Uncorrected Evidence 25

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Oral Evidence

Taken before the Health Committee

on Monday 18 February 2008

Members present

Mr Kevin Barron, in the Chair

Mr Peter Bone

Jim Dowd

Stephen Hesford

Dr Doug Naysmith

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Ms Lorraine Rogerson, Director, Policy, and Head of Profession at the Border and Immigration Agency, Home Office, and Ms Judith Macgregor, Director of Studies, Foreign & Commonwealth Office, gave evidence.

Q766 Chairman: Good afternoon. Can I welcome you to the sixth evidence session of our inquiry into Modernising Medical Careers. I wonder if I could ask you to give your name and the position you hold for the record, please.

Ms Macgregor: My name is Judith Macgregor and I am Director for Migration at the Foreign & Commonwealth Office.

Ms Rogerson: My name is Lorraine Rogerson and I am the Director of Policy and Head of Profession in the Border and Immigration Agency.

Q767 Chairman: Good afternoon and welcome. I was going to start with Liam Byrne but, given that he has not been able to get to us this afternoon, Ms Rogerson, the first question is for you. When did the Home Office become aware of the Department of Health's policy of making the UK more self-sufficient for its medical workforce?

Ms Rogerson: The Department of Health first approached the Home Office in 2005 about using the Immigration Rules to limit further competition for training posts from international medical graduates.

Q768 Chairman: So it was 2005?

Ms Rogerson: That was the first approach. Do you want me to tell you the first change to the Immigration Rules?

Q769 Chairman: Yes.

Ms Rogerson: We first made a change which took effect on 3 April 2006 which restricted the provisions of the postgraduate doctors and dentists category.

Q770 Chairman: I think we will be asking you a few questions about that as we go along. Given that the move towards self-sufficiency began in the year 2000, why has it taken so long to address the number of overseas doctors? Did it not seem obvious to anybody that the increase in home-grown doctors would need to coincide with a reduction in overseas doctors or did you not hear any of this at all until 2005?

Ms Rogerson: As far as I know we were not approached about this until 2005. Before that we were still requiring quite a lot of international doctors to fill vacancies in the Health Service.

Q771 Chairman: You will have seen the headlines in the media over the last 12 months about whether or not this situation we are currently in has cut short careers for graduates here in the UK. Do you think there has been a failure of the Home Office and the Department of Health and the Treasury to co-ordinate this type of policy?

Ms Rogerson: We have been reviewing the impact of the changes of 3 April 2006 and also working with the Department of Health and other government departments to identify the best way of addressing this. It was based on joined-up thinking and a total government approach that we change the rules now.

Q772 Chairman: It is when the thinking came into being that we are more interested in. It seems it was a long time the Department of Health was setting goals that you were not asked to respond to until much later.

Ms Rogerson: We changed the rules on 3 April 2006. In January 2006 we were writing the command paper about changing the Immigration Rules and creating the new points-based system, and at that point we were looking with the Department of Health at restrictions on the Highly Skilled Migrant Programme and changing it to the new points-based system. It is that policy change which we have just done now.

Q773 Chairman: You introduced that on 6 February, preventing non-EEA doctors from applying for UK training posts from 2009. The memo that we received states that you were asked to make this change as early as June 2006. Why did it take so long?

Ms Rogerson: The Department of Health is the driver of the policy and there are a number of steps which they are thinking of taking to address the problem. The immigration solution is one part of that and we wanted to check what the evidence was about the change that we made in April 2006 and we were also discussing this with other departments. We wanted to check how this fitted. The Highly Skilled Migrant Programme, which was the one which was the concern, is a programme which is meant to enable non-EEA nationals who want to come here and who meet a certain level of qualification and skills to have access to the labour market, and as part of that the principle is that we would not restrict what they would have access to, and we have been looking at other ways with the Department of Health at meeting this concern.

Q774 Chairman: Your submission acknowledges that the rule change goes against your Home Office policy of attracting the brightest and the best to the UK.

Ms Rogerson: Yes.

Q775 Chairman: Was this agreed by the Home Office?

Ms Rogerson: Yes.

Q776 Chairman: Was it ever debated in Cabinet?

Ms Rogerson: It was. It has been debated through the Domestic Affairs Committee of the Cabinet. I think the Department of Health will be able to tell you more when you see them about the other steps they are taking. We have made this change which restricts the access by highly skilled migrants and forthcoming Tier 1 people to have employment in training places as a short-term step. It is implementing government-wide policy. It is not quite in step with our overarching principle of the Highly Skilled Migrant Programme but it meets this need and seems an appropriate thing to do for a short time while other more sustainable policies are put in place by the Department of Health.

Q777 Chairman: I was going to ask you about that because the Department of Health has described these provisions as "temporary changes". How long will they be in force and why would you now reverse them when UK medical school output is still increasing quite rapidly if you look at the figures? What is behind this temporary change?

Ms Rogerson: The intention is that the Department of Health should find and are working on other methods of making a sustainable change to being self-sufficient and that it would not necessarily need to be a restriction like this on an immigration route.

Q778 Chairman: We may pursue that a bit later this afternoon. Could I finally ask you this? If the Department of Health's guidance is declared lawful by the House of Lords will these rule changes become obsolete and, if so, will they be withdrawn?

Ms Rogerson: We need to review that at that time.

Q779 Jim Dowd: Before we go any further, Ms Rogerson, what is a Head of Profession?

Ms Rogerson: I am the Head of Profession for Policy in the agency.

Q780 Jim Dowd: Yes, I heard you say that before. I do not know what a Head of Profession is.

Ms Rogerson: I take care of the policy skills and ensuring that we are developing policy in line with good standards.

Q781 Jim Dowd: Assuming that the House of Lords does not uphold the department's guidance, will the Home Office come under pressure to make further restrictions through the Immigration Rules?

Ms Rogerson: We will have to look at that at the time. No further suggestions have been made about further changes we might need to make.

Q782 Jim Dowd: So you are making no preparation for an adverse decision at all?

Ms Rogerson: The current restriction is meant to have the same effect regardless of the House of Lords decision. We have made a restriction so that people coming in under the Highly Skilled Migrant Programme will no longer be allowed to have access to these training places. That is the short-term solution. There has been no suggestion that we need to make any further change.

Q783 Jim Dowd: You are saying that the House of Lords decision will not affect that one way or the other?

Ms Rogerson: If the House of Lords upheld the guidance then we would not need to have a restriction in the Immigration Rules.

Q784 Jim Dowd: And if they do not you do not need any other arrangement?

Ms Rogerson: No. At the moment the suggestion is that this change to the Immigration Rules that we have made would be enough in the short-term to relieve the pressure on the places.

Q785 Jim Dowd: The Appeal Court ruled in November that the department's guidance was unlawful as it did not have the authority of Parliament. Why did you not just take the opportunity when amending the Immigration Rules to enforce the department's guidance by law?

Ms Rogerson: The Department of Health guidance?

Q786 Jim Dowd: Yes.

Ms Rogerson: I am not sure that we are able to do that. What we are able to do in the Immigration Rules is give effect to the Secretary of State's decision about the purposes for which people might be able to come here and the conditions and restrictions that might be placed on them when they are here, and that is what we have done in these rules.

Q787 Jim Dowd: Do you know whether the department have asked you to do this?

Ms Rogerson: I believe that what we are doing is in line with what the department have asked us to do, which is to make any immigration changes a short-term contribution to the solution but it does not affect the Department of Health guidance.

Q788 Jim Dowd: This question again was originally meant to be directed to the minister so if your reply is somewhat more guarded I fully understand. Is the Home Office frustrated by the Department of Health throwing a spanner in the works of your attempt to introduce a fairer and simpler immigration system?

Ms Rogerson: One of the Border and Immigration Agency's jobs is to manage migration in the interests of the UK and the changes we have made are about short-term immigration restrictions to meet a government objective agreed by the whole of government.

Q789 Jim Dowd: Is that why you only agreed a temporary exemption for doctors?

Ms Rogerson: Because the Department of Health has a whole range of packages of things that they can do and they are working on a more sustainable solution, it was intended that this would be a short-term contribution rather than the whole answer. Immigration control can only play a part in meeting Department of Health Workforce objectives.

Dr Taylor: I am very sorry the minister is not here and you are having to bear our attacks.

Jim Dowd: No - inquiries, Richard, not attacks.

Q790 Dr Taylor: This seems to me to be about the best or the worst example of unjoined-up thinking across four government departments that we have ever come across because we have got the Department of Health, the Treasury, the Foreign & Commonwealth Office and the Home Office. You have told us that the Department of Health was the driver and that there was a Domestic Affairs Committee. My question is really to Judith. Was your department represented on the Domestic Affairs Committee, because the very full and very helpful paper that you have given us suggests that really your involvement was pretty limited. Is that fair?

Ms Macgregor: We certainly were involved in the DA Committee, absolutely. Yes, I suppose, if you like, we are neither the drivers of health policy nor the drivers of immigration policy, so our involvement in this had been primarily to put in the foreign policy implications of any particular course of action and help steer the discussion in that way, so limited in that sense but very full nevertheless, I can assure you, within that.

Q791 Dr Taylor: So with the new immigration restrictions have they taken your advice into account?

