UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 25-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

MODERNISING MEDICAL CAREERS

Thursday 15 November 2007

SIR LIAM DONALDSON KB, PROFESSOR MARTIN MARSHALL,
MS CLARE CHAPMAN and MR NIC GREENFIELD

Evidence heard in Public Questions 1 - 149

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 15 November 2007

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Sandra Gidley

Dr Doug Naysmith

Mr Lee Scott

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Sir Liam Donaldson KB, Chief Medical Officer, Professor Martin Marshall, Deputy Chief Medical Officer, Ms Clare Chapman, Director General of Workforce, and Mr Nic Greenfield, Deputy Director of Workforce, gave evidence.

Q1 Chairman: Could I welcome you to the first session of our inquiry into Modernising Medical Careers and ask you, for the sake of the record, to give us your name and the position you hold.

Sir Liam Donaldson: I am Liam Donaldson, Chief Medical Officer for England.

Professor Marshall: I am Professor Marshall, Deputy Chief Medical Officer for England.

Ms Chapman: Clare Chapman, Director General of Workforce for England.

Mr Greenfield: I am Nic Greenfield. I am Director (Education, Regulation and Pay) Workforce.

Q2 Chairman: Welcome, once again. I will start with the general question. The implementation of the new MMC specialty training schemes, through the MTAS recruitment process, has been described as "the biggest crisis within the medical profession in a generation". Do you act accept that MTAS has been the disaster that people say it has been?

Sir Liam Donaldson: I think it was a very, very distressing experience for all the junior doctors concerned, and for those of us who care about people, which I and my colleagues do, it was a very distressing experience for us watching the process. The consultants, who did a formidable job in carrying out the thousands of interviews that needed to be carried out, also had a very difficult time, and the postgraduate deaneries, which carried the brunt of the details of the application process, did as well. It was a traumatic and highly unsatisfactory experience. I think there are some positives to come out of it as far as learning for the future is concerned, and in some specialties and in some parts of the country the problems were not nearly as great as they were in other parts of the country.

Q3 Chairman: There were demonstrations on the streets of London. Up to 30,000 doctors were caught up in this chaotic event and the demonstrators were arguing that these 30,000 doctors had been treated unfairly and inhumanely. Would you agree with that?

Sir Liam Donaldson: I have already said that the experience for the junior doctors concerned was dramatic, distressing, created a lot of anxiety, and I have publicly apologised for that in April. Patricia Hewitt, the previous Health Secretary, did as well. We deeply regret that. As far as unfairness is concerned, in any large-scale recruitment process there will be some examples of unfairness but, across the board, I would not agree that the outcome has led to wholesale unfairness, no.

Q4 Chairman: In terms of project management, what does it say about the Department of Health? It seems to me that MTAS has been about project management. Do you think it has damaged the Department of Health, in terms it being able to manage change on the scale that was envisaged?

Sir Liam Donaldson: Any central government department like ours is sometimes put in charge of big programmes of change but often those are developmental and do not involve detailed technical aspects of implementation. When you look at the causation of the crisis - and no doubt you will be asking us about our views on that later - having read myself thousands of documents and reflected on the experiences, I am quite clear what the main causal factors were. Certainly one of the main three was aspects of the application process itself, but the rationale for adopting that application process - given that aspects of it had been used in the foundation programme, which, on the whole, has been a pretty successful implementation process, and aspects of it had been used in other settings - and the principles underlying it, of trying to move away from vaguer systems of recruitment to more competency-based judgments, were sound and widely accepted. But the technical aspects of implementation clearly went badly wrong.

Chairman: We will be picking up some of those issues as this evidence session goes along. I will move on to Charlotte.

Q5 Charlotte Atkins: The original aim of the MMC was limited to reforming the senior house officer grade. How did the programme expand so massively to include the whole medical training system?

Sir Liam Donaldson: I know that some of this is caught up in language and terminology, but might I just clarify that to begin with. The original programme was not called Modernising Medical Carers. It was, as you rightly say, a reform of the senior house officer grade, which was, in my view, an educational scandal in this country and needed to be remedied. I produced a report, advised by members of an expert committee, which suggested reforms to the SHO grade. The Modernising Medical Careers programme then was a broadening out of that. We received representations that if you are going to change the first two years of training and make it completely different, then that creates a problem for the interface with the next phase of training, so arguments were made that we needed to look at the specialist training as well. Essentially, the Modernising Medical Careers programme - and you could argue that there were other elements of it as well - contained these two big blocks: the SHO reforms, which came from Unfinished Business, and then the broadening out, on the grounds that if you are doing the first two years afresh, then you really need to look at the specialist training as well. Each specialty, 58 of them, looked at their curricula, they looked at the design of their training programme, and they made recommendations to the postgraduate Medical Education Training Board about the reform of specialist training as well. These two programmes were run in synchrony but the foundation programme was delivered first.

Q6 Charlotte Atkins: Did it not mean that, because you had this so-called "broadening out", this led to the project being rushed and also to some confusion about the aims of the overall project?

Sir Liam Donaldson: I do not think there was any confusion about the overall aims of the project. Indeed, I think those were absolutely clear, and we can go into that if you like. As far as being rushed is concerned, it depends what you mean by that. Some would have argued that you cannot go on having old specialist training programmes set alongside a new foundation programme; that would have been dysfunctional and you needed to bring the two in together. The curricula were all revised and all were in place in time, which involved a lot of hard work by the Royal Colleges, the training bodies and others. If you then say, "Well, maybe the implementation could have been deferred," there is an argument for that but the other side of the coin, of course, is that you would have then been having this problem with the interface between the two new schemes. With the benefit of hindsight, I think probably one thing that should have been done was that the implementation should have been phased or staggered over a period of time.

Q7 Charlotte Atkins: You used the word "dysfunctional". Is that not what we ended up with?

Sir Liam Donaldson: I do not think so, no. If you look at the design of the specialist training programmes, the accusation has been made that we should never have introduced run-through training, but a lot of professional bodies are in favour of that for their specialties and there are some advantages to it. Again, with the benefit of hindsight, there should be more flexibility, so that not all programmes are run-through training but for those doctors who want to progress their career more quickly and are absolutely clear what they want to do, then run-through training is probably still a good option.

Q8 Charlotte Atkins: We will be looking at that in more detail later on. Let me just ask you about the issue about the major changes to the specialist registrar grade which obviously was created by the Calman reforms in the 1990s. What evidence was there that this grade needed reform?

Sir Liam Donaldson: We received representations from some professional groups and bodies. There was a lot of discussion about it. There was a groundswell of view that the curricula of each specialty needed to be looked at again. For example, the urologists came to see me and maintained very strongly that their specialty had changed a great deal since the implementation of the Calman reforms, which were necessary to meet European legislation at the time. They said that the office-based urologist who did not do surgery had emerged as a very strong model of practice and was distinct from the surgical urologist and that their training programme just did not address that at all. Cardiologists were making points about the growth of interventional radiology. I think the principle of having a fresh look at each specialty was not a bad one. To move to more defined curricula, competencies defined, is a good thing I think for patient safety, as well as for trainees knowing where they stand as far as their experience is concerned.

Q9 Charlotte Atkins: But this grade had emerged out of the Calman reforms just in the 1990s. Was there ever a proper evaluation of the Calman reforms or were they just brushed aside?

Sir Liam Donaldson: I do not think they were brushed aside. They have served us in good stead for a period of ten years but, in Medical Workforce terms and in the way that medical technology changes and the content of specialties change, ten years is a long time. In some ways, it would have been cavalier to say, "Don't let's bother to review things after ten years."

Charlotte Atkins: Thank you.

Q10 Dr Naysmith: Sir Liam, you mentioned the single run-through grade. That was not part of the original concept, was it? When and why was the decision taken to create the run-through grade?

Sir Liam Donaldson: In the original proposal in Unfinished Business, my report, there was a mention of the need to look at specialty training and the design of specialty training and the concept of run-through training was aired in that report. The next major publication was by the four UK health ministers, a report called Modernising Medical Careers and, again, the need to look at the specialty training was addressed. The next major publication, again produced by the four UK health departments, was called Next Steps in Modernising Medical Careers. It was at that point that the concept of run-through training was majored on and developed further. There had been a lot of discussion with professional bodies and others which led to that point. Mr Greenfield was involved in some of that and might be able to give more detail.

Q11 Dr Naysmith: Just to be clear, in Unfinished Business, it was envisaged, clearly, that there would be two separate specialist training grades rather than the one single run-through grade. That was a conscious decision to change it, in discussion in these later papers. Is that right?

Sir Liam Donaldson: It was a conscious decision to change it. The original Unfinished Business suggested a period of general professional training, followed then by the higher specialist training, yes.

Q12 Dr Naysmith: But as you have already said, the run-through grade appears to make the new training system very inflexible and you are suggesting having to introduce flexibilities into it.

Sir Liam Donaldson: Yes. It has some advantages over the old system, in that for people who are absolutely clear what they want to do it gives them the opportunity to get on with things. In America, you can move more or less straight from medical school to run-through training and it seems to work pretty well there. It also creates more stability for the trainees: rather than having to apply for another job every six months, they can move forward knowing what their career plan is, and it allows a greater integration of training. It has the downside that for people who want to change specialties, who change their mind about what they want to do, it is rather inflexible. Also - and this is I think relevant to the problems that developed with implementation - it creates a high-stakes application at a time when doctors feel this is an "all or nothing" decision for their careers.

Q13 Dr Naysmith: That is to do with the computer system and the way of organising the applications.

Sir Liam Donaldson: I do not think it was purely to do with the computer system. I think it was the fact that, because the run-through would then take people right through to becoming a consultant or a principal in general practice, the feeling amongst the junior doctors, many of them, was: "This is a once-in-a-lifetime decision. We have to make that decision at this one point in time." Irrespective of the computer, it was rather inflexible and created a high-stakes situation.

Q14 Dr Naysmith: One of the stated aims of the MMC system was to increase flexibility. That was one of its main, stated aims, and it ended up doing the opposite.

Sir Liam Donaldson: As far as the foundation programme was concerned, I think there was much, much more flexibility as well as many, many other benefits. In respect of changing specialties, I think, yes, it did not improve flexibility.

Q15 Dr Naysmith: Also, in terms of the National Health Service, where there are some specialties where it is really difficult to get candidates and others where there is over application, it would be a good idea to have more flexibility.

