to medical training. The NHS: MEE as envisaged by the Tooke Review would be, however, a step too far. The MMC Programme Board already brings together the medical profession, the Department of Health and the NHS and can therefore assume this co-ordinating role, provided that it is swiftly strengthened and reconstituted as we propose. We therefore recommend that the Department does not create a new national body and focuses its attention instead on improving performance management and on supporting and reforming the Programme Board.

345   Ev 6 Back

346   Ev 8 Back

347   MMC 57 COPMeD Back

348   Aspiring to Excellence, p.53 Back

349   Ev 99 Back

350   Ev 147 Back

351   Ev 16 Back

352   Ev 90 Back

353   Q 563 Back

354   See Chapter 6 Back

355   Ev 99 Back

356   MMC 57 COPMeD Back

357   Ev 147 Back

358   Ev 174 Back

359   Ev 160 Back

360   Q 616 Back

361   Aspiring to Excellence, p.93 Back

362   See Ev 132 and Ev 187 respectively Back

363   Health Committee, Workforce Planning, Fourth Report of Session 2006-07, HC 171-II, Q 736 Back

364   Ev 174 Back

365   See, for example, Ev 96 Back

366   Ev 116 Back

367   Qq 698-700 Back

368   Q 697 Back

369   Q 695 Back

370   Ev 141 Back

371   Q 651 Back

372   See Ev 76 and Q 616 respectively Back

373   Q 708 Back

374   Ev 74 Back

375   Aspiring to Excellence, p.144 Back

376   Q 720 Back

377   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.39 Back

378   Q 156 Back

379   Q 710 Back

380   Ibid Back

381   See Ev 66, Q 710 and Aspiring to Excellence, p.143 respectively Back

382   Q 757 Back

383   Q 710 Back

384   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.59 Back

385   For more details, see Aspiring to Excellence, pp.31-33 Back

386   Ev 71 Back

387   Ev 116 Back

388   Ev 167 Back

389   Ev 191 Back

390   Ev 161 Back

391   Ev 116 Back

392   Ev 167 Back

393   See Chapter 4 Back

394   Ev 104 Back

395   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.43 Back

396   Aspiring to Excellence, p.116 Back

397   See Ev 167 and Ev 116 respectively Back

398   Qq 641, 643 Back

399   Q 144 Back

400   MMC 27A Back

401   Q 637 Back

402   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.43 Back

403   See, for example, Ev 160 where the Royal College of Physicians described PMETB's inspection processes as "not rigorous enough". Back

404   Aspiring to Excellence, p.60 Back

405   Ev 94 Back

406   Qq 201-2 Back

407   Q 238 Back

408   Ibid Back

409   Q 404 Back

410   Q 56 Back

411   See Chapter 6 Back

412   Aspiring to Excellence, p.53 Back

413   Q 162 Back

414   Ev 189 Back

415   Aspiring to Excellence, p.7 Back

416   MMC 61-Tooke Review Panel Back

417   Q 651 Back

418   Q 652 Back

419   Q 540 Back

420   Q 607 Back

421   Q 718 Back

422   MMC 45A-NHS Employers Back

423   Q 722 Back

424   MMC 61-Tooke Review Panel Back

425   Q 886 Back

426   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, pp.54-55 Back