Ms Macgregor: I think that our concern, as Lorraine has said, was that an immigration restriction can be only one part of a broader policy, so to the extent that we have a situation where an immediate challenge has been assuaged by recourse to the immigration system while other more sustainable policies are sought, I think we would say that this was something which was in the national interest to do. I think also the way in which the restrictions have been brought in, which is essentially to be prospective so that people coming to apply for the scheme know the score before they apply, is very important. I think governments do understand that other governments have to regulate their workforce supply but clearly the aim of the immigration system is to be as clear as possible about what that is going to be and how it will affect individuals at the time when they apply, and so in that respect, yes, I think our arguments were taken into the discussion and were respected.

Q792 Dr Taylor: You say in your paper that you recognise the tension between the desire for self-sufficiency and the supply of doctors and an open-door policy. Is there a compromise? Do you think this is an acceptable compromise?

Ms Macgregor: Compromise is never a finite thing; I think it is dynamic, and I think compromise is perhaps necessarily imperfect, but if we can achieve through this a better understanding of longer term, more sustainable solutions, and this will in the immediate term obviously prevent a very serious displacement of UK-trained doctors, then I think it has the merits of that. Obviously, we will look to see how the situation develops. The points based system which is being introduced is an innovative system. We will see how that also goes through and how that works out. Our concern was that it should be as clear as possible at the time of its introduction, which I think in this way now we have perhaps achieved: it is clear what it will cover and what it will not cover.

Q793 Dr Taylor: I think you suggested that it makes doctors an exception and sets an unwelcome precedent.

Ms Macgregor: We were concerned that, if you like, a permanent restriction at the time of something beginning would in itself not be a very good signal. I think something which is inherently stated not to be a permanent solution and is something which can be looked at again meets those conflicting requirements.

Q794 Dr Taylor: It is well known that we owe an awful lot over many years to lots of doctors from India. Do you think the new regulations will damage the relationship with India?

Ms Macgregor: It will be something that we will continue to handle very carefully and very sensitively. Again, I think that governments, including governments like the government of India, will understand and respect that we have to regulate our workforce and our labour supply. The important thing is to be clear and to be timely and not to affect and disadvantage people who have come in in good faith under another system.

Q795 Dr Taylor: So those who are already here, halfway through their training, are going to be saved, are they?

Ms Macgregor: Our understanding is that they are not prevented, that is right, from applying for these speciality training courses.

Q796 Chairman: Have the Foreign Office had discussions, to your knowledge, with the Indian government about these changes?

Ms Macgregor: About these specific changes?

Q797 Chairman: Yes.

Ms Macgregor: When Liam Byrne was in India two weeks ago he did mention that this was likely to happen, yes.

Q798 Chairman: And the outcome of it is not known at this stage, presumably?

Ms Macgregor: To be fair, he also mentioned it publicly because he was in India at the time of the changes being announced, so he also, of course, made that public at the time.

Q799 Chairman: Do you feel, when we have recruited from the Indian sub-continent in particular something like 25%-30% of doctors coming into the National Health system over many years, that these types of changes are acceptable or unacceptable?

Ms Macgregor: I think it is incumbent upon everybody to take it very seriously and to look very closely at what can be done, as I say, to be both in good faith but also nevertheless over a period of time make clear what the policy of the Government is. As you have said, the policy of self-sufficiency has been one which has been coming through and I think in discussions we have made that clear. If you like, our role has been to interpret to both sides that there is this policy of self-sufficiency and that it will obviously have knock-on effects, but at the same to bring into the domestic debate precisely the fact that we have had very good service over many years from Indian doctors and nurses and it is only fair to ensure that the greatest clarity is given to them and the situation has to change.

Q800 Mr Bone: I think you said in your answer that the Indian government would understand. If I were the Indian government I would not understand. I would see all these people from the European Union being let in all of a sudden and yet people from India, who have been doing a wonderful job for years, we are suddenly stopping. Do you think the Indian government really understands? I would be a bit miffed, I think.

Ms Macgregor: I cannot answer for what the Indian government does or does not think.

Q801 Mr Bone: I think you said earlier on in your answer that the Indian government would understand.

Ms Macgregor: I think they would understand that each government has the right and the ability to regulate its own labour supply. This particular restriction, of course, does not stop Indian doctors from coming and working in a wider range of posts inside the National Health Service, nor other medical care people. It is very targeted at these speciality training posts. To that extent it is not seen as closing a door entirely and, obviously, were that the case there would be greater unhappiness.

Q802 Dr Taylor: "A wider range of posts" - how would they get in if they do not get in into these training posts?

Ms Macgregor: My understanding is that they could come to study in the United Kingdom in the medical profession. They could presumably come in also in some consultancy or ancillary way. It is access through this particular competition to the speciality training posts in my understanding that this restriction applies.

Q803 Dr Taylor: But is not the only reason they want to come to get the speciality training?

Ms Macgregor: I am sure a number are wanting to do that because that is why there has been a large number of applicants, but I think it is also the case that people are coming under other streams of activity.

Q804 Dr Naysmith: I would like to follow up one or two of these matters with Judith. You have said that the Immigration Rules changing should be temporary; that is the favoured solution, and that the department's guidance is the preferred way of restricting non-EEA doctors. Why is the use of guidance preferable to any other system?

Ms Macgregor: There are two reasons. One was because, as we have said in the evidence, of the introduction of the new points-based system and Tier 1 in particular is, if you like, fairly untrammelled. You do not need to have a contract before you arrive. It is based on your qualifications and your background, and the feeling was that to, as it were, stop a particular category of people ran counter to the principle of that, which is that you are qualified in your profession and you are free to come and look for work in the United Kingdom. The guidance also, as I understand it, was guidance literally to the recruiting people that they should give preference to candidates from a UK training background but not exclusively, therefore, when other candidates could be found. The Immigration Rules therefore, if you like, cut off at source people coming in whereas the guidance gave more discretion, and I think that was our preference, therefore, but that was something we fed into the debate at an earlier stage, obviously.

Q805 Dr Naysmith: That is because it is speciality training that we are talking about; is that right?

Ms Macgregor: I was talking about speciality training.

Q806 Dr Naysmith: And that is the thing that makes guidance more applicable than just allowing people in to take work, no matter how qualified they are?

Ms Macgregor: That is right. In this context it was the guidance, yes.

Q807 Dr Naysmith: What happens if the House of Lords does not uphold the department's guidance? Are you concerned that the changes to the Immigration Rules will have to be made permanent?

Ms Macgregor: As my colleague said, I think it is very hard to pre-judge exactly what would be the Department of Health's decision in that case. It would be for them to decide, so I think we have to take that one step at a time. We would hope, obviously, that some solution could be found that would give a sustainable solution without a permanent restriction through the points-based system, but that is as yet to be discovered and taken forward.

Q808 Dr Naysmith: But you must be thinking about alternatives. When you introduced guidance, for instance, you must have thought about other ways of achieving the same result.

Ms Rogerson: At the same time as we made the rules change the Department of Health issued a consultation paper which is now consultation about the new guidance and the way in which this issue might be addressed, but I am not the person you need to talk to about that. It would need to be them.

Q809 Dr Naysmith: Can you talk about it?

Ms Rogerson: No. I think the Department of Health should talk about that.

Q810 Dr Naysmith: No, no. The Foreign & Commonwealth Office will have a view on the consultation that is taking place, will it not?

Ms Macgregor: I think we have not yet taken a formal view on that, to be fair, and I think we would really want to see where the consultation lay and the different expert views and then we would obviously take account of that in due course. At this stage it really would be very difficult for us to say that we had a preferred view. We do not.

Q811 Dr Naysmith: Finally, how many doctors do you predict will come to the United Kingdom from within the European Economic Area over the next ten years? Do you have any idea?

Ms Macgregor: Sorry, I do not with my background have an idea on that, I am afraid.

Q812 Dr Naysmith: And no-one has mentioned any figures? Presumably when you introduced this policy you had some idea of what effect it would have on the restrictions.

Ms Rogerson: In terms of the restrictions in the current rules the Department of Health estimate is that there will be, through this restriction to the Highly Skilled Migrant Programme, 3,000 to 5,000 fewer people applying for places. We do not have any immigration prediction of people coming from within the EEA.

Q813 Dr Naysmith: But you have not had any advice from the Foreign & Commonwealth Office? Are these your predictions or are they in conjunction with the Foreign & Commonwealth office?

Ms Rogerson: We do not have any predictions.

Q814 Dr Naysmith: So where did this figure come from?

Ms Rogerson: The Department of Health estimate.

Q815 Dr Naysmith: That is what I am saying. That is a prediction, is it not?

Ms Rogerson: No. Their estimate is that in 2009, just in 2009, the impact of this rules change would be that there would be 3,000 to 5,000 fewer.

Q816 Mr Bone: I am sorry the Minister is not here and that you are having to bat on a sticky wicket, but if you do not know the number coming from the European Union how can you match the supply? Somebody must have that figure, we hope.

Ms Rogerson: We are working on the basis of Department of Health Workforce planning. Because it is self-sufficiency they will know how many people they are expecting to come through the system.

Q817 Mr Bone: Should the Home Office not know that really, migration? Is that not the Home Office?

Ms Rogerson: EEA?

Q818 Mr Bone: Yes.

Ms Rogerson: No, we do not have predictions on that.

Q819 Chairman: Who would look at the movement of the workforce throughout the EEA then under these circumstances?