Sir Liam Donaldson: I think flexibility is always a good thing. I think it is a difficult question to answer whether run-through training made specialty planning worse in the NHS. In some ways you could argue that it created greater certainty, because it was clear which numbers would be allocated to each specialty. It is not an argument I would particularly make, but it is a more difficult question, without really thinking about it further, to give you a clear answer to. But I absolutely agree that one of the things we have to learn from this is that there needs to be much more flexibility in the future.

Q16 Dr Naysmith: The MMC system has created a large number of one-year Fixed Term Speciality Training Appointments (FTSAs - there are lots of acronyms in this business). Doctors in these posts have no set career path and limited opportunities to continue in training. Have you not just recreated the "lost tribe" which people used to talk about?

Sir Liam Donaldson: I do not think so because these posts are in the minority. The number of full-blown training posts has increased, compared to the past, and many more doctors are in them than would have been the case in the past. The "lost tribe" accusation was because the old SHOs had no educational content to their job at all and were just beasts of burden doing Health Service work.

Q17 Dr Naysmith: What is going to happen to them now?

Sir Liam Donaldson: Even the fixed term posts have a proper educational content and, indeed, would prepare a doctor very well, I think, for entering the training rotations which are the longer term posts.

Q18 Dr Naysmith: If you start with the run-through system, there are not going to be any vacancies for these people, are there?

Sir Liam Donaldson: There will be a fresh round of applications.

Q19 Dr Naysmith: They are competing against new graduates all the time.

Sir Liam Donaldson: Yes, but they will have a considerable degree of experience from that one-year posting.

Q20 Dr Naysmith: We will make sure that the application forms allow them to put that down on the form.

Sir Liam Donaldson: The application forms have been redesigned.

Dr Naysmith: Thank you.

Chairman: Richard.

Q21 Dr Taylor: Thank you. Good morning. Talking about the supply and demand of training posts in the UK, the figure of 6,000 was quoted in the Tooke Review and appeared in your invitation to tender for the design of MTAS. In fact, it appears that that was a gross underestimate, because there were something like 32,000 people looking to these jobs. Which of the groups had you forgotten? You seem to have thought only of the people going from F1 to F2 to the specialist training, and not taken account of the huge numbers of SHOs who were having to move sideways. Is that were the discrepancy arose? How did it arise?

Sir Liam Donaldson: We can come back to the point about the SHOs, but the big picture point on the numerical discrepancy was the fact that the planning assumption going into this whole programme was that international medical graduates would not compete until the later stages when there were vacancies created.

Q22 Dr Taylor: Yes, we will come to international graduates in a minute. I am trying to get at the UK graduates of that 32,000. Six thousand, plus, presumably, many thousand SHOs moving sideways. Why were those forgotten?

Sir Liam Donaldson: I do not know that they were forgotten. Might I ask Mr Greenfield to comment on that.

Q23 Dr Taylor: Yes. How do we jump from 6,000 to 32,000? That is what I am trying to find out.

Mr Greenfield: The number of 6,000 is from the initial invitation to tender to WPP. Is that the figure you are quoting?

Q24 Dr Taylor: Yes. We presume that is the number of people moving up from F1 and F2 to specialist training.

Mr Greenfield: The original ITT was focused on the recruitment to ST1, the first level only. That was subsequently expanded. But it was 6,000 per round, not 6,000 in total.

Q25 Dr Taylor: I am still trying to get at where the other 26,000 come from.

Mr Greenfield: We commissioned WPP initially and MTAS to be designed for 30,000 applications.

Q26 Dr Taylor: You commissioned them to be designed for 30,000.

Mr Greenfield: I am trying to be clear if you are saying MTAS or WPP, because there were different figures for each. The MTAS system, the electronic system, we commissioned initially for 30,000 and that was subsequently increased to 40,000.

Q27 Dr Taylor: Did the people designing the computer system know this?

Mr Greenfield: Yes.

Q28 Dr Taylor: Why did we get into so much trouble then?

Mr Greenfield: It was not about the MTAS capacity. That was not the problem. There was not a capacity problem, except on two occasions when the system slowed down for a sum of around 11 hours. The MTAS system was sufficient for the demands that were placed upon it, and, for that 11 hours when it slowed down, we extended the recruitment window by a period just slightly longer than that to make sure that those who wanted to apply had an opportunity to apply.

Q29 Dr Taylor: I am sorry, I am completely foxed. The figure of 6,000 was in the invitation to tender for the design of the MTAS systems, is that right?

Mr Greenfield: The system that was originally commissioned for MTAS, which was by methods consulting, was for 30,000 in total. That was expanded to 40,000, is my understanding.

Q30 Dr Taylor: That is not what it says in our briefing at all.

Mr Greenfield: Would it be helpful if I provided the detail in writing to you?

Dr Taylor: Could you do that.

Q31 Chairman: This is probably something we could usefully come back to. I think it is crucial that we know exactly.

Professor Marshall: Could I add something to your specific question, Dr Taylor. The original commission to WPP was for the transition between F2 and STT1. That is where the 6,000 came in. The original commission was not for all applicants across the whole of the system.

Q32 Dr Taylor: Why was it not for all of them? This is where one of the huge problems has arisen. It seems to me that it was these SHOs who were moving sideways who have completely over-swamped the system.

Professor Marshall: It was because the commissioning was done in phases and the first phase, the priority phase, was that first transition from F2 to ST1. There were then subsequent phases and subsequent commissions that went to WPP to look at the transition between ST2 and 3, and 3 and 4.

Sir Liam Donaldson: Chairman, this is your first hearing. We will be able to get a letter to quickly, so that it will be available for subsequent hearings.

Chairman: Could we do that. We will move on.

Q33 Dr Taylor: We have had so much paper and what really bothers me is the effect of the European Working Time directive on training. One of our experts has told us that, under the old system, junior doctors would have something like 30,000 hours of training and under the new system that training is cut to a mere 6,000 hours. How is the profession going to cope with that? Does that not mean that there have to be more training posts to make up for this?

Sir Liam Donaldson: It is a strong point that is repeatedly made by medical trainers that they are worried about the clinical experience that doctors get. On the other hand, the European Working Time directive is the European Working Time Directive and we have to abide by it. It is, to some extent, a consumer protection measure: you want to avoid tired, fatigued people treating patients. On the other hand, it does have this downside on experience. That is one of the reasons why the competency-based approach to training was brought in, so that we can test competencies more easily. It is possible, also, in some specialties to intensify the training with modern methods of education. For example, in radiology now, rather than waiting for the trainee as an apprentice to see cases coming through the X-ray department, there are training programmes in which trainees are shown hundreds of digital x-rays and given the opportunity to interact with them on a computer. There are modern educational methods in some cases that can substitute for that lack of experience. But I agree with you: it is a problem that we need to continue to revisit.

Q34 Dr Taylor: Should you not really be looking at lengthening the training? Because you are shortening the number of hours, as it stands at the moment.

Sir Liam Donaldson: Lengthening it just without purpose is difficult. Again, that is why defining competencies is perhaps a better way of doing that. Obviously, if people do not achieve those competencies in the time that has been allocated then you would have to look at lengthening.

Q35 Sandra Gidley: I would like to come back to the 6,000 because I have here a copy of that Tooke Report Aspiring to Excellence, which I have obviously looked into very thoroughly. In appendix 5 it mentions the invitation to tender and goes on to say the scope of work stated, "The number of applicants expected to apply for entry into speciality training is approximately 6,000 plus. Applications will be via a single electronic national portal system. The original ITT was to deliver a short-listing process for ST1. The companies tendering were not asked to deliver the selection methodology for doctors in transition via ST2, ST3, ST4, nor for FT FTAs." It seems to me that history is being rewritten here.

Mr Greenfield: Not at all. The point I was trying to clarify but perhaps did clumsily was that there were 6,000 applicants at each of those levels. The first, ITT, only focused on ST1. That was subsequently increased with ST2, ST3 and ST4, which are the subsequent years of recruitment, and in total that was then increased so that MTAS in its final form was commissioned for a capacity of 40,000.

Q36 Sandra Gidley: How late did they get the final spec?

Mr Greenfield: I would have to go back and check those details and give them to you in writing.

Sir Liam Donaldson: An earlier paragraph on the same page does in fact mention the 30,000. The capacity defined in the DH invitation to tender was 30,000 candidate users. That is in the middle column, the third paragraph down.

Chairman: Could we have that clarified and we can all look at it. Let me move on to Howard.

Q37 Dr Stoate: Thank you. I would like to talk about the rather sorry situation of the international medical graduates. I am sure you would agree that without international medical graduates the Health Service would long since have ceased to exist, if it would ever have got off the ground in the first place. I think we owe a huge debt of gratitude over the years to medical graduates from other countries. However, they do seem to have been spectacularly badly treated with this current system. The Department made several attempts in 2006-07 to try to exclude IMGs from applying for MMC posts or, indeed, to ensure that the system discriminated against them. I have to say I have real concerns about this. Legal action, as you know, prevented that happening, but surely there must be a feeling in the Department that they were treated spectacularly poorly even above any other system that was being introduced.

Sir Liam Donaldson: I would 100% agree with you that the international medical graduates have been great servants of the NHS and we do owe a great debt of gratitude to them. I would say - and I say this quite neutrally, because it is simply a statement of fact - that the planning assumption going into this whole programme was that international medical graduates would not compete for posts in the early stages of the programme until there were vacancies at the end. That was the planning assumption and everything was geared towards that is being implemented. When the judicial review was won by the Department of Health, the Secretary of State for health at the time was advised that it was then too late to implement the existing policy of its excluding international medical graduates but that the rules would be applied in Round 2 of the competition. The situation was further compounded by the fact that the Douglas Review, for all the right reasons, created a Round 1B, which in fact made Round 2 a very, very small round. As a consequence, there were a large number of additional applicants, who were not anticipated or expected, competing for posts. You may say why was the policy there in the first place? The policy was there in the first place, notwithstanding the great service that the international medical graduates were giving, because the Government had declared a policy of self-sufficiency wherever possible, because, with such competition internationally, particularly from the United States, to attract medical graduates, it is a very high-risk strategy permanently to decide you are going to base your Health Service on doctors who might be attracted to go and work in other countries. That is why new medical schools were opened as a result of this policy of self-sufficiency. In my view, had the numbers not been as they were in the implementation, we would not have had the majority of the problem that we had. So that is, in my view, one of the causal factors and I say that quite neutrally, simply as a statement of fact, and not with any intent behind it.

Q38 Dr Stoate: Sure, but it does leave a rather nasty taste, that guidance was issued to employers not to consider IMGs for posts unless there was no suitable candidate from within the EEA. Surely that must have rung alarm bells that it was going to be illegal, and surely morally it is a pretty reprehensible position in which to find yourself?