Ms Rogerson: The Department of Health Workforce planning would be looking at people who would be coming to work in the National Health Service.

Q820 Chairman: And they would look at that from within the EEA as well, would they?

Ms Rogerson: I do not know how they do it. That would be a question you would need to put to them.

Q821 Chairman: It seems to me that with all these people going through medical school now the Home Office should be taking action against international medical graduates, but as far as any movement within the European Economic Area is concerned the Home Office is not making any predictions about that?

Ms Rogerson: No.

Q822 Chairman: So, no matter what we are doing here, that could be disturbed if people were applying to come and work in the UK in years to come?

Ms Rogerson: I think it is something you need to put to the Department of Health in terms of how that would relate to their self-sufficiency in graduates.

Q823 Chairman: But you could not restrict them from a Home Office point of view because they have the right to -----

Ms Rogerson: Freedom of movement, yes.

Q824 Dr Naysmith: We still have not had an answer to whether the Home Office and the Foreign Office have been discussing these numbers with the Department of Health. Do you know if they have or not?

Ms Rogerson: Which numbers, sorry?

Q825 Dr Naysmith: Predictions about where doctors are going to come from if you cut off the supply from, say, India, but there are more coming in from the European Economic Area. Has there been any discussion about what these numbers mean between the Department of Health, the Foreign Office and the Home Office?

Ms Rogerson: Not that I know of.

Dr Naysmith: This is talking about joined-up government. There are at least three departments involved, and each one seems to be taking a different point of view, so avoiding - I am not supposed to say this - the Sir Humphrey effect.

Q826 Jim Dowd: Ms Rogerson, the number you quote of 3,000 to 5,000 in 2009 was included in the Department of Health's press release announcing the consultation on the restriction, which goes on to say that because of the high level of potential IMG applicants that will be exempt from the Home Office regulations, apparently estimated at around 10,000, without further action on behalf of the Immigration Rules the department estimates that around 71,100 UK doctors will be displaced and unable to secure a training place in 2009, 2010 and beyond, so even that figure you give us of 3,000 to 5,000 is not going to be enough to reduce the potential fall?

Ms Rogerson: The potential IMG exempt are the people who are here already and because the rule change we are making is prospective in order to not to destabilise that is why the Department of Health needs to be looking at ways of managing this. We have made a change which would have that estimated impact in 2009.

Q827 Jim Dowd: Right, so essentially you are saying you have done the best you can to help them with this position, there is still more work to be done but it is the Department of Health that has the lead on that?

Ms Rogerson: We will continue to discuss with them and review what happens in terms of migration changes but at the moment the migration change we have made has that predicted impact, yes.

Q828 Mr Bone: My questions are about joined-up government and who is talking to whom. I have to say I am a bit miffed at the moment. We have had to rearrange this meeting to get both ministers here and they do not seem to be able to co-ordinate their diaries and have left you to take the flak. It is not a really good start. I think your two departments probably come out better in this because the Tooke Review really said it was leadership from the Department of Health that was weak in the implementation of MMC, so that is probably helpful from your point of view. Do you think that is why the failure was, that there was not better communication between the departments, because of lack of leadership from the Department of Health, as Tooke suggested?

Ms Rogerson: Our part of this has been trying to see to what extent the immigration system which we manage can and should be used to help to solve a problem that is government-wide, which we do quite a lot, but our part in that is to advise and implement when agreed and to support, and that is the role we played.

Q829 Mr Bone: Now that this has happened and MMC has been a pretty miserable event for the Government, I wonder if within your departments something from on high has come down saying, "We really must not do this again. We have got to improve our communication between departments". Has there been some sort of memo or seminar or have ministers been exploding? Has anything happened?

Ms Rogerson: We have been asked to continue to work closely together, yes.

Q830 Mr Bone: "Continue to work closely together" means no change really because clearly you were not working closely together, or do you think you were working closely together?

Ms Rogerson: We have been working closely in terms of advising and supporting the implementation of this as part of the overall package.

Q831 Mr Bone: Can I try a different way? What are the current mechanisms for communicating with the Department of Health? Do you have a meeting every Monday morning or do you just wait for the phone to ring?

Ms Rogerson: We have been working with them closely on this particular area of work, so that is phone calls and meetings, and supporting the Domestic Affairs Borders and Migration Committee. Officials will meet co-ordinated by the Cabinet Office.

Q832 Mr Bone: In some businesses where you have diverse departments they will meet once a week, say, on a Monday morning, to discuss anything that goes across their department. Does that happen? Do key officials meet regularly on a particular day to see how policy in one area is affecting policy in another department?

Ms Macgregor: The Border and Immigration Agency and the Foreign & Commonwealth Office obviously have very regular consultation across a range of immigration and migration issues. We have quite a few, including at ministerial level, where we have fortnightly meetings also to review progress, particularly on illegal migration, which is somewhere where we are particularly looking to foreign partners for assistance, but also across the board in legal migration as well. With the Department of Health I would say that our contacts have been, as Lorraine says, regular over this particular issue over the recent period.

Q833 Mr Bone: But more back office than formalised?

Ms Macgregor: They have not been formalised. Obviously, there have been ministerial exchanges as well by letter. On the figures point I wanted to say that we have worked very much on the basis of the figures that have been supplied to us by the Department of Health in terms of the numbers of applicants that they were expecting to have in this competition and in 2009, but we have not made any independent or separate estimates of figures beyond that.

Q834 Chairman: Obviously, the Domestic Affairs Committee involves the Treasury as well. What role does the Treasury play in any of this?

Ms Rogerson: They put in views and ideas and query proposals in the same way as anyone across government would.

Q835 Chairman: Have they been helpful in terms of getting the business sorted out from your perspective? Has it been a helpful situation?

Ms Rogerson: Yes, I think so. What we have been doing collectively is looking at what the issues are that need to be addressed, looking at the options for addressing the issues and trying to come up with proposals which would do that.

Q836 Chairman: Were the Treasury involved from very early on?

Ms Rogerson: Yes, I think so. They were not closely involved at the point that we made the changes to the postgraduate doctors and dentists route, but they have been closely involved in all of the development of proposals for the points-based system, so they have been involved in those discussions as far as I know from the outset.

Q837 Chairman: Do you have much discussion with the Treasury?

Ms Macgregor: Certainly. The Treasury have been involved in all the discussions that I have been involved in and they are very closely involved in the whole concept and rolling out of the points based system, particularly Tier 1, obviously, to attract the best and brightest and talents to support and sustain the UK economy, very much so.

Q838 Dr Taylor: Could I come back to something I did not quite clarify before? When we were talking about the other jobs, the non-training jobs that are still open to foreign applicants, are we really talking about those sorts of staff grade jobs that are perhaps in the back of beyond without any supervision at all and are we thus going to have a second-class group of doctors with no formal training?

Ms Macgregor: I do not think it has been our intention that it would be jobs in the back of beyond. I think the understanding has been that the restrictions are limited to the speciality training slots; therefore, all other jobs that foreign applicants have been applying for and have been taking up are not affected by that.

Q839 Dr Taylor: And the Tooke Review does suggest that staff grades probably have a route into higher training. Is that going to queer the pitch as well?

Ms Macgregor: I think it is probably a question that the Department of Health could advise on in terms of what course leads into the next. As I say, our understanding is that these particular slots are affected but other slots are not affected.

Q840 Dr Taylor: But it is not very attractive, I would have thought, to people from the Indian sub-continent to be coming to purely service jobs without any training. What do the Indian authorities feel about that? Has that been put to them?

Ms Macgregor: I certainly have not been aware of that particular point being made to the Indian authorities. As I say, the point that we were discussing in India two weeks ago was specifically this particular scheme, so I cannot really comment further on that.

Dr Taylor: It has long been felt that some of these people are brought in just as drudges to do the unpopular jobs, so it is very sad if that continues.

Chairman: Maybe we could take that up in the next session, Richard. Could I thank both of you for coming along this afternoon and helping us with our inquiry.

Witnesses: Rt Hon Alan Johnson MP, Secretary of State, Mr Hugh Taylor, Permanent Secretary, Sir Liam Donaldson, Chief Medical officer, and Ms Clare Chapman, Director General of Workforce, Department of Health, gave evidence.

Q841 Chairman: Could I first of all welcome you to our sixth meeting of taking evidence on our Modernising Medical Careers inquiry. I wonder if, for the sake of the record, I could ask you to introduce yourselves and the position that you hold.

Ms Chapman: Clare Chapman, Director General of Workforce.

Sir Liam Donaldson: Liam Donaldson, Chief Medical Officer.

Alan Johnson Alan Johnson, Secretary of State.

Mr Taylor: Hugh Taylor, Permanent Secretary.

Q842 Chairman: Thank you. The first question is for the Secretary of State. Why was the project management of MMC and MTAS by the department so inept?

Alan Johnson: Probably because the accountability was spread so widely. When you look back at how this was all put together, you had four UK departments of health, you had all the educational bodies, you had the bodies that set standards, you had the regulatory organisations, and all of that put together led to a classic case, I think, of systems failure. For instance, you had the policy being set by something called the UK Strategy Group. You had the criteria being set by the Specialist Training Action Group. Implementation was the responsibility of the MMC Programme Delivery Board. The Strategic Health Authorities through the Deaneries were responsible for implementation in England, local implementation. You had another body dealing with the selection criteria, so it was very disparate and it was, as it has been explained to me, a difficulty of knowing who had the lines of accountability with all of that group trying to work together.