Sir Liam Donaldson: It was consistent with a policy of self-sufficiency. I do not think I heard any particular criticism of that whenever it was first introduced. I certainly did not hear any criticism when we were expanding the medical schools - indeed that was welcomed. Many other countries have this policy. It is not to say that Britain would not continue with its tradition of training overseas doctors in this country. That could easily continue or would have continued to be part of the programme. It is just that the policy of self-sufficiency and the policy of open borders would be bound to lead to this. You say it is illegal. The subsequent appeal has said that, but, at the time, the judicial review did not say that it was illegal.

Q39 Dr Stoate: The Appeal Court has now ruled that this guidance cannot be applied in 2008 either. It has now been estimated that there will be three times more applicants applying for posts than there are posts available. Does this, also, not make a mockery of the selection process?

Sir Liam Donaldson: We have only just received the judicial review and have not been able to take account of the implications for 2008 but we are looking at that at the moment.

Q40 Dr Stoate: Your own evidence estimated that between 1,000 and 1,500 UK graduates will be unable to find training places in 2008 as one of the consequences of this ruling. That is a quarter of our indigenous output of graduates. Is that not rather alarming?

Sir Liam Donaldson: We have to look at what the implications of the Government are and the number of training posts, and that is something we have not had an opportunity to discuss with ministers yet.

Q41 Dr Stoate: Assuming those figures are broadly correct - and there is little evidence otherwise - what opportunities do you think can be available for that 1,000 to 1,500 UK graduates who will find it very difficult to continue their careers?

Sir Liam Donaldson: Again, I cannot commit myself to things we have not discussed as policy options yet, but I think every effort will be made to help those doctors, just as we did in the packages that were put in place in the 2007 recruitment.

Dr Stoate: Thank you.

Chairman: Lee.

Q42 Mr Scott: Thank you. My question is around workforce planning. The number of students graduating from UK medical schools is growing rapidly but you are unable to prevent doctors from applying from anywhere in the world for UK training posts. As a result, there will be a huge overspill of junior doctors for the foreseeable future. Do you accept that recent workforce planning in the NHS has been "disastrous"? If so, who is responsible for this?

Sir Liam Donaldson: Perhaps I could ask Ms Chapman to come in on that, as the Director of Workforce, but I would not accept the comment that the whole of our workforce planning is disastrous.

Ms Chapman: There are a couple of things I would say. One is that if you look back at the decisions that were made as part of the Douglas Review to make sure that the distress that the Liam talked about could be minimised, some of the workforce planning assumptions have really helped us work our way through the solutions to get a very high fill-rate for the doctor vacancies in the UK this year and perhaps one of the highest fill-rates for the hard to fill specialties. In terms of the short-term workforce planning, I think that good data, which certainly we have had through this year's recruitment processes, has helped us make good decisions. With regard to the broader workforce planning, I think Sir Liam mentioned that thoughtful workforce planning has been done in terms of broad thinking around self-sufficiency, to make sure there are sufficient people coming through to cope with the European Working Time Directive, and also the significant increase in doctors since 1997 which has been in the region of 30%. So I think there have been some broad things done well. I do think - and the Sir John Tooke inquiry points this out - there are some elements of policy that are not clear and that does make workforce planning more difficult - particularly around the role of the doctor and the extent to which the service is consultant supported or consultant delivered, does make some of the elements of workforce planning more difficult.

Sir Liam Donaldson: There are 21 countries ahead of us in the latest OECD rankings in numbers of doctors per head of population, so we are still not "well doctored".

Q43 Mr Scott: The MMC reforms mean that many more doctors will complete specialist training in the near future. Surely this is going to lead to heavy numbers of unemployed doctors.

Sir Liam Donaldson: It depends on the needs of the NHS. As I have said, I have not so far seen the NHS complaining that it has too many consultants and principals in GP. As I say, we are still relatively low compared to other OECD countries. The increase in medical schools which was introduced at the time of the NHS plan took into account that we needed to expand the infrastructure of the NHS, get the access times down to the best in Europe, so I do not think we can necessarily draw the conclusion that you have drawn at this stage.

Mr Greenfield: In the review of the number of undergraduate medical places that we conducted as part of our preparation for the CSR this year, we reviewed some of the factors that could shift demand quite significantly. One particular issue is that of the changing social attitudes among those who qualify as doctors, whereas, for example, their participation rate, the amount of full productive career time they spend within the service, is significantly shifting. This is linked too, with the increased number of women entering the profession, which is now at undergraduate medical school in excess of 60%, and higher education colleagues are investigating that. That can have quite a dramatic shift, so, for every seven doctors that we have at the moment, we would have to provide 11 to provide the same level of service because they are working more part-time, more flexible hours. It is issues like that. I would go back to the CMO's comment about the impact of international recruitment. It is very clear at the moment that we have, to develop and support the Working Time Directive, relied on international doctors and have expanded with their excellent support, but we cannot rely on that in the future because other countries, English-speaking countries, Australia, New Zealand, America, are only training somewhere near 75% of that to meet their own needs and those doctors will be attracted to those places and we could not afford to take that risk.

Q44 Mr Scott: Sir Liam, what numbers of extra consultants do you predict are going to be needed over the next decade?

Sir Liam Donaldson: I cannot give you an answer to that question at the moment.

Mr Scott: Thank you.

Chairman: Richard.

Q45 Dr Taylor: Thank you. I have been around quite a long time, as you know, and the whole business of workforce planning has gone in cycles. We have gone through one stage where we were training too many, then we were not training enough, then we were training too many. What can you do to stop that cycle, to get to a position where we really know the number of doctors we need and we do not go up and down, up and down?

Sir Liam Donaldson: The short answer is that for planning workforce over these long periods of time there are so many uncertainties that you could never get it 100% right.

Q46 Dr Taylor: Could we get it nearer than we have got it in the past?

Sir Liam Donaldson: I do not think so. No, I do not think so. There are so many uncertainties. If you look, for example, at specialties like cardiothoracic surgery, it takes a long time to train somebody, you put a training programme in place and then suddenly interventional cardiology takes off and you do not need so many. You are always going to have things like that. Without wanting to sound too positive, because I know that is sometimes criticised, you say there have been ups and downs, and I absolutely agree with you about that, about the accuracy of some of the planning, but I cannot recall a time when the NHS was seriously disadvantaged by any of those things, where patients were left untreated. At least we have the basics right, even though the precise numbers in particular specialties at any one time may have gone awry, as they did in obstetrics recently, as they have in cardiac surgery/cardiology and so forth.

Q47 Dr Taylor: I would agree in the NHS but this is the first time that a full cohort of trainees has been massively disadvantaged.

Sir Liam Donaldson: In what way have they been disadvantaged?

Q48 Dr Taylor: You only have to see some of the letters that I have received in hundreds.

Sir Liam Donaldson: Yes.

Q49 Dr Taylor: There are couples who have been split up because they have been unable to match their jobs.

Sir Liam Donaldson: I absolutely agree. I went to particular trouble at the beginning to explain my distress and regrets for that. We do not have, of course, any benchmark data with the previous system. It seems to be assumed now that those problems to which attention has been drawn now did not happen under the old system.

Q50 Dr Taylor: But at least they had another chance. Under this system they have one chance and then nothing else for a whole 12 months.

Sir Liam Donaldson: Absolutely. I think that is one of the inflexibilities but weigh that against the situation where SHOs were wandering the face of the earth, applying in ratios of 1:900 for jobs and being rejected, going back and applying for another job in a ratio of 1:500, totally uncertain about their future, having to make compromises about their choice of specialty, where they live, moving their children from school, perhaps having no career advice. The old system was not the rosy world that some people have portrayed it as.

Dr Taylor: I think we agree on that.

Q51 Chairman: In relation to workforce planning, I do not have a copy of our inquiry now, but I do recall that it was not the issue of under-recruitment as much as over-recruitment in some areas inside the National Health Service, leading on from the projection in the NHS 2000 Plan, and some of them over 300% over-recruited. We felt at that time that the NHS lacked the structure for that type of planning. Would you be able to estimate where the workforce should be geographically, as it were? Are you confident that we have moved on a bit since we published that inquiry? Presumably your SHAs are capable of doing that now, when we thought they really had not been capable of good workforce planning in years prior.

Sir Liam Donaldson: I think things have moved on. The SHA structure, the fact that they now involve the postgraduate deans as part of their management structure, I think things have moved on. Having said that, as far as the future is concerned, I am not sure where the philosophy of planning will come in against a devolved and more diverse Health Service which is based much more on decisions by individual organisations about their needs for staff.

Chairman: We will move on.

Q52 Dr Naysmith: Sir Liam, I would like to look at a little bit of the detail of the MTAS selection process and the timescale for implementation. All of the changes to specialty training were introduced all at once in 2007 and candidates were given only one main opportunity to apply for training posts. We are all agreed on that. Why was this "big bang" approach adopted? Surely this vastly increased the risk that something would go wrong, and we did see that this year things did go wrong.

Sir Liam Donaldson: With the benefit of hindsight, as I have said, it might have been better to have staggered the entry periods. It probably would have made things much less difficult, but I do think the numerical problem dominated everything. Had that not been a feature, then, as with the foundation programme implementation, which did have its bumpy phases but the numbers were matched more closely, it would have been possible to allow more flexibility at the implementation phase. But the decision was taken, I think, because it would have been difficult to have run for any length of time an old- fashioned system with the old SHOs and other posts, those doctors possibly being disadvantaged and held back while others were going forward, and it was felt, on balance, it was better to do the transition all in one go as a matter of principle.

Q53 Dr Naysmith: Some people would argue that there were doctors disadvantaged with what happened this year. You mentioned the foundation and a few bumps as it was being introduced, but it was introduced over a number of years and it seemed to have gone relatively smoothly. Also, with the changes in GP training, that took a few years to do and it seems to have worked very well. Why on earth did you not to learn from those two?

Sir Liam Donaldson: The foundation programme was also introduced as a "big bang". It was not introduced over years. I think people gained confidence from the fact that that could be done. You are right to draw attention to the GP training, because that in many ways is an exemplar of the application process. They had developed their computerised application system over a period of years and had gained experience in it. They use a knowledge and judgment examination as part of their recruitment process and other specialties have looked to do something differently. But, you are right, that was not brought in across the board and possibly that would have helped.

Q54 Dr Naysmith: Could there not have been some element of piloting in the system, selecting maybe one area and developing it there? Pilots have been very useful in other parts.

Sir Liam Donaldson: In retrospect, I think that would have been helpful, yes.