Q843 Chairman: We will move on to that in some detail in terms of leadership or perhaps a lack of it, but did ministers know about the situation? Were ministers kept informed about what was happening? I know it was before your time.

Alan Johnson: I was not there at the time, but yes, they were. Indeed, one of the other problems was that Lord Warner, who was very closely involved in this and took a very hands-on approach, went, for personal family reasons, in, I think, December 2006 but at a time when his knowledge and expertise we could have done with, so there was a problem there as well, but as far as I am aware, yes, ministers were fully aware of what was going on.

Q844 Chairman: What have you done to improve project management in the light of this last 12 months and the Tooke Review?

Alan Johnson: A far simpler structure for a start. The Douglas Review very early on made the point about ensuring that we had a simpler structure, so, for instance, we had a single senior responsible officer, a single chief reporting officer that we introduced, a chief operating officer, but I think the most important innovation was the establishment of a Programme Board that had the medical profession represented on it as well. Tooke has made an enormous contribution but from before that when the Douglas Review came out we sought to streamline what was a pretty unstreamlined management structure.

Q845 Dr Taylor: Secretary of State, I am going to continue on the same line because when Alan Crockard came to us, and I am quoting, he said, "There was a clear dichotomy between the education and training role overseen by the MMCB and Workforce needs overseen by the Workforce Directorate which resulted in two separate senior officers in charge of MMC and MTAS without close working of their teams. Never should a project have two SROs overseeing two parts of the same project." Therefore, Secretary of State, when you listed at the beginning all the bodies involved it is really no wonder if it fell down in tremendous chaos?

Alan Johnson: No, and there were two lines of accountability on the issue as well. There was the policy accountability through the Chief Medical Office and there was the implementation accountability through the Workforce Directorate. I think that was a major problem. Once that was clarified and rationalised we saw the system work much better, and again that was something that the Douglas Review helped us with and the Tooke Review has helped us with even more.

Q846 Dr Taylor: On a rather wider note, do you think we risk the same thing on an even wider basis, having the equivalent of three permanent secretaries?

Alan Johnson: No, I do not, but we have had a capability review of our department and one of the central features of that was the leadership in the Department of Health. The capability review said we were a very good department at delivering. There was an issue about leadership, but personally I would not want to go back, and I do not think anyone would, to a joint Permanent Secretary/Chief Executive of the NHS, the Nigel Crisp position, but how we manage that better is something we are looking at all the time. As far as I see that was not the problem in terms of MMC.

Q847 Dr Taylor: No, it was not. I am just illustrating a potential snag with three leaders.

Alan Johnson: One leader, three -----

Q848 Dr Taylor: Okay. That is absolutely right, and I am delighted to hear it. This is to Mr Taylor. Was it a serious error to have no permanent Director of Workforce during the key phase?

Mr Taylor: In one sense it was far from ideal but the important point to make about that is that there was continuity of senior leadership because Nick Greenfield, who became the acting Director-General for Workforce during the interregnum while we were advertising and waiting for Clare to take up her appointment, had been closely involved with the MMC project, so from the point of view of continuity that was certainly maintained during that period.

Q849 Dr Naysmith: Mr Taylor, it has been suggested to us that the shortcomings in the governance and management of these two projects, MMC and MTAS, suggest that civil servants in your department are simply not up to the job. Do you think that is fair?

Mr Taylor: No. I think it is much too sweeping a generalisation. I think we could point to a number of examples of excellent collaborative policy making and excellent delivery, but I think we have to accept responsibility for the fact that the governance arrangements for this programme in retrospect were not adequate. We have done, not just connected with this but more generally, a lot of work in the department over the last 18 months to significantly up our game in terms of risk management, for example, and overall support for people on policy governance issues generally and on project and programme management. It would be idle to pretend there were not lessons to be learned from this episode and those are lessons which I am determined we will take to heart.

Q850 Dr Naysmith: So you think there were problems and you are doing something about them? Are you doing something about them quickly enough?

Mr Taylor: As the serious problems with the implementation of the programme began to unfold in 2007 the department did move pretty quickly to establish much clearer lines of accountability and put real operational management in, and with the support of the Douglas Review and the Programme Board which emerged from that began to get a grip on the issue, so in relation to handling the particular operational issues around MMC I think we took action very quickly. More generally, we have been working hard at improving governance processes across the department through the introduction of stronger and more effective risk management processes. When you look back on this what you see in a sense is project management disciplines being followed in relation to different components of this overall programme but I think in retrospect what we see is a problem with looking at the programme as a whole and the impact it was going to have on junior doctors and consultants out in the field. You can apply risk management to an individual project or good project management disciplines, but if you are not looking at the thing as a whole then you are running into a problem. I cannot ever say that we will never hit another problem again but I think we have learned some lessons about how to run these sorts of big projects.

Q851 Dr Naysmith: Can I ask what your opinion is of the situation that Richard Taylor touched on rather lightly a few minutes ago, the fact that you have three individuals of the status of permanent secretary in the department, Sir Liam, yourself and David Nicholson? All three of you are permanent secretary status and now you have Alan Johnson telling all three of you what to do. He cannot do that all the time; you have to co-ordinate. Is there a problem there?

Mr Taylor: We do not find that a problem on a day-to-day basis. It is pretty clear that my responsibility is to make sure that the department runs effectively. David has responsibility for the operational management of the NHS and for advising ministers in relation to that. Liam is the Chief Medical Officer with a defined set of responsibilities. It is our job to make the best of those three important parts, all having critical roles for the department, so in relation to MMC, the management board which David runs, which is the NHS Management Board, that will be overseeing the operational management and the implementation of MMC during 2008. In relation to the more strategic issues affecting the future direction of medical education workforce policy those sorts of issues would come initially to the departmental board which I chair, and in practice David, Liam and I have formed together a sub-committee of that board to oversee the co-ordination of thinking around medical education, training and workforce issues and MMC on a regular basis, so we are meeting frequently to make sure we stay absolutely together on this.

Q852 Dr Naysmith: Is not one of your roles to warn ministers when their plans for change are over-ambitious? One of the main functions of Sir Humphrey of television fame was to stop ministers walking into disasters and falling down elephant tracks. If that is the case and you agree why on earth did you or other civil servants not stop the MMC being implemented with such reckless speed? It must have seemed like that to you, having overseen a few policies in your time.

Mr Taylor: That was not the view that was being taken of the programme at the time. We were, I think, at senior levels in the department monitoring a number of the key risks associated with it. A lot of effort - and I think this is all pretty well documented in Tooke and other places - was going into some of the key risks which were identified about the number of training places, for example, the plans that were put in hand to restrict access of people on the Highly Skilled Migrant Programme to the first cut of offers of training places and in relation to the computerised project. Assurances on all those three things were sought specifically. What, I am afraid, collectively we and others across the system failed to do was to look at the risk right across the system as a whole and draw what might in retrospect have been the right conclusions.

Q853 Mr Bone: Just before we move on, you never said to the minister, "This is a courageous policy"?

Mr Taylor: No.

Q854 Dr Naysmith: Why were the red light risks highlighted by Tooke repeatedly ignored? You mentioned Tooke just now.

Mr Taylor: Specifically those things were not ignored, is my recollection. The two things that were highlighted were the risks around the computerisation programme and specific assurances were given in relation to those in relation to the -----

Q855 Dr Naysmith: I am not sure it is a good idea to mention the computers.

Mr Taylor: I am just honestly answering your question, which was that those risks were highlighted and assurances were taken in relation to that. Whether it was then right in retrospect to proceed straight into the national implementation of an unpiloted, untested system, particularly one which I think to some extent people were not fully prepared for, is a separate question, but in terms of pure project management assurances were obtained about the operability of the system. The other red lighted issue was that of the whole question about the policy in relation to people on the Highly Skilled Migrant Programme and their active risk mitigation being in place and I think it has been pretty well rehearsed what the circumstances there were, having taken a decision to issue guidance which would have had the effect of excluding people on the HSMP from the first round of applications. There was a judicial review challenge and so on and we got into a difficult sequence of timing around that. It was not that those risks, in the jargon, were not being actively managed; they were. I think the bigger question was whether the totality of risks associated with the project were overseen and that is where I think in practice we probably fell down.

Q856 Dr Taylor: Going on to policy development, Unfinished Business seemed to have fairly general support but in the move from that towards Modernising Medical Careers a lot of the principles seemed to get lost. The BMA puts it that of the seven principles only two were realised during implementation. How did this happen? Obviously, we cannot blame ministers because ministers change fairly frequently, but this is exactly where one needs extremely strong civil servant backing to make sure that these things do not happen and that these agreed principles do get translated into action. Does this mean the Department of Health really is not very good at policy development?