Q55 Dr Naysmith: You were not on your own in this: the Royal Colleges were involved and other professional bodies as well. At what stage did they draw your attention to the fact that it was not working? Are they as culpable as you are for this disaster?

Sir Liam Donaldson: The involvement and the accountability was quite widespread. There were four UK health departments, many bodies and organisations involved with different roles: some educational, some standard-setting, some regulation, some responsible for detailed aspects of implementation, so I think it was a very widely participative programme. Everybody involved, I think, who has expressed an opinion, has expressed regret for the problems that occurred, but, if you look at the causation of it, I think it comes down to two main factors and then one which is debatable. The first is the numbers: the policy decision - and we have explained the background to that, about the international medical graduates and the unexpected nature of the turn of events on that, following the legal challenge. The second is the MTAS application form. Serious aspects of that were not fit for purpose, particularly for judging more experienced trainees. Then it is the run-through grade. I do not think you can condemn that as something that should have never happened because there is strong support for that in some quarters. It did lead to this situation of people having to make the decision on one day and the degree of anxiety and distress but the two main causal factors were the international medical graduates and aspects of the design of the application form. Although there were problems with the computerisation, they were not as major and they have got muddled together, I think, in some of the coverage with the design of the application form.

Q56 Dr Naysmith: The BMA called on a number of occasions for the introduction of ST training to be delayed by at least one year because recruitment systems were not properly ready. They drew your attention to it. Why did you ignore these pleas? With hindsight was the BMA not exactly right?

Sir Liam Donaldson: 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, different opinions, and ----

Q57 Dr Naysmith: They were the voice of the people you were trying to get on board.

Sir Liam Donaldson: The BMA are an important voice but they are not the only professional body or the only interest involved in this. Indeed, the BMA expressed other opinions. They argued, for example, that we should give the trainees four choices instead of two. If you want to get forensic about it, I can show you how that, in itself, although it was done for the right reasons, also compounded the problems of numbers and interviews.

Q58 Dr Naysmith: Were they the only voice saying that or did any of the colleges say that they wanted a delay as well?

Sir Liam Donaldson: There were concerns expressed in a number of quarters. There were also many people who were saying, "This is a great idea. The principles of modernising the education system are very sound. Let's get on with it and let the trainees have the benefit as soon as possible."

Q59 Dr Naysmith: So it was project management really that was at fault?

Sir Liam Donaldson: Yes, I think that is a fair summary.

Chairman: We will now move on to Robert.

Q60 Mr Syms: Why was responsibility for implementing MMC divided between two separate parts of the Department of Health? Was this not a fundamental and basic mistake which made problems with coordinating the project very much more difficult?

Sir Liam Donaldson: In retrospect, yes, the governance - and Sir John Tooke has commented on this, we have in our own evidence and I have as well in my evidence to the Tooke Report. Yes, we acknowledge that the governance needed to be changed. It was in fact more complicated than that because it was not an England-only programme; it was a UK programme, so there were eight different elements: the medical elements and the workforce element in four different departments. I agree, the governance structure needs to be simplified, but it is difficult to put weight entirely on one element: the workforce versus the medical.

Q61 Mr Syms: Your submission states that the governance system for NMC and MTAS evolved over time. Why was the system just left to evolve? Why did no one take responsibility for ensuring proper governance for this complex project?

Sir Liam Donaldson: At the time, the concern was to ensure as wide a participation and consultation as possible, so there were a lot of extra committees and fora created for trying to ensure that participation and consolidation, and that led to a lot more complexity with the governance. To simplify it to a single management strand, I think, would have led to the accusation that people were not having a fair opportunity to influence things. In other areas of policy and implementation this can be a problem as well. Balancing the need for widespread ex-eternal stakeholder participation and clear-cut management decision-making can lead to dysfunctions and problems and misunderstandings. Might I ask Ms Chapman to comment further, Chairman?

Ms Chapman: I would support Sir Liam's view that it was trying to get the breadth that added to the complexity. When I joined, and in March, as we were working on the Douglas Review, we wanted to simplify governance and also put in simpler project management, we looked back to see what learnings could be pulled from what had gone before. I think there was a review done the year before that pointed to the benefits of breadth and a lot of involvement in sub-committees, but actually, given the tightness of time, one of the recommendations was to narrow down the focus of various groups, and I think that one of the things we therefore saw was that you had numerous silos of groups working to a much tighter focus, as per the recommendation, but one of the things which that led to then was elements of the system really not joining up to deliver us the type of solution that we wanted.

Q62 Mr Syms: You started off with the specification in the tender documents and then you had an evolution, so there must have been changes as we went through the project. Would you be willing to share with the committee the tender documents and the evolution we went through in terms of the specification?

Ms Chapman: I will need to ask my colleague, Mr Greenfield, to comment on that because I was not around at the time.

Mr Greenfield: The tender documents for the MTAS project were covered by one of the SROs. I was not that SRO, so I would need to go back and change what the arrangements. I am happy to write to you about that.

Q63 Chairman: You could share them with us under open circumstances or part closed circumstances.

Sir Liam Donaldson: If we are allowed to, we would be very pleased to share them.

Q64 Chairman: We would look at that, if you feel there are issues of commercial confidentiality that may compromise that, but I think it is important that we do look at the detail.

Sir Liam Donaldson: Yes.

Q65 Mr Syms: Could I pose another question for Clare Chapman. You came to the Department from the private sector in early 2007. What was your view of the governance and project management arrangements for MMC and MTAS? Would the private sector have used a similar approach?

Ms Chapman: In hindsight, we recognize that because it was very complex and because there were so many stakeholders involved and multiple countries, the governance system was too complex. My experience from the private sector, sitting down with my colleagues and going through that, that is what led us to take the decision earlier this year to significantly simplify it, to set up a single line of governance and a single line of accountability, particularly around implementation, whereby we could bring in a chief operating officer to bring all of that together. One of the factors that is different from the private sector is that we had a lot of partners - Royal Colleges, union partners - who wanted to be part of the solution not part of the problem when the Douglas Review started, and I do think that one of the benefits we have had is the broad involvement in the solutions for this year from those partners. I do think that the internal governance that was set up within the Department learned from best practice, both within government and private sector, but I do think that one of the characteristics of why the Douglas Review has helped us get through this year is because of the close involvement of other partners. That is what the programme board has achieved and that is what Professor Marshall has led in going through the solutions for 2008, so that we have used a very similar approach in doing the design for next year.

Mr Syms: Thank you.

Q66 Dr Naysmith: I was going to ask this question of Sir Liam, but in view of what Ms Chapman has just said it has made me decide to ask her this question, because she was saying that since she has been in she has been having a look at these things. What specific project management resources in terms of funding, staffing and expertise did the Department have to support the implementation of NMC and MTAS? In your opinion, having looked at them now with hindsight, do you think they were adequate?

Ms Chapman: Dr Naysmith, I think I spend more time looking forward than looking back.

Q67 Dr Naysmith: That is okay, but I am sure you have an opinion.

Ms Chapman: Indeed. In March, we dramatically changed the resources in three areas. We brought in a single line of project leadership, with strong experience of doing that, so there was a programme office that could look at the various elements of implementation and make sure that that all came together with the absolute intent of making sure that that worked for junior doctors and worked for consultants. It was very much looking at how it would land as opposed to how it would be designed. That was one thing. The second thing was a much tighter set of milestones and review mechanisms. When we looked back, those did exist in each of the elements, so that was not something that was missing.

Q68 Dr Naysmith: But not clearly enough.

Ms Chapman: What was missing was across the entire programme, with all the various contributors and making sure that that worked across countries. As Sir Liam pointed out, one of the complexities was multiple countries. The programme board mechanism gave us one place where everything came together, so decisions could be taken. The third thing we did was to make sure we increased resources on things like communication, particularly around how to make sure that messages are got out, because we did recognize, in retrospect, that there were consequences to a number of the things that Sir Liam pointed out, particularly the four preferences. If those have been communicated sooner, people would have been more likely to accept that in Round 1, although there were 40,000 interviews being scheduled, the likelihood would be that the best candidates would get an interview first and, indeed, therefore a lot of people would not be getting interviews until Round 2.

Q69 Dr Naysmith: I will switch back to the one person who was around in all of this, Sir Liam Donaldson. The Tooke Report shows that progress on developing the MTAS computer system and on resolving the status of IMGs were both given a red-risk rating by officials from mid-2006 onwards. I am not quite sure what "red risk" means, but it obviously draws attention to something that might happen disastrously if something is not done about it. Why did this not persuade you to delay implementation for a year? That is the question I have already asked you. Why were these problems not escalated appropriately?

Sir Liam Donaldson: On the first causal factor, the extra numbers of international medical graduates, it was not foreseen that the Department would not be able to continue to implement its policy of excluding them until later rounds. That came in the judicial review challenge in which the Department of Health's position was upheld. It was not anticipated that the timing of the judicial review would be such that the Secretary of State was given advice that it was too late to implement that policy, but, nevertheless, it was decided that it would implement it in Round 2. We could not have foreseen then that the Douglas Review would decide to extend Round 1, making Round 2 largely inevitable. I think that would have been a very difficult situation to have foreseen. On the question of the MTAS, this was looked at. Indeed, Mr Greenfield will want to comment, I think, but he did, himself, commission an audit of that and took account of the concerns that were raised and with his team addressed them. He might, with your permission, want to say bit more about that.

Mr Greenfield: The issues of governance were very important to me when I became SRO. I commissioned a health check that is reported in the Tooke Report. That was about August 2005 and there was a subsequent report that was undertaken in September 2006. It was quite right that in the Tooke Report on page 50 they identified the risk we attributed to MTAS but also in the Tooke Report they identified that we received repeated assurances that it was going to be available on time. We had contingency plans for the foundation programme when that was recruited and we kept an MDAT system in the West Midlands running until we were sure we could take our foot off one steppingstone and put it on the next. For the specialty recruitment, our contingency was always that we would go to a paper-based system. You will appreciate that the massive gains from having an IT-based system, the savings, the reduction in administration, the simplicity of having one application for individual applicants, these were very attractive things and we were probably overambitious in trying to achieve them, but MTAS was delivered broadly on time. The report said that, whilst timing was tight, the key elements should be deliverable. That was the assurance that we took and so we progressed with it because we felt it would be effective.