Alan Johnson: No, it does not mean that. In terms of the involvement of all the different bodies in the principles here, the phrase is that success has many parents and failure is an orphan, but from the start of these principles, from the time when Liam published Unfinished Business, there was a fair consensus around about the need for change. Indeed, most of the people I have spoken to are highly critical of how MMC was implemented but the actual principles behind it they support and I have not met anyone who would want to go back to the old system. It was unfair, it was opaque, it was blue-eyed boys and girls, so the principles behind the change were absolutely right. In terms of the department's capability to implement policy, I think you only have to look at the cancer strategy, what we have done with cardiovascular disease, heart disease and the stroke strategy just before Christmas. Developing policies is one of the strengths of the department and delivery of policies is one of the strengths as well. What happened here, I think, as Hugh has just alluded to, was that there were lots of things happening at the same time, lots of things that were the right thing to do but all being done at the same time and an assumption that we would not have the problem with international medical graduates that proved to be a false assumption. There were also the points I have made about the lack of accountability in all these different organisations together and no-one quite sure who was in the lead on it, and a computer system that was not piloted, MTAS, in advance. Put all that lot together and you get the disaster that was MMC. You have made the point very fairly about ministers changing, but Patricia Hewitt on several occasions apologised for the way this caused disquiet and huge problems for people in the medical profession, junior doctors in particular.

Dr Taylor: I do like your quote. Is it a proverb, "Failure is an orphan"?

Jim Dowd: It is. It is Chinese.

Q857 Dr Taylor: Is that a proverb that I have not heard about?

Alan Johnson: I would like to say I made it up but I think it is a proverb of some description. It is a Hull proverb from my constituency.

Jim Dowd: Hull in China then, is it not?

Q858 Dr Taylor: I rather get the impression that you feel in retrospect that the big bang approach was misguided and wrong.

Alan Johnson: Liam might like to say a word about this but, as I understand it, the argument that we should have phased this in had a number of problems as well in terms of what that would mean. "Phasing" is an easy word to use but if you look at the practicalities of phasing in different aspects of this, there was a strong argument to say, "Look: if we are going to do this let us do it all at once because if you try and phase it you just lead to a long period of confusion, et cetera", so that argument probably went on. If you are looking at the cause of the problems here, certainly it has been said to me by many clinicians that we tried to do too much at once, but no-one was really looking in any depth at what the alternative was because I am sure there were problems there as well.

Q859 Dr Taylor: But if there had been better in-depth planning perhaps a staged introduction could have been brought in.

Sir Liam Donaldson: I think it would depend how you staged it because let us say that you were to stage it geographically or by speciality, then doctors hoping to apply as their first choice for a speciality that was not phased in may have worried about their future and have been forced to go for a second choice option, so I think the option of phasing it in was not free of problems and risk either.

Q860 Dr Taylor: I always accept your comments about cancer and cardiac care, which obviously have improved, but in items like this what lessons have you learned for policy development?

Alan Johnson: The need to have a very clear accountability structure on this in particular. Because we did it with four countries in devolved administrations and a whole set of other people involved there were no clear lines of accountability, is my answer to that first question, and however complex the issue is we have to make sure that we do not repeat those mistakes, and indeed the lessons we have learned and the lessons that we are still learning from the final report from Sir John Tooke, who has done an excellent job at finding a way through this and making very clear where the errors were, as did the Douglas Review very early on.

Sir Liam Donaldson: Could I just add something on that? The other lesson to learn is that it is not always clear that implementation is free of the need for policy making. Before this crisis developed, if somebody had said, "The detailed design of an application form - is that policy or implementation?", I guess most people would have said it was implementation, but in fact it probably ended up being one of the biggest policy considerations in the whole thing. Realising that apparently minor aspects of implementation need a much wider participation of policy makers, particularly clinical policy makers, is one important lesson that maybe could not have been foreseen but is obvious whenever you look at the causation of the crisis.

Q861 Mr Bone: My questions are all to do with leadership. It seems to be accepted now that leadership was very weak during the implementation of MMC, both in the Department of Health and within the medical profession. Does everyone agree with that or am I being unfair?

Alan Johnson: I do not think you are being unfair because it is an obvious question. I think the governance structure was too complicated. I do not think the answer lay in the leadership of the department. I think it lay in that complication. Okay, you can say that we should have recognised the perils of that very early on. The fact is we did not, and certainly the issue about having a clear level of accountability, which we changed very early on when Douglas first raised it, but there was a problem in terms of the accountability for the policy being with Liam and the accountability for the implementation being with Clare's predecessor, and I think at one stage there was absolute ambiguity about who was responsible for what.

Mr Taylor: I would certainly say in retrospect that leadership was diffused and that is an issue. That was on both sides and that is not meant to be a critical comment of my colleagues in the medical profession, but I think one of the catalytic effects in positive terms was bringing the key elements of leadership and the medical profession together under Professor Douglas initially and then in the Programme Board, which provided a much better and stronger forum for issues to be thrashed out in a coalition than had been the case previously. I think it was the absence of that very strong policy-making forum for collective leadership, if you like, that was missing.

Q862 Mr Bone: Just following up on that point, most of the leaders who were involved in this are still leading whatever part of it they were before. At any one stage one of those leaders could have said, "This is going horribly wrong. Stop", and none of them did, so what confidence do you have that leadership has improved now and that we could not have the same thing happen again when there was a group from the medical profession and the Department of Health embarking on a major project?

Alan Johnson: This was a complex issue. I do not believe it can be laid at the door of an individual. Indeed, I think Tooke said something very similar in terms of the whole history of MMC, that there was not one person that should be carrying the can for this. It was a collective failure right through the system. If there were lots of occasions of this happening in complex areas then there could be a criticism of the leaders involved, but I hope this is definitely going to be a one-off. There has been nothing like this before. No-one ever attempted to make all these changes to the curriculum, to the way that the system worked, to the whole structure of the medical education and training all at one time, and I really do not believe that there is any individual at whose door all of the blame can be laid.

Q863 Mr Bone: I would like to follow on from that and get some specific comments on it, but your answer sounded a bit to me like when Social Services report that some young child has been killed. They say it is a systematic failure of 30 people but no-one individually is to be blamed and it will not happen again. Unfortunately, in Social Services it happens time and time again, but you think this is a one-off?

Alan Johnson: Yes. I think the analogy with Social Services is wrong, actually.

Sir Liam Donaldson: I do not think the analogy is fair. In some of those child protection cases that you referred to the evidence is revealed over and over again to different people. It is just that they choose not to act on it. If you look at what happened in the MMC, the biggest risk that was flagged up to ministers was the risk that there would not be sufficient training posts to fulfil the demands of the programme and Lord Warner acted immediately to counter that risk and announced the creation of more posts and guaranteed a level of posts. Secondly, as the permanent secretary said, there was a full discussion at the NHS Management Board, which is the most senior governance structure in the NHS, of the programme just before it went into the final stages of implementation and reassurances were given about the risks and therefore the board corporately decided to proceed. If you look at the point at which the crisis was in its early or mid stages Patricia Hewitt appointed Professor Douglas to chair a group to take further decisions and that group had the opportunity at that point to cancel the programme but they did not, and I think they were right not to because at that stage a large number of interviews had taken place and a lot of consultants had given their time to undertake the interviews. There was not a point at which the whole risks of this programme were revealed in an unambiguous way and no action was taken, and I do not think the analogy is fair.

Mr Taylor: One further point on this is that I do think it is very important to build into your corporate governance systems proper challenge as well as assurance. One of the things that we have sought to do as a department is use our strategic risk register, which we take now to our audit committee which is run by non-executives and expose that to them in a much more systematic way than, I have to say, we were doing at the time when some of this was under way. The risk with all that is that you are still not seeing the things coming round the corner to hit you. I do think we have better systems in place now to give not just the leadership authority that you are talking about but some of the challenges to that which you get in effectively by having corporate governance systems.

Q864 Mr Bone: This is just for the Secretary of State. I know, Secretary of State, you have more or less answered this, but because this is an evidential session I would like to get it on the record. Some people have said that the Chief Medical Officer is the architect of these failed reforms, and if that is the case do you think that the CMO is the best person to resolve the crisis? I know you have indicated what you think but perhaps you could give a formal response to that.

Alan Johnson: Yes, I do. I think the CMO has done a terrific job over ten years. On this particular aspect let me remind you of what John Tooke said. He said that MMC was an honest attempt to accelerate training and assure the fundamental abilities of the next generation of doctors. In fact, I think this began in 1988 under the previous Government. I am paying a tribute to the previous Government.

Q865 Mr Bone: Oh, sorry! Do carry on!

Alan Johnson: It happens very rarely. The previous Government recognised the need for change and reform to medical education and training. It was Liam's report, Unfinished Business, that galvanised action and on those very important principles. See what comes out of your report but I do not think there is anybody hankering for the old system in the sense of all that unfairness and the opaque nature of that system. I think it was an honest attempt. It went wrong in the implementation. That is now being put right and, as I say, I do not think there are any scapegoats in this and as far as Liam is concerned I think he is absolutely the person to take through the implementation.

Q866 Mr Bone: Thank you. Can I just move to Sir Liam? One of the problems with reports, and the Tooke report is no exception, is that you can read them in several different ways. Sir Liam, I think you said that you would not resign because the Tooke report supported the principles of MMC which the Secretary of State just referred to, but Sir John told us that he could not even work out what these principles were. He and others have argued that MMC swapped one "lost tribe" for another. If that is the case thousands of careers have been lost, confidence in the profession has gone and some people would say you are more of a hindrance than a help now. Would that be totally unfair?