Sir Liam Donaldson: Dr Naysmith, it was not as if officials were raising points. Mr Greenfield, as the senior responsible offer for this part of the programme, did look at it carefully and took account of the concerns that were raised, but if you want me to say what the principle risk was that was in all of our minds, it was that at the time the NHS had serious financial deficit, the budgets had been devolved to the strategic health authorities and the predictions from those who were making gloomy predictions was that the budgets would be raided, the training posts would be cut and the number of training posts would be quite small compared to what was needed. That did not happen. We made representations to ministers about the risk and I can remember discussions with Professor Marshall when we were both extremely concerned that this would be a showstopper.

Q70 Dr Naysmith: But this was designed when you were not expecting these cuts. Now you are saying they were proposed budget cuts and then they did not happen.

Sir Liam Donaldson: It was not that they did not happen.

Q71 Dr Naysmith: Are you sure they were not designed for -----

Sir Liam Donaldson: No, no, the context was much, much more complex and serious than that. The risk was that when the NHS was threatened with not being able to afford patient care that it would move to removing money from other budgets.

Q72 Dr Naysmith: Which it did in some areas - training nurses, for instance.

Sir Liam Donaldson: We went to the Chief Executive of the NHS, to ministers, to the strategic health authorities, to say, "Training is still important and, despite the fact that you have your hands on these budgets, we want you to preserve them." It led to more training posts being created than in the previous year. Whatever you want to say, the fact that out of this we got more training posts in place cannot be rubbished as a conclusion from the process.

Q73 Dr Naysmith: No one would rubbish it. It is not really a conclusion; it is a fact. There were more training posts available. But you should have been designing a system to cope with that, because you did not anticipate at the time the system was being designed that the effect would be fewer training posts, surely.

Sir Liam Donaldson: We did have the training posts in place.

Q74 Dr Naysmith: The system had been designed for that.

Sir Liam Donaldson: But we were worried that the funding would be taken away from them. That is what we were worried about. They were there, but we were worried that the funding would be removed because of the financial crisis the NHS was in. And the NHS managed to do both: to solve the financial crisis and to preserve the training - which I think is quite an achievement, especially given that a lot of people say that NHS managers do not care about education and training.

Q75 Dr Naysmith: I would never for one minute say that.

Sir Liam Donaldson: No, I am sure you would not but others do.

Q76 Dr Naysmith: Maybe others do. Some aspects of this project management are pretty damning about professional standards amongst civil servants at the Department of Health, are they not, to produce a system like this that did not work in such a spectacular way?

Sir Liam Donaldson: Aspects of the implementation ----

Q77 Dr Naysmith: Project management really is what we are talking about, and it is not the only example.

Sir Liam Donaldson: If you reflect on programmes which involve the need for a UK-wide approach and wide professional and stakeholder participation, you have to strike a balance between clear management decision-making and participation. If you were to allocate responsibility for implementation of this programme to a professional body, you would then possibly have the opposite problem, that the management expertise needed to do it and would not be contained within the infrastructure of such a body and would need to be built up over time. The problem with this programme was that it was of such intense interest to so many people that the participation was very wide and you just could not sit in a small executive team and take all the decisions. It was just such a complex programme.

Q78 Dr Naysmith: That is what you ended up trying to do and that is what the problem was at the end of the day. There was a system that was working, devolved out to the various deaneries and various areas, and there were problems with it and you set about solving the problems by designing a system that was going to be administered from the top and it went disastrously wrong. Is that unfair?

Sir Liam Donaldson: I think it is unfair to imply that a small group of people sat and took the decisions. That was not the case.

Q79 Dr Naysmith: You said that, not me. I said it was centralised; you said a small group of people.

Sir Liam Donaldson: It was a very complex programme. Aspects of the implementation did go badly wrong. I think we recovered a lot of the lost ground, so that the outcome is not quite as bad as people are painting. There are more training posts; many very high quality appointments that have been made. There are a few urban myths around. People have screamed that doctors have gone abroad in droves. If you look at the latest GMC figures, they are lower than the previous two years, so let us get rid of some of the urban myth in this and concentrate on the facts.

Chairman: Howard.

Q80 Dr Stoate: Thank you. Most of what I wanted to clarify has already been touched on, but perhaps I could clarify one point. When we did our enquiry into deficits we did find that SHAs had chosen to cut back on their training and education budgets in 2006-07. Are you saying that really had no material effect on the MMC programme?

Sir Liam Donaldson: Nic, perhaps you can comment.

Mr Greenfield: There was no doubt that during 2006-07 SHAs cut their budgets, but particularly the areas which were probably more easy to cut and which they did cut were around the education commissioning, in the short term primarily for the non-medical professions. That was cut by around 6.5% - nurse commissions, et cetera. Some GP appointments may have been cut, because those too are made on a regular annual basis, but I do not think that any SHA, as far as I am aware - and I will check this - said, "We are stopping those in training." As has been made clear by Sir Liam, on the number of training places - which was one of the issues that the BMA came to represent to me personally and which we took to our ministers, Lord Warner made a public statement that he would guarantee 18,000 places - we liaised with the SHAs and we delivered more than that.

Dr Stoate: Thank you, Chairman.

Q81 Dr Taylor: Short-listing. The process has been very widely condemned, as you know. The Royal College of Surgeons: "fundamentally flawed"; radiologists: "essentially random". When you look at it more and more, your own answer about this is really quite odd. You say it is very difficult to short list from an application form for the first level of specialist training because the applicants have relatively little experience and yet, in the white box, they get asked questions, we are told. I have not actually seen a white box, but this is the question quoted to us - and this is to a chap or a lady who has done their first 12 months - "Describe a situation when applying your clinical judgement had a significant impact on patient health. What did you do and how did your judgement contribute to patient health?" I would have been terribly pushed to have answered that question after being qualified for five years or more. This really seemed to be a test of imagination and creative writing. You are allowed 150 words on this sort of question and you were awarded a vast number of points for it. In one voice you are saying that they do not have enough experience on which to base the application form and then you are asking them theoretical, impossible sort of questions that, if they have a good imagination, they could floor you with very well. Was the short-listing process not pretty awful? Surely the first thing of a short-listing process is a CV to see what they have done, and you got rid of their CV.

Sir Liam Donaldson: There are reasons why the form was designed in the way it is, and let us come to those in the second. I agree that aspects of the short-listing system were not good. I am surprised to hear the president of the Royal College of Radiologists say that the process was "random" because I met each of the college presidents individually in the later stages of the application and she did not say that to me. In fact, she said that they had some of the highest quality applicants and appointments they had ever had in history. That was her comments. No doubt it is another urban myth. We did have problems with the short-listing, particularly for experienced candidates who had trouble reflecting their experience - and highly qualified candidates - in the application form. The application form was more suited to doctors coming off the foundation programme who had not accumulated a lot of experience. Perhaps I could ask my colleague Professor Marshall to talk in a little more detail about the rationale behind the application form and whether the outcome was random, as has been portrayed.

Q82 Dr Taylor: Could I ask him to tell us a little about the work psychology partnership and the forming of that. Did it have on it any people who had been medically trained, people who had gone through training?

Professor Marshall: The work psychology partnership is one of the most respected groups in the UK and maybe even internationally in terms of designing recruitment and selection processes for medicine. It is headed up by a person called Professor Fiona Patterson. She has done a lot of work in this field and a lot of work specifically with a number of Royal Colleges, particularly the Royal College of Surgeons, and for many years the Royal College of General Practitioners

Q83 Dr Taylor: In what field is she a professor?

Professor Marshall: I think her background is in psychology, but she did work extremely closely with a whole range of different professional stakeholders. You will see the consultative process that she went through described in our submission to you.

Q84 Dr Taylor: There were a lot of doctors who had passed these rather odd questions.

Professor Marshall: Who had been through that process. Perhaps I could talk about what you describe as "rather odd questions" because there have been a lot of criticisms about the nature of the application form. I have to say that at the time most of those criticisms were being expressed and the Douglas Review Group was trying to come up with a solution to a problem, we did not have any answer to whether those criticisms were valid or not. Subsequently, there have been formal evaluations of this process, a number of them, and we include the evaluation particularly from the Peninsula Deanery which demonstrates quite clearly that the process was not fundamentally flawed. There might be some legitimate questions about how it ran - for example, whether the traditional academic merits, like higher degrees or prizes, were involved: I think those are legitimate challenges which need to be addressed and are being addressed - but if you look at the data from the Peninsula Deanery, it shows a number of important points that I think need to be recognized when we describe this process has fundamentally flawed.

Q85 Dr Taylor: I am sorry to ask, but do we have that?

Professor Marshall: Yes, you have.

Q86 Dr Taylor: I am afraid I have only just received this booklet today.

Professor Marshall: That is in your evidence, yes.

Q87 Dr Taylor: The Peninsula evidence about this was in there.

Professor Marshall: It is in the summary. Could I describe it to you. (1) The process was not random. If you look at the short-listing scores of all the candidates who applied, there is a normal distribution - so it was not random, it was entirely what you would expect of a scoring system. (2) If you compare the different parts of the application form - and I know there have been some criticisms of particular parts of the application form - there is a good correlation between these different parts; that is, some parts were not very weak or some parts were not very strong, there is a good correlation between them. (3) If you look at the independent scoring of different independent scorers, the correlation between those scorers was again very high - for those who are interested, over 0.85, which is a very high correlation, so surprisingly high. Finally, and perhaps most importantly: (4) The correlation between the short-listing score and the final interview scores was, again, very high. We have here an evidence base here for this process being far more rigorous and far more discriminating than many people criticised. The problems, I think, are not that the process was fundamentally flawed in its design but that it did not operate well in certain circumstances. The prime circumstances, I think, were probably the very large deaneries, like London and the West Midlands, where they were just overwhelmed by the numbers and therefore the processes did not work as effectively as they should have done

Q88 Dr Taylor: The complaints we received or I received time and time again were from consultants who were extremely bothered that their very bright, very effective, very efficient juniors had been passed by by the system.

Professor Marshall: Yes, that has been a criticism that has been made, and, indeed, there was one survey which suggested that that might be the case. I have to say that the survey itself was rather flawed in its design, but if we accept that there might be some high quality candidates who were not selected by this process, then I think I have two responses: first of all, t'was ever thus - no selection process has ever been perfect and there have always been good quality candidates who have not got into post - and, secondly and most importantly, I think what this reflects is the very high competition ratios for certain specialties. If you have 200 applications for two posts, for example, you would expect the first unsuccessful candidate to be of extremely high calibre and, indeed, you would expect the eleventh candidate, if you were only short-listing ten, to be of extremely high calibre as well; so the fact that there are certain very high calibre candidates who did not get posts reflects the high competition ratios rather than anything flawed about the process.

Mr Greenfield: I think it is also worth noting that the application form that was designed for use on MTAS was not dreamt up in isolation from best practice that had previously existed within a paper-based system. It actually took the best practice from two deaneries, London (probably the largest deanery) and Yorkshire, where we had used similar questions, similar approaches, with some differences, but we had used the principle of white space within those processes in those deaneries when it was a paper-based system; so we were not designing something from scratch.

Q89 Dr Taylor: Coming back to the Work Psychology Partnership, they have told us, "At the outset we were asked to deliver a short listing process for ST1. We were not asked to deliver the selection methodology for doctors in transition via ST2, ST3, ST4 and FTSTAs. We were led to believe transition arrangements would be delivered by local processes." Were local people given any power to alter the short listing? I do not think they were, were they?

Professor Marshall: Perhaps Mr Greenfield could answer this question.

Mr Greenfield: I think this leads back to the question you asked at the start: at what stages did we decide to extend their remit from ST1 to include the subsequent more senior rounds? If I may, I will address that in the note we promised you.

Q90 Sandra Gidley: In the department's evidence it says, referring to a lot of unhappiness after round one, "In practice many would have got a post in round two, because only about 50% of posts would have been filled in round one", and then goes on to say, "It appears applicants and their colleagues did not appreciate this, suggesting it could have been communicated more effectively." Why was this fairly arbitrary 50% chosen? It seems to have been plucked out of the air almost in retrospect. Actually when was this 50% post-filling common knowledge? It is actually a key fact about the application system. If people had known about it, there may not have been quite such an outcry. What communication was there? Did everybody just miss it or was there not anything at all.

Professor Marshall: The 50% figure of projected fill-rate for round one, if it had been allowed to go ahead as was originally designed, was not plucked out of the air, it was based on modelling and it was based on the modelling that would result from people having four preferences. That is where that figure came from. The question about whether that figure was appropriately communicated to applicants so that they would understand the implications of not getting an interview in the first round I think is a legitimate criticism.

Q91 Sandra Gidley: When you say "modelling", can you clarify, because you had 32,000 eligible applicants, four choices each, competing for 44,000 interview slots. I find it hard to believe that there would not have been sufficient people to fill those slots almost first time round. Where did this 50% cent come from?

Professor Marshall: I am not an expert modeller either. Perhaps Mr Greenfield can describe the process.

Mr Greenfield: I can confirm that we did modelling for---

Q92 Sandra Gidley: I am sorry, are we talking about a computer model here?

Mr Greenfield: No. Essentially it is a mathematical model, saying that if you give people four choices, the people who will select the shortlist will generally choose the people who are of the highest calibre. They may be the same people in every case. So the top 25%, as an extreme, could be the ones who get four interviews. In practice, because not everyone applies for different posts, competition ratios vary quite a lot. The natural conclusion of giving people four choices is that the people who are the best get more interviews, and I think 17% got four interviews. We went through the modelling with the JDC, but there was a very strong feeling from the JDC that the first round was about maximising individual doctor choice. Bear in mind that where we come from was a system where we could apply for any job at any time whenever it happened to arrive; so that was important to them. The decision was made at the UK strategy group, under pressure from the JDC, to protect that in round one, and then the second round would be about filling the remaining vacancies. I am sure we would be happy to share with you the modelling for those.

Q93 Sandra Gidley: So those remaining vacancies would be the less popular jobs?

Sir Liam Donaldson: No. Can I just add, and I know that this may be getting into more numbers and technical detail than you want, but basically, because the decision was taken to move to four offers under pressure from the medical profession, for all the good reasons, this meant that 60% of the interviews in the first round - 19,000 out of the 32,000 - went to a sixth, the 17% of candidates. So, as a result of such a small number of people getting interviews, many good candidates would have been squeezed out of round one. That is why it was necessary to have a full round two. If the choices had only been two choices, as originally envisaged, there would have been more people getting jobs in the first round.

Q94 Sandra Gidley: What was the percentage number of jobs left in round two then?

Sir Liam Donaldson: As far as interviews are concerned, 40% of jobs would have been available, but then the Douglas Review extended round one and created a round 1B, which again, for all good reasons, confounded some of the other problems we had with numbers.

Q95 Sandra Gidley: Was your modelling actually right when you looked at it in retrospect. Did your modelling get the right answer?

Sir Liam Donaldson: The fill-rate on rounds 1A and 1B became around 72%, but we had not envisaged having a round 1B.

Q96 Sandra Gidley: I am asking about 1A, because that is what the model was designed to do.

Sir Liam Donaldson: We cannot really tell that now easily, because the two rounds blended into each other, but I would guess it would have been pretty accurate.

Professor Marshall: I think that is right. Certainly, subsequently, looking further down the process, for example, the fill-rate at the end of round 1B proved to be highly accurate? I think we predicted 85% and it was about 85%.

Q97 Sandra Gidley: Can you tell me who knew about this and how it was communicated, the 50%?

Professor Marshall: Certainly the MMC team and the workforce team working within the department knew about it.

Q98 Sandra Gidley: Yes. I am thinking about the poor people who actually had to apply for these jobs?

Professor Marshall: It was not adequately communicated to the applicants, and I think if it had been---

Q99 Sandra Gidley: Was it communicated at all?

Professor Marshall: I do not know the answer to that. I do not think it was.

Mr Greenfield: I would be certainly happy to look into that, but, if I might go back to the point, this was not something proposed by the department - the department would have wished to have fewer choices - it was a response to the requests of the representative body of the junior doctors, the JDC.

Q100 Sandra Gidley: That is a bit of a wriggle, if you do not mind me saying so.

Mr Greenfield: I am only saying that that was the position as it was.

Q101 Sandra Gidley: Did you take responsibility?

Mr Greenfield: We did, but we were trying to arrange this arrangement. Round one was about maximising choice; round two was now ensuring the fill-rate. We did communicate with all the junior doctors, because clearly the JDC is just one part of that. We ran websites on MTAS, websites on MMC, and it is those I will go back to, but we updated those on more than a weekly basis over the many months throughout this process. I will look at those and find out that detail for you.

Q102 Chairman: Some of the criticism of the short-listing process was that it did not give enough weight to academic achievement. Do people with first-class degrees make better doctors?

Sir Liam Donaldson: My own view is that it is wrong if doctors have got extensive high level academic qualifications, MDs, PhDs, and they are rejected by the process. It is very important that we have those high-flyers in the system and, if any of them were rejected, and we do not have, as Professor Marshall said, a comparison with the old system to know whether that was a good way of including them, but for those who were rejected, I think they were rejected in two ways: one was through the short listing process, but I heard accounts of interviews where the consultants doing the interview said, "Well, this person may have a first-class honour's degree but we are not sure they are the right person as a practical doctor in this particular post." I think we need basically both for medical science in the future, which we do very well as a country internationally. We want to continue to have a strong academic cadre, but we also need doctors with the interpersonal skills and the caring skills necessary in the National Health Service, and the two often come together in the same person but sometimes they do not.

Q103 Chairman: Do you agree with that, Professor Marshall?

Professor Marshall: Yes, I do, absolutely, and that is why it is not possible to answer your question in the way that you ask it. There are lots of different types of doctors that require different skills. I know that there is no evidence that correlates having a higher degree with being a good caring doctor providing clinical services on the ground. I suspect there is a lot of evidence that having a higher degree correlates very well with being an excellent clinical academic and, as Sir Liam says, that is a really important part of British nursing.

Mr Greenfield: Whilst we might think all higher degrees have the same currency, an MD means different things in different parts of the world, and there was caution around making sure that was taken properly into account.

Q104 Dr Taylor: Coming to the Douglas Review, which was obviously formed because of the tremendous tide of criticism that was coming, I have not, I am afraid, been able to find out its constitution or its powers. We know it had members from the Department of Health, the BMA and from the Royal Colleges. What was the sort of proportion of members of this?

Sir Liam Donaldson: Mrs Chapman and Professor Marshall were particularly involved with it. The majority were professional members, but I do not know whether we have got a list. It will probably be in one of the annexes to the Tooke Report and I can look it up for you.

Mr Greenfield: It is Appendix 9.

Q105 Dr Taylor: Appendix 9.

Mr Greenfield: Yes, I have actually got the list in front of me here and I can count them.

Q106 Dr Taylor: What page?

Sir Liam Donaldson: Page 175.

Mr Greenfield: I cannot see the membership.

Q107 Dr Taylor: If you will forgive me for putting it like this, people employed by the Department of Health come at this from a rather different angle, I suspect, from people who are pure, unsullied independent doctors, and I am trying to get at the proportion of the unsullied and the potentially sullied.

Professor Marshall: As someone who is sullied, certainly Professor Douglas made it very clear what kind of membership he wanted for the group, particularly in terms of the professional members, and he wanted strong representation, both from the Royal Colleges and from the BMA and from junior doctors, and that was what was achieved. In addition to that, he accepted that this process could only be taken forward in conjunction with the department, since the department was funding it, and ministers were responsible publicly for the process of delivering the medical education system; so there were Department of Health and deanery and NHS representatives in the group as well.

Sir Liam Donaldson: I can say, Dr Taylor, from my observation of the group's work, that it was largely the professional view at this phase of the crisis that held sway and led the process.

Q108 Dr Taylor: Would it have had the powers to stop the whole process in its tracks at that stage?

Sir Liam Donaldson: Yes, it would. If they had made that recommendation to Patricia Hewitt, that is what would have happened.

Q109 Dr Taylor: Why did they not make that recommendation?

Sir Liam Donaldson: I believe they were right not to. A very substantial number of interviews had already been scheduled or taken place, we were getting feedback from the deaneries that, despite the great difficulties and pressures they were under, they were short listing apparently good quality candidates and at that stage it would have meant that the career of those doctors would have been cast into uncertainty, and, indeed, some interviews had already taken place, I think, at that stage, so it would have caused a different sort of problem, I think.

Q110 Dr Taylor: Although there would still theoretically have been time to have gone back to the old process just for this year?

Sir Liam Donaldson: What, put people back into SHA old posts and make them apply in a ratio of 900 to one? I do not think that would have been a good idea. I think we had to try and improve and manage out of the crisis, which I think, with the leadership of the Douglas Group, is what happened.

Q111 Dr Taylor: Was it a question that you were absolutely committed to going on regardless, whatever criticism?

Sir Liam Donaldson: Absolutely not, no. We were under severe criticism and I think were really dependent on the Douglas Group for coming up with a balanced view in the middle of a furore about what the right way to proceed was, and that was the view they came up with.