Sir Liam Donaldson: I do not think I did ever say that. If I said anything along those lines it would be that Sir John had commended the principles of Unfinished Business, but essentially in the Modernising Medical Careers programme the part of that which has become controversial was the reform of specialist training. There were many other aspects of it that have not been part of the criticism and controversy of Modernising Medical Careers, so the Unfinished Business proposals led partly to a foundation programme, they did not recommend wholesale introduction of a specialist training run-through grade. They said yes, it should be looked at along with other factors, and the programme broadened out over time. If you look at the factors that precipitated the crisis, in my view there were three. One was the planning assumption of international medical graduates being excluded could not be adhered to. Secondly, the design of the application form proved to be faulty and led to difficulties with discriminating the right candidates for the right jobs, and, thirdly, wholesale run-through training was introduced, but that itself is a factor on which there are mixed views, some Royal Colleges strongly favouring it, others now having reservations, some having favoured it initially and now withdrawing their support. I was not responsible for the decision on international medical graduates and I was not responsible for the detailed design of the application form.

Q867 Mr Bone: I suppose one of the things that some people would find strange is that nobody is taking the rap for this disaster. Some people could unkindly say, Sir Liam, that you are more concerned about saving face than the future of medical teaching. That I think would be one way people could look at it but can I put it to you another way? If you really thought this was your fault would you have resigned? You mentioned that there were other areas, but if you thought that you were the driving force - and it has gone wrong; nobody argues with that - would you have gone?

Sir Liam Donaldson: As the Secretary of State said, it was a widely participative process with a lot of different stakeholders involved. Had I been the single person sitting in my office having these risks played to me repeatedly by different people and ignored that, then yes, obviously, that would not have been a competent performance, but that was not the way it was.

Q868 Mr Bone: the other thing that I have not got my head round is that Government is normally very cautious when it is bringing in major changes and lots of different things at the same time, you know, you have pilot schemes and so on, and in fact yesterday the Government announced a pilot scheme on a new Sarah's Law, so why were so many decisions and changes taken at the same time? Who was responsible for the fact that it all happened at the same time?

Sir Liam Donaldson: In the end 57 specialities redesigned or reaffirmed their training programmes and those were all signed off by the main regulator, the Postgraduate Medical Education and Training Board, so there was a groundswell of view that because the SHO programme was being changed it therefore threw out the interface with the next level of training and the training needed to be redesigned, so each of those specialities looked afresh at their training programme above the level of what was the SHO and put in reforms to their training programmes, so 57 different groupings looked at it.

Q869 Mr Bone: Yes, so it is like if a committee decides something it finishes up with a camel; it is that sort of thing. In hindsight, and hindsight is a wonderful thing, would it have been better to have one person driving it through rather than almost having committee-like decisions on the MTAS?

Sir Liam Donaldson: I think it probably would but in the past we have been accused by stakeholders of being undemocratic for taking that approach.

Q870 Dr Naysmith: Secretary of State, the Tooke Review has been mentioned quite a lot this afternoon and it has usually been in a congratulatory way. One of the things it very clearly recommended was that the Department of Health needed a dedicated lead for medical education. Do you agree with that?

Alan Johnson: Yes, we have accepted that recommendation that was made. Indeed, we implemented that before the Tooke recommendation when we put Dr Martin Marshall in, who in effect became the dedicated lead. Now Martin has moved on and when he left we put David Sowden into the job, so yes, we do accept that recommendation.

Q871 Dr Naysmith: David Sowden, when he was here, told us that you cannot appoint a permanent head of medical education over the next six to nine months because of "some particular issues within the Department", and he would not expand on that. What was he referring to?

Alan Johnson: I do not know. If he did not expand on it --- you should have pushed him a bit further because I cannot speak for him.

Q872 Dr Naysmith: Maybe I will just quote a little bit. What he said was, "For my sins, I said I would be prepared to do it" - that is, lead the MMC - "as a secondment for a short period ... There are some particular issues within the department which would have made it difficult for them to make a permanent appointment over the next six to nine months. It seemed important that there was somebody in place who could take forward the 2008 process and lead on the development for 2009". You have no idea why he would say that?

Alan Johnson: I have not, no. I do not know whether Hugh has.

Mr Taylor: I am not sure. One point that it is just worth mentioning is that one of the things we wanted to do was to get somebody into the post and, to be blunt, to do that quickly we needed to make a temporary appointment. If we want to make a permanent appointment and it is a Civil Service appointment we have to go through a proper selection process involving the Civil Service Commissioners and so on. Because in effect we can put him in on a short-term basis it meant that we could make the appointment straightaway. He was on a temporary basis because that was the quickest way of getting somebody with his expertise and relevant qualifications into that role.

Q873 Dr Naysmith: Do you have any idea, Sir Liam, what he might have been referring to?

Sir Liam Donaldson: No, I do not, I am afraid.

Q874 Dr Naysmith: Can we move on then to the other actors in this drama? It has been suggested here as well that there have been tremendous weaknesses exposed in the Academy of Medical Royal Colleges in providing a coherent voice for the profession. Do you agree with that, that the academy could have been much better in giving a lead?

Alan Johnson: Yes. In a sense it is less important whether we agree with that. That was a specific recommendation in the Tooke report and I think it is a matter for the profession to respond to that. That is one of those recommendations that is not for us to act upon. Given the amount of analysis that Tooke's people did, I think it would be very difficult to argue that that is not a sensible recommendation and a valid point to make about this lack of coherence.

Q875 Dr Naysmith: It is a good point to make, and it is probably right, but actually getting all of the Royal Colleges herded together and going in the same direction is quite a difficult thing to do, I suspect, but you think it is the right way to go, do you?

Alan Johnson: I do not think it is impossible to get better coherence from the different specialties. As far as I am aware, they have not acted with any hostility towards Tooke's Report and I presume that they are looking, even as we speak, at how they can actually give that some substance.

Ms Chapman: Secretary of State, can I add one thing on to that, and that is when the difficulties first started to emerge it was Carol Black and the Academy that actually raised the point that the Academy wanted to be part of the solution, not the problem, and then that led to the recommendation for a review and obviously the Douglas Review ensued. The work that was done on that group and subsequently on the Programme Board has shown that when you bring the people together across the profession to a place where actually consensus can be reached so recommendations can go to ministers then a very productive role can be played. I would just point that out.

Q876 Dr Naysmith: It is interesting you say that because we put both to Carol Black and Bernie Ribiero, the President of the Royal College of Surgeons, that they had been present at crucial meetings when they could have stopped things going ahead and they both admitted that they had been but had not done so without explaining why. I suspect it was to do with the fact that they were not quite sure what some of the people who were recommending that they be there would say if they did. That is why it is important to have some kind of coherent voice for the medical profession at this higher level of training.

Ms Chapman: On the Douglas Review and then subsequently on the Programme Board, that has actually been happening because they have been sitting around the table and are able to see the whole programme as opposed to individual component parts.

Sir Liam Donaldson: Could I just add, Chairman, that does beg the question again that when they were sitting there in those meetings, what was it that was worrying them that they wanted to put their foot down on and say it should not go ahead. At that point, as I said before, the principal risk identified was that there would not be sufficient training posts. That was what we were lobbied about repeatedly and that was where Lord Warner stepped in and increased the number of posts. On the detailed aspect with the application form at that stage, I think people at that level would have appreciated that there could have been a problem with that. The international medical graduate situation, at that point it looked as if the planning assumption would be adhered to so there would not be an excess of numbers over applications.

Q877 Chairman: Can I ask, when will the Department respond to the final Tooke Report?

Alan Johnson: At the end of February. I have given an assurance that we will publish our response by the end of February. There will be some bits of our response that will be an immediate response because of the nature of the recommendations. Some, like MEE for instance, that only appeared in the final report upon which there has been no consultation might take a bit longer. We will issue a response to the Tooke Review by the end of February. I have to say, John Tooke was very pleased about that. His fear and worry was that it would gather dust on a shelf somewhere for months or even years.

Q878 Chairman: Obviously you are not going to respond to it in total by the end of February from what you just said, Secretary of State. Would you like to give us a percentage of what you are likely to respond to in terms of recommendations? Will it be 50% or more?

Alan Johnson: Most, I think, because we have had since last October from the interim report to look at 47 of the recommendations. There were two that came up in the final report that were not in the interim report. There is also the issue about the next stage review that Lord Ara Darzi is leading for us where some of these aspects relate to specific work streams that he is doing, so it would make more sense for him to look at that in the round and then report in the summer. The vast majority of the recommendations we will be able to give an early and a full response to.

Q879 Chairman: So it would be wrong of us to read into the situation that those which you did not respond to would be those you did not agree with?

Alan Johnson: No. The things we do not agree with we will say. I have already put it on record, and I have certainly said to John Tooke, that I think this is a really, really helpful report. He has done an excellent piece of work. The thrust of what he is putting forward I agree with, but some of the recommendations are for the professions, as we have just mentioned, not for us. Some have very clear structural problems that, having been through MMC and seen the results of perhaps acting too hastily, we want to take a bit more time about and so might the organisations that he is referring to. He suggests the GMC should merge with PMETB. We cannot give a full response on some of these without more consultation and a bit more time to think it through. You should read into the fact that we are going to publish a response by the end of February that we think this is a very good piece of work, the momentum for which needs to be maintained.