Professor Marshall: Certainly, as a member of the Douglas Review Group, I do not remember many meetings at which whether the process should be stopped was not discussed and considered, and the decision, as Sir Liam said, was that, on balance, the benefits of continuing far outweighed the benefits of stopping the process.

Q112 Dr Taylor: From memory, did you get many letters from consultants, juniors, saying, "Please stop it"?

Professor Marshall: Certainly there were a lot of letters, e-mails, blogs on websites, that suggested the process should be stopped, and I think the voice of those who felt that it should continue was muted, particularly in the spring in the heat of the problems, but those voices were expressed very strongly. They were expressed by a lot of the candidates who had had interviews, who wanted them to stand, they were certainly expressed by the service, who did not want a vacuum created on 1 August, and they were expressed by a lot of educationalists as well.

Q113 Dr Taylor: Is it fair to ask: did you get roughly an equal balance of people who wanted it scrapped and people who wanted it to continue?

Professor Marshall: In terms of volume, certainly not, though in terms of the amount of noise that was created certainly not. The people who wanted it stopped were making a much louder noise but the decision had to be a rational one, not one based on the amount of noise that was going on in the system.

Ms Chapman: Dr Taylor, like Professor Marshall, I was a very active contributor to that group and I think two things. At the beginning the noise around stopping the process was quite high. One of the things that the Douglas Review did was to try and get as much evidence as possible to make sure that any decisions that were taken were proportionate to the issues that were on the table, and I think over time, as the information started to become clearer, both in terms of what doctors themselves wanted and also what the service needed, on balance the decision was a difficult one but taken because it was felt that to carry on and put in the commitment to an interview for everyone was a proportionate response. It honoured those people that were already going through the process and pleased with what they were getting from it, it enabled us to protect the service in the way that Professor Marshall talked about in terms of fill for 1 August and, because we tried to take out of the process those parts which were most contentious, particularly around short listing, we tried to make sure that we took out as much of the anxiety as we could.

Sir Liam Donaldson: The two big questions that arose at the first meeting were that there was the strong impression that the interview, the short-listing process, had not been a good discriminator of good candidates. As Professor Marshall said, it is not as straightforward as that when you look at the eventual outcome, but, on that basis, the argument was made to give as many people interviews as possible. There was even a suggestion that everybody should be interviewed for all of the four choices, but the logistics of that were just impossible, you could not do it, and an argument that I made very strongly at the first meeting that we should create a special strand for the academic trainees, to look at them separately, because it was clear that some very good candidates had been disadvantaged. Things moved forward from there.

Q114 Dr Taylor: So the doctors on the Douglas Review agreed with the Department of Health people. They were not just steamrollered into it?

Sir Liam Donaldson: Absolutely not. It was the opposite. If anything, we were looking to them, I think, for their leadership, and certainly Patricia Hewitt was---. Absolutely not. If they had recommended anything differently, it would almost certainly have been adopted.

Mr Greenfield: It might also be worth pointing out that the issue of whether we could stop the process and start again was considered by judicial review, and the evidence was presented and that upheld the approach and the recommendations of the Douglas Review Group.

Q115 Dr Taylor: Although the judge did make some pretty condemnatory statements about the whole thing.

Sir Liam Donaldson: Yes, he did.

Dr Taylor: Although he did not overrule it.

Q116 Chairman: Can I ask you about the on-line computer system and the security field. There were clearly two major failures of the on-line application system in late April 2007. Who was responsible for that?

Sir Liam Donaldson: Maybe I could ask Mr Greenfield to answer.

Mr Greenfield: There were two significant security failings. The first one was actually not a systems design failure but was a breach of the agreed protocol which we had contracted with the supplier where an individual working for the contractor sent information to deaneries about foundation applicants which was not adequately password and otherwise protected. It was not about anything to do with the fundamental design of the system, it was about an individual human error but one which breached the contractual agreement we had and the principles and protocols that were in place. That one meant that a large number of foundation applicants were exposed for a brief time, and clearly we took action to remove that as soon as we became aware of it. The second security breach was of an individual who was eligible to apply, register and get into the system who then chose to manipulate his or her password (their unique identifier) and, by manipulating the numbers, they were able to again access to certain messages that were going to people with that other number. So it was not about people outside the system being able to access it, it was about someone who was either a candidate or someone who was in the system eligibly not doing what they should have done. It is right that that should have been picked up perhaps under user-testing; it was not. As soon as the fault was identified, it was corrected. Of course those two events together rocked confidence among our junior doctors, the members of the review group and the trust in the system and, therefore, we felt obliged to take action and suspend its use in the full range of purposes.

Q117 Chairman: Have you taken any further action other than suspending the use of this in 2008?

Mr Greenfield: With the one incident, a police investigation followed of the person who had abused the normal processes. The police investigation, I understand, has been now ceased. That is a matter for the police. They are from a university. We have passed them the information and they are looking to see what further action might be taken. That is considered a proportionate and appropriate response.

Q118 Chairman: What about the breach of contract, or breach of protocol as you first called it? Has any action been taken against the company on that basis?

Mr Greenfield: I would have to check that, but I would be happy to do that and to come back to you.

Q119 Chairman: Whilst I recognise that it will be commercially confidential, could you tell the Committee, or share with us, if that has caused a loss of income to the company concerned?

Mr Greenfield: I will include that in my response to the extent I am able.

Q120 Dr Naysmith: We have talked a bit about Sir John Tooke's Review of MMC and he has recommended some further changes that seem to be quite widely accepted by the medical profession. Are you embarrassed by the popularity of Tooke's proposals?

Sir Liam Donaldson: No, I think we welcome the report. I think it is an excellent report. I think there are some differences of view on the proposals. We are very much looking forward to working with Sir John, seeking his on-going advice and trying to build his ideas into a new system for the future.

Q121 Dr Naysmith: I have seen it argued that his review has achieved more in a few months than the department has managed in five years. Would that be a fair criticism?

Sir Liam Donaldson: I do not think so. I think it is a very, very good report and, as I say, we will be using it. You will have noted, in his report he does say a lot of positive things about the original principles behind the training programme, which I set out in my report.

Q122 Dr Naysmith: You may have answered this question already earlier when we were talking about the project management, but is it quite clear that one of the four of you will accept personal responsibility for responding to the Tooke Report?

Sir Liam Donaldson: I think the response to the Tooke Report is a response primarily to be made by health ministers in the Department of Health.

Q123 Dr Naysmith: It will not be your responsibility then as Chief Medical Officer?

Sir Liam Donaldson: It will be our responsibility to give advice. The precise way in which we construct that advice will be---

Q124 Dr Naysmith: Clearly, one of the problems, and we have talked about it earlier, is there have been too many people involved in taking control of different parts of this project. If it is going to go through with Sir John Tooke, is there going to be one person responsible in the department for this?

Sir Liam Donaldson: I think there are two aspects to that. One is determining the way forward with the design of the training programme for 2009 onwards (we have got four UK health departments), and then it would need to be consulted on quite widely. I think the second question is: in the future what organisation implements any training programmes and whether that should be retained centrally within the Department of Health? I think that is a big question that needs to be very carefully thought through.

Q125 Dr Taylor: Continuing with the Tooke Report, one of the criticisms is that by going straight from foundation year to specialty training very early on you do not have the time and the chance to make the right choice. Tooke recommend uncoupling the run-through training, reducing the lengths of foundation training so, in fact, you have a longer period of broad-based training in which you can come to a decision about what you want to do eventually. Is not this just going back to the previous system?

Sir Liam Donaldson: No, it is not. It is going back to the unfinished business proposals which I made in my report and it is restoring that. Portraying it as having a period of time for people to make up their minds may be a bit of a luxury. I think there is an element of that in it, but I think it is also about gaining experiences and competences. Certainly if you contrast our system with the US system, which a lot of people do, they do not have this period, they do not even really have much in the way of foundation, they move straight from medical school, many of them, into run-through specialist training. Indeed, when I met recently to talk to them about their system, they were very surprised that we needed to have such a period of general training as we may now have. I think there are different views on the best way of doing it, but certainly I think restoring an element of general professional training, as in the unfinished business, would be a good thing, but I do think you have to think about the situation of people who have made their minds up, more mature graduates who want to move straight into specialist training and how you would take account of that. In other words, whether you would ban them from doing that under a new system which would introduce its own form of inflexibility.

Q126 Dr Taylor: I did not really mean just giving them time to make a choice, I meant time to get a broad base?

Sir Liam Donaldson: Yes.

Q127 Dr Taylor: Because, as an ex-physician, you do not want a surgeon who has done nothing but surgery.

Sir Liam Donaldson: No, that was what was envisaged in the unfinished business.

Q128 Dr Taylor: Tooke also proposes extending GP training. Will we ever be able to afford that?

Sir Liam Donaldson: The GP training scheme is already a very good one, but Professor Marshall is actually a qualified GP himself and might want to comment on that.

Professor Marshall: I think, although the quality of general practice training is generally regarded as very high and general practice has in many ways led the educational work for the last 20 or 30 years, I think there is a question to be asked about whether training is sufficiently long enough for the extended role of the GP in the future. Whether that requires an increased length of training in the future I think is one that we need to consider carefully when we look at the final Tooke recommendations, and we need to consider the cost of doing that against the opportunity cost of it.

Q129 Dr Taylor: Going on, the Tooke Report, very helpfully, in the first few pages gives us the abstract with eight crucial points. The fifth one is: "The medical profession's effective involvement in training policy-making has been weak", and the recommendation is that, "The profession should develop a mechanism for providing coherent advice on matters affecting the entire profession." Is there really one medical leader of the whole professional at the moment, and who is that, and should there not be one leader?

Sir Liam Donaldson: There is not one leader, and it goes beyond medical education into other areas of health policy. I think some have been arguing that there should be a single medical body to cover medicine.

Q130 Dr Taylor: Who, in your opinion, should it be? I do not mean the individual, I mean the type of individual, the background?

Sir Liam Donaldson: Perhaps when I have retired, Dr Taylor, I would love to pontificate on these provocative subjects, but it is not for me to tell the medical profession what to do. Otherwise I would be in the soup.

Q131 Dr Taylor: So it is not you as the leader?

Sir Liam Donaldson: No, it is not.

Q132 Dr Taylor: So really there is not one?

Sir Liam Donaldson: I think the Chief Medical Officer has a role in leadership, but I think I would be seen as not a true, pure professional given some of my roles within government, and so on.

Q133 Dr Taylor: Is not this one of the problems: we have got a BMA, we have got umpteen Royal Colleges and we have got nobody at the top?