Q880 Jim Dowd: Having said that you will respond in general by the end of February I am now going to pursue a line of questioning where I will try and get out of you what it is you are going to say by the end of February. You mentioned MEE and I was going to start there actually. I quite understand you say we have got to wait a couple of weeks for this, but do you broadly accept the need for a centralised overseeing of medical education in England?

Alan Johnson: I am afraid you are going to get a straight bat on all of these because we are not going to respond until we respond with a full and detailed response. It is fair to say MEE is one of those recommendations which will take an awful lot of thought and consideration. I doubt very much whether we will be able to give a full response to that at the end of February and, indeed. I do not think John Tooke is expecting it. The fact that it appeared in the final report suggests that he too went through a long thought process to decide whether that was a sensible recommendation or not.

Q881 Jim Dowd: Putting MEE to one side for a moment, would I be overstating the case if I suggested that there is a recognition, whether it is a reorganisation of SHAs, and I know you spoke to this Committee immediately after you took up this appointment and said you were reluctant to look at structural change within the NHS, if there is no central body surely there is a case for reorganising the responsibilities of the SHAs, for instance in the way they commission education and training.

Alan Johnson: I am not going to be drawn on this. The other thing about MEE is this is a specific strand of work that 1,500 clinicians are working on at the moment with Lord Darzi, so for me to give an off-the-cuff response would not do you a proper service in terms of your inquiry and would not be fair to the amount of work that is going on out there at the moment looking into this subject in more depth.

Q882 Jim Dowd: Clearly I would not ask you for an off-the-cuff remark in response to this but it is not as if we just dragged you off the corridor and asked you to come and give evidence. This is our sixth session and you have had the Tooke Report for three months or more, so it is not quite off-the-cuff.

Alan Johnson: Not this particular recommendation we have not.

Q883 Jim Dowd: It is an informed response. What about the issues that he raises around compromise? Will you be seeking a compromise between Tooke's suggestion and the current situation, for example by creating a small new national organisation to oversee the work of SHAs?

Alan Johnson: That is another straight bat.

Q884 Jim Dowd: So you are taking the Fifth?

Alan Johnson: What we are determined to do is to publish our response to the Tooke Report in one document at one time in one place and not to dribble out bits and pieces of it.

Jim Dowd: I stand rebuffed and rebuked, Chairman.

Q885 Mr Bone: I know we have rearranged this meeting once, Secretary of State, but it is pretty useless having a Secretary of State for Health coming here and taking the Fifth Amendment on something that he says he is going to announce in a few days' time. If that is the case, why on earth did you not wait until after Tooke to come here? This is hopeless in terms of a select committee when a Secretary of State cannot answer the questions, it is horrendous.

Alan Johnson: I came when I was asked to come. The question was when will you be responding to the Tooke Review and the answer was the end of February and that is very, very quick. Expecting me to give a response to the Tooke Review just in response to questions here is not the right way for government to proceed and it actually does a disservice to Tooke's work. I do not accept that criticism and I do not accept that we have come along not to answer questions. On this specific issue the response will be at the end of February.

Q886 Chairman: MEE is about medical education, it is not about workforce planning, something this Committee has looked at in recent years and found wanting as far as the National Health Service is concerned. It is not necessarily about budgets, and we looked at the issue of overspend in the National Health Service in our deficits inquiry last year and there were issues about the raiding of education budgets up and down the land, and some of it was anecdotal but we did find some evidence of it. Are all of these things going to be looked at when you look at the future outcome of the recommendations of Tooke?

Alan Johnson: Yes. Indeed, as I have mentioned, the work is going on at the moment in the next stage review and training and education is a specific strand of that. This thought of putting one organisation in charge of that has got its advocates and its detractors. Since Tooke's Report was published I have had many people saying to me that they do not agree with that recommendation. The deaneries have put on record their concerns about that recommendation. Given that is the case, we need to consider it and we need to consult, which is why, as I say, even if you invite me back in early March it is not a case of not wanting to give a response on MEE, it is a case of wanting to consult properly before we give a response.

Q887 Chairman: In view of what I said and in view of why we are here looking at MMC as an inquiry, it is pretty crucial in terms of the outcome of the Tooke Review to know where medical education is going pretty quickly in view of the circumstances of last year, this year and future years as far as we can see at this stage. When do you think you could respond on a wider view on that particular recommendation? Not the end of February and not the end of March?

Alan Johnson: If it is in with the Darzi Review it will be July.

Q888 Chairman: It could be as late as that?

Alan Johnson: It could be, but it was not in the October report. It is in this report and there has been no consultation on that.

Q889 Chairman: I accept that.

Alan Johnson: Perhaps the outcome of this inquiry might, as it often does, decide the course of events. You would have an influence over this as well.

Chairman: We will move on.

Q890 Dr Naysmith: I count the Secretary of State as a friend of mine so I may be about to lose that friendship by pursuing the Tooke Report just a little bit further. I will have to rephrase the question I was going to ask. One of the things that are recommended by Tooke is the uncoupling of run-through training and particularly splitting the 2-year Foundation Programme. We have had a lot of evidence, and I know from my own area, that there are people who think that the 2-year initial F1 training Foundation is a good thing and has contributed a lot. Tooke recommends that disappears. Are you prepared to say anything about that? The reason I am asking that is before you give your initial response at the end of this month I hope you will take into account the fact that there has been a lot of evidence to this Committee that not everyone in the profession is united in getting rid of the 2-year Foundation.

Alan Johnson: You did rephrase it very skilfully, and our friendship will not be affected by this, but it is the same answer. Indeed, I do not know yet what our response is going to be on that, we are still thinking that through.

Q891 Dr Naysmith: That is all I wanted to hear, that you have not made up your mind yet.

Alan Johnson: Mr Bone said that we would be giving the response in a couple of days, but actually it is not a couple of days until the end of February. In terms of the way our thought process is going, we have not got an answer to give you at the moment. It deserves proper consideration. It was in the original report in October and we do expect to be able to give a definitive response in February rather than a watch this space response.

Q892 Dr Naysmith: Could I ask you, does the requirement of the Medical Act for medical schools to guarantee their graduates employment until they register fully with the GMC fall foul of EU employment laws? Is that why splitting the Foundation Programme is desirable, that you become qualified as a doctor after one year of post-graduate training rather than two years? Perhaps we could ask Sir Liam Donaldson.

Alan Johnson: It is back to us having to consider that as part of the work that we are doing on the Tooke recommendations. I cannot give you a response on that.

Q893 Jim Dowd: Just on that point, this is the final evidence session of this inquiry so do you think our final report would be better informed and save a lot of tedious repetition if we were to wait until the Department's full response to the Tooke Review was available before we concluded this report?

Alan Johnson: That is a matter for you. All I can say is that it would be quite normal for governments of all political persuasions to spend more time considering a report like that before giving a response. The reason I said we will respond by the end of February, and the reason why John Tooke is absolutely delighted with that and people in the medical profession are delighted with that is they recognise that is the quickest that Government can go on a report of that nature. You would have to decide yourself when to bring your investigation to a close. All I can say is we are working as quickly as we possibly can on that Tooke Report.

Q894 Mr Bone: We are going to move on to self-sufficiency and competition and the EU and non-EU, so this is something you can get your teeth into, you will not need to take the Fifth Amendment on this one. The Home Office has introduced new immigration rules preventing non-EEA doctors from applying for UK training posts from 2009, and we heard some evidence about that in the previous session. What impact will this have and why was it not done earlier because did the Government not talk about self-sufficiency in 2000?

Alan Johnson: Well, in 2005 really the monitoring suggested we were going to have a problem in 2007 and as soon as we found that was the case we acted immediately on something called permit-free training and it stopped that year in 2005. Then the question was how to tackle this issue of international medical graduates because we cannot have, on the one hand, a policy of self-sufficiency and, on the other hand, an open door policy. The original way to tackle this and the preferred way to tackle this was not through the Highly Skilled Migrant Programme, it was through employment law guidance that we can issue ourselves in the Department of Health that will ensure not just those people who have not yet come to this country as IMGs but those who are already here would only take post-graduate places if UK trained students could not fill those places. So our preferred route was down the guidance route. As Liam referred to earlier, we were stopped from doing that because there was a legal challenge. We actually won the legal challenge but we won it too late in the day to actually allow us to implement it. That is our preferred route. The decision made by the Home Office on 6 February was very helpful. It will stop around 3,000 additional people applying for posts in 2009.

Q895 Mr Bone: I think the Secretary of State has been most helpful in his answers on this subject. I think what you are saying really, and I think most people will commend you for saying, is UK jobs for UK citizens as far as possible but you were not allowed to go down that route because of a legal challenge. We understand that 3,000 less people will come in because of that, but two things have come up. There are around 10,000 IMGs already here, so that is not really going to reduce it too much. The extraordinary thing we heard in the last session was nobody knew how many people would be coming from the EEA, the European Union. Is it right that nobody in the Health Department, nobody in Government, knows how many people because if you do not know how many people are coming how on earth can you plan for self-sufficiency?

Ms Chapman: Approximately, if you take last year's information, it was about 5% of applicants came from the EEA, so if that is repeated again this year that would be the dimension.

Q896 Mr Bone: That is fine if that is the case but nobody has made a forecast of the actual numbers that are going to come. The Foreign Office has not, the Home Office has not and apparently the Health Department have not. Is that right, you do not actually make an estimate of how many are coming in from Europe?