Sir Liam Donaldson: We do have representative bodies. You have mentioned some of them. We have corporate representative bodies, we have an academy of medical Royal Colleges, we have an academy of medical sciences. We do not have a unified professional body. There are not many countries that do. They have all got diversity, and I am not quite sure whether having a single person would necessarily solve things because nobody would agree with him or her all the time.

Q134 Chairman: The last question on the Tooke Report. It criticised the MMC for focusing on competence rather than excellence. Do you accept that argument?

Sir Liam Donaldson: I take a slightly different view, in that I think both can be---. I do not think necessarily by saying that you are looking at competence that somehow you are going down to the lowest bare minimum. I think you can combine the concept of excellence with competence, but I do think that the idea of competence is that it is associated in people's mind with a more basic standard of care, but I do not think so. I think there have been many examples where in the past patients have been harmed by doctors not being aware of the limits of their competence or stepping outside and, especially as we are moving into an area of team work, I think it is much better for us to be clearer about the competences of not just doctors but each member of the team and people stick to their competences rather than stepping outside. My colleague Professor Marshall might want to add, but I do not think that necessarily excludes the concept of excellence.

Professor Marshall: I agree; I do not think they are mutually exclusive. What I do think is that the concept of competences, of identifying what somebody needs to learn in order to be a good doctor in whatever specialty, is a very important idea and one that we need to keep on pushing because it does come under some threat occasionally. As a junior doctor, in a way that I did not when I was a junior doctor, first of all, you have got to know what you have got to learn in order to be a good doctor and, secondly, that you will be assessed in terms of your ability to learn those things has to be a good thing for the patients and the public.

Q135 Chairman: Is competence easy to measure and easier to plan for in terms of knowing what you need to teach and the cost of doing that?

Sir Liam Donaldson: Absolutely. Certainly when I was a trainee in surgery I was completely thrown in at the deep end - I was practising on patients - and I do not think that is the right thing to do.

Q136 Chairman: It is a wonderful expression, but we have had that before in the Committee about practising on patients.

Sir Liam Donaldson: Yes. It is not right. It does not happen today, except, I am sure, in rare cases, but I think being much, much clearer that when you go to do an operation, if you are a surgeon, that you have seen one, you have perhaps have even gone into a simulator and practised the skills required, you have been overseen by somebody experienced and only then do you operate on your own. I think that is the model of training that we need.

Q137 Dr Stoate: Briefly some questions about workforce planning. You will know that earlier this year we produced a report on workforce planning which was somewhat critical of the way the NHS goes about it. In the light of the MMC, do you think that the department will take a more robust view of workforce planning to try and sort these issues out?

Sir Liam Donaldson: Clare, would you like to start?

Ms Chapman: Certainly. In the light of the Select Committee Report, action has been taken, particularly around some of those things which were very practical and needed to be operationalised quickly. I think it is worth pointing out that all the evidence from across the world would suggest that, if you want to try and get workforce planning better, you have to try and bring supply and demand as close together as possible, and that is also a very good way of giving out much better demand signals to higher education so that we are able to be truly demand-led rather than supplier-driven. I do think that this idea of bringing supply and demand together is important, which is why the deaneries and the SHAs working together in the regional health economy is important, and at the time of the Select Committee's Report I think that accountability had been in place for less than a year. So work has gone on to try and improve accountability and definition and, back to our last conversation, if you cannot describe what good looks like you cannot teach it, and I think work is going on to be able to describe it. Having said that, I do think that what Sir John points out in the review is also true, and that is that if we are going to improve workforce planning in a much more devolved health system, we actually have to change, not just the structure of it, but the methodologies that are used. So, as part of NHS next stage review that Lord Darzi is leading, one of the enablers that is a critical piece that is being commissioned is what do we need to do to change the methodology so that, as Professor Marshall pointed out, there are a number of things that influence workforce planning, like the shape of the service you want to have delivered, like the demographics and some of the formalisation issues that Mr Greenfield pointed out? There needs to be a much better methodology for doing that.

Q138 Dr Stoate: There is a problem though. Sir Liam has just talked about the importance of the team. You do not talk about doctors in isolation, it is now a team approach, and you should integrate a team and plan for a team. Yet Tooke is suggesting creating new bodies dedicated to medical workforce planning. Surely that is going to exacerbate the existing problems rather than make them better.

Ms Chapman: I think that is why it is important, Dr Stoate, to recognise that part of the principles behind MMC was around how to make sure that doctor training is not done in isolation of the rest of the healthcare professionals they are working in the team with. A piece of work that is going on at the moment is to look at integrated care pathways and actually understand what the workforce implications are of those, which, of course, will cover all of the professionals involved in delivering that care. I think that it is both. I think that it is professional workforce planning and integrated patient pathway planning that will get you to a better answer, but I come back to my first point, which is that there is no point in setting up big centralised solutions for this. Part of it is to try and make sure that you have got a methodology for the supply and demand to come together as effectively as possible and as locally as possible.

Q139 Dr Stoate: We have all this wonderful jargon like "integrated patient pathways" and all this stuff. Where is the actual evidence that doctors, pharmacists, nurses, and so on, are training together and sharing medical either undergraduate or postgraduate training? It does not actually happen.

Ms Chapman: In terms of some actual evidence, I was out in the service last week with some social care colleagues and it is very clear to me that, when patients think about the service, they do not think about whether it gets delivered by the NHS, or by social care, or by one professional or another, they actually think about the service they are receiving. This is actually starting by looking at what are the skills to ensure that is delivered across the entire system.

Sir Liam Donaldson: There is more of the multi-professional education now in some of the new medical schools but, I agree with you, at post-graduate level there is not very much of it and it is something that we need to address.

Q140 Dr Stoate: Do you think you will be able to do something about that? I constantly meet GPs, pharmacists, and so on, who often want to work together in a post-graduate setting, but there was no opportunity?

Sir Liam Donaldson: I think it is something that will be addressed.

Q141 Dr Naysmith: The Post-graduate Medical Education and Training Board is another player in this drama and it has been widely criticised for its inflexibility and unwillingness to take responsibility for any of the problems with MMC and MTAS, but it has told us in its evidence that it is not responsible for recruitment and selection. Is that right and, if it is, why was a body created which is responsible for the quality of training schemes but not the quality of the process for selecting doctors to undertake these training schemes?

Sir Liam Donaldson: It is a regulatory body and we have limited powers to intervene in its style of working. I have seen the comment made that the PMETB commented but was not responsible, and I am not quite clear how they were making that distinction. As I understand it, they did have responsibility for approving, not just the curricular of the new specialty training programmes, but also the applications procedure. I am sure that they are not maintaining that they did not have any significant role in all of this, because I think they did.

Q142 Dr Naysmith: Could I quote to you what they say in their evidence: "PMETB's statutory remit in matters of selection for specialist training is limited to determining that the selection process can identify those who are eligible to undertake it." That is what they are saying is their responsibility.

Sir Liam Donaldson: I think that is quite an extensive role, given the context that we are talking in.

Q143 Dr Naysmith: In your report on medical regulation you recommended that the GMC's role in education be taken over by the PMETB.

Sir Liam Donaldson: I changed my mind on that, and fairly publicly.

Q144 Dr Naysmith: I was about to say, two reviewers suggested the exact opposite.

Sir Liam Donaldson: 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.

Professor Marshall: Can I come back solely on your question about PMETB? I think there are some obvious clear advantages to separating out the regulatory standard setting role from the implementation role, and that is where PMETB's role is different, it is at the regulatory standard setting role, and I think that the differentiation is an important one.

Q145 Dr Naysmith: Just the standards for admission to training?

Professor Marshall: Yes, for admission to training and for outcomes at the end of the process as well.

Q146 Sandra Gidley: The previous Secretary of State has apologised on several occasions for this whole fiasco. You tell us you apologised in April. I have to say, most of us had not noticed. Can you tell us what form that apology took?

Sir Liam Donaldson: Yes, I will be absolutely sure I have got the date correct, but it was at a major surgical conference, with the media present. I also apologised in other more informal fora and also, I think, in a television interview.

Q147 Sandra Gidley: That is fine. Is an apology enough? Seeing as you were the architect of the MMC reforms and also the person ultimately responsible for overseeing their implementation, should you not have actually resigned?

Sir Liam Donaldson: The principles and the policy were commended in the Tooke Report and by others, so I do not think the question of criticism of the policy arises. As I indicated to you, accountability did not rest only with me, it was spread quite widely, and I have already given a pretty full analysis of that in response to an earlier question. Policy in relation to the two factors that made the biggest difference, I think, in the crisis were on international medical graduates and on the design of the application form, and those were not matters where I had overall or sole responsibility.

Q148 Sandra Gidley: If the responsibility was spread, how can doctors who are going to have to apply in the future have any confidence that the department can rectify the problems with medical training, seeing that most of the people who were responsible for the initial problems remain in post?

Sir Liam Donaldson: Because I think a lot of the problems that did occur with the implementation were put right, or at least mitigated, by the follow up action that took place from March onwards. The Tooke Review was commissioned, and we have pledged ourselves to redesigning the system, taking account of the Tooke recommendations, so we are looking to learn as much as we can from the things that did not go well in the process and, as you will have heard in response to some of your earlier questions, the negative has been overwhelmingly emphasised. Nobody has said anything positive about the outcome, and there are some positive points to be made, and those are things that we will build on.

Q149 Sandra Gidley: Was not one of the problems that nobody seemed to take overall responsibility and there may be a lack of leadership on this? I fully accept that you have to take account of concerns that came up along route, but the fundamental problem here seems to be that things were changed at the last minute, something else was put into it, there was lack of time for consultation over any changes. Nobody really seemed to have a steady hand on the tiller with this. Would you accept that?

Sir Liam Donaldson: I think it is very difficult. If one single person had been in overall charge, taking all the decisions, that would have brought its own problems of maybe insufficient participation, different points of view, not having the opportunity to be expressed; and in a government department we have to accept also the need to involve ministers - that is very, very important in some of these big policy decisions - so I think it is inherently in such a programme quite a complex governance structure, and I do not think there is any simple way out of it. I am sure that it will be, and can be, improved but I do not know that somebody could just sit down and say: this is the thing that you need to do and the problem is all solved. It is not as simple as that.

Sandra Gidley: That was not quite what I was saying, but we will move on.

Chairman: Could I say to all of you, we actually published the written evidence for this inquiry earlier this week. It is now in the public domain and on our website as well if anybody needs to access it. Could I thank all of you very much for coming along and giving evidence to us this morning. I have no doubt that you will be watching with eager eyes the events of the next few months when we are looking into Modernising Medical Careers, but thank you very much for this first session.