Alan Johnson: Our estimate is 5%.

Ms Chapman: The estimate would be 5%. One of the things that we did get as a result of last year was much better data because of the centralised system in terms of information to interrogate. I think the 5% is a pretty solid number to forecast against.

Q897 Mr Bone: So the Health Department is putting its head on the block saying it is 5%.

Ms Chapman: I am saying that last year it was 5% and if the last year is a good predictor then that is a good basis for planning.

Q898 Mr Bone: What some people cannot seem to handle on this is, yes, you are taking historic data and saying if that is repeated again that is what will happen, but what some people say you should be doing is actually forecasting the numbers that are likely to come in, not saying that last year might be repeated again. Has the Health Department actually done a forecast?

Ms Chapman: There are two things on that. One is that as a result of the forecasts that were done in spring/summer of last year we actually forecast very accurately the number of applicants and also the likely success rates of all of the applicants, and it was our forecasting that really helped us to put together a very targeted support package for any doctor that was identified as having the potential to succeed in further specialist training, so there is plenty of evidence that our forecasting really helped to inform decision-making.

Alan Johnson: Two things on this. First of all, it is the international medical graduates that are the problem; it is not people coming here from other European Union countries. Secondly, for us to set up a system to accurately predict how many students will come from 27 Member States I would suggest is the way we sometimes respond to written questions and the cost of providing that information would be far in excess of the results that it would produce. Working on the basis of what the normal number is, which is around 5%, is pretty good. The second point is we did not know anything about these ratios, we did not know very much about these ratios at all until we introduced MMC which gives us a much better picture. All the problems that are going on in MMC were going on before, they just were not centralised in one place, they were happening all over the country, so one did not get the same volume of difficulties because, as I say, it was an opaque system. It has enabled us to predict much more clearly what the ratios are going to be, which is why we predict for this coming year we are going to have three applicants for every place and last year it was 2:1. You are right, as a responsible Government we have to try to tackle this in any way we can. We are not just stopping at the basis of the Home Office ruling, we are also pursuing an appeal on the guidance that will actually prevent IMGs who are already here to the House of Lords. The end of March will be the hearing so I am not too sure when we will get the result.

Mr Bone: I am sure most people think self-sufficiency is a very good idea and would welcome what the Government is trying to do but it has got tangled up in the legal system. Just put it the other way round, if we were not in the European Union you would not have to take people from the European Union and you would be self-sufficient.

Jim Dowd: It is not the EU, it is the EEA.

Q899 Mr Bone: I know, but I am just using that as an example.

Alan Johnson: It is the EEA. That is not the problem. It allows medical undergraduates in this country to go and train for post-graduate education in any other part of the European Union, that is not our problem.

Q900 Mr Bone: I understand the benefits of it, but if you are trying to say that it is only people outside the EEA that you can control then it would be easier if you could control the whole lot because you are running a state health system employing 1.3 million people. If the state could actually control it you would do better at it, but you cannot because whatever you say about estimates you really do not know how many people are going to come in from the EEA.

Alan Johnson: It is a question on the free movement of labour in the European Union and I believe that is a very good thing for the European Union.

Q901 Mr Bone: Does it make your job more difficult?

Alan Johnson: No, it does not make the job more difficult at all. The problem we have is international medical graduates and the fact that well over 50% of international medical graduates go back after 2-4 years of working in the NHS so you actually lose them as well.

Q902 Mr Bone: The other side issue is you have messed around with what I think the Foreign Office said was an "unwelcome precedent" in what you have done in changing the rules. For the Foreign Office that is pretty strong terms saying, "Butt out, you should not be doing this".

Alan Johnson: That was a Government decision cleared through the whole of Government.

Q903 Mr Bone: The Foreign Office should not say those things?

Alan Johnson: I have not heard the Foreign Office saying those things, but this was a Government decision.

Q904 Chairman: Can I just ask you about what you are saying. This comes from many years of the NHS not meeting our own quotas, as it were, from medical graduates here in the UK. This change has taken place in the last 8-10 years. Prior to that, and even during the time that these changes were taking place, we were bringing in quite a large percentage of National Health Service doctors and other health workers from areas of the world like the Indian subcontinent. Do you feel that we have any moral obligation to countries like that which we have relied on for many, many years to run our National Health Service?

Alan Johnson: I think two things about this. First of all, the contribution of those international medical graduates has been immense, and you are quite right, Chairman, we would not have been able to run the Health Service effectively without their contribution. That is the first point to make. The second point is they themselves understand this. I saw a quote from the organisation representing doctors of Indian origin on 7 February after the Home Office decision which said that they agreed with that decision and it should have been done years ago. One aspect of that is we have denuded the world of medical graduates that their own countries were very keen to ensure they kept. I do not think the open door policy was the right policy for us but I also do not think it was the right policy for countries like India, Pakistan and other areas where we took their medical talent, if you like, and brought them over here. Now that we have built four new medical schools, now that we have increased the number of medical places, including, I am pleased to say, the fabulous Hull-York Medical School that we were arguing for for 25 years and we have finally established, the policy of self-sufficiency makes sense for us and certainly on the facts and on the basis of all the arguments no-one could suggest this is in any way failing to meet some moral obligation, it is actually the right way for us to go. Of course, for many of the people who have come through the system, they have gone back to their own countries and have really benefited from the UK expertise in medical education.

Q905 Chairman: Do you see a situation where this country could not be training international medical graduates to be able to go back into different parts of the developing work and work there and improve their health services?

Alan Johnson: There could be programmes, the kind of medical equivalent of Chevening or whatever that we could use for that, of course. There is no other country in the world that has this kind of open door policy and does not have a policy that says we will train up our graduates and if there are shortages then we will take people who are international medical graduates to fill up those shortages. That is the way America runs their system, Australia, Canada and it is the way now, because of the investment we have put in medical schools, we can run our system in the same way.

Q906 Chairman: I am going to ask the CMO, when I said about the situation of people coming here maybe for specialist training for different aspects and then returning to the developing world, that has happened and it does happen now, but will these regulations in any way, no matter what happens in the next few months, change that at all?

Sir Liam Donaldson: No. I think it is important that we continue to run fellowship programmes of the kind that the Royal Colleges have traditionally run to allow people to come here to gain experience, receive training and go back again, but as a strand of an overall programme of training.

Q907 Jim Dowd: You have referred to the judgment awaited from the Lords and I think they will be looking at it towards the end of this month and reporting sometime in late spring, early summer. If the guidance is upheld in the Lords, do you think any further measures will be required or would you consider that to be the end of the matter?

Alan Johnson: If it is upheld I doubt whether we will need any further requirements. We are looking at other ways to do this, like, for instance, a fees system, but I think the guidance should resolve the problem providing it is robust and we could be confident that it would remain in place.

Q908 Jim Dowd: Would you then honour any commitments given to non-EEA individuals in the meantime, any contracts?

Alan Johnson: We would need to look at how the ruling goes but we said last year, for instance, before the challenge that we would allow those who were already in the system to complete their training.

Q909 Jim Dowd: Already in the system up to what point?

Alan Johnson: Already applied, I think.

Ms Chapman: This year we are actually going to have more than one pulse of recruitment, so there will be the opportunity for ministers to make a decision on whether or not any guidance would apply to further recruitment rounds that would happen this year.

Q910 Jim Dowd: I think I understand that.

Mr Taylor: It does not take away people who are on the system. It does not take people out of positions.

Q911 Jim Dowd: I understand that, but what we are trying to get at with this particular line of questioning is if it is upheld ultimately by the Lords it is perfectly legitimate for them to say it was always legal and, therefore, anything that happened between the time it was first challenged and now you can go back and revisit, or are you going to take the position which the law understands that until it proves to be unlawful it remains lawful, or vice versa?

Alan Johnson: We would not apply it retrospectively.

Q912 Jim Dowd: The Home Office describe the new rules as a short-term solution to the current problems, but if your guidance is not upheld in the Lords, and I put this to anybody who may have an answer, will the changes not have to be made permanent?

Alan Johnson: If the guidance is not upheld then we will continue to look at other options rather than through the Highly Skilled Migrant Programme. We do not like using the Highly Skilled Migrant Programme, these people are highly skilled, and the Home Office were reluctant to take that route, as were we, but they accepted, as we did across Government, that we had to get in a position to ensure that as far as we can in 2009 we do not repeat the problems that we had last year. There are other things that we are looking at and other ways of doing this. There are not too many other options but we are exploring them all.

Q913 Chairman: Could you tell us what those other options are, Secretary of State?

Alan Johnson: I mentioned one, which is a fees regime. The other is to see whether we could pass into legislation from my Department something that would cover this rather than dealing with it through the Highly Skilled Migrant Programme. This is predicated on the fact that we lose the appeal. If we lose the appeal, how we can get that guidance into a much firmer setting. We would have to look at the reasons for losing the appeal, and I hope we will win it and we are quite confident that we have got a good case to put to the appeal, but we need to ensure we have got a mechanism in place to ensure that we have a self-sufficiency policy, not a self-sufficiency and an open door policy.

Q914 Dr Naysmith: Following that up, Secretary of State, do you think that the current capacity of our medical schools in the United Kingdom is about right at the moment or are there any plans to increase or even decrease the numbers in the future?

Alan Johnson: I think it is about right. The number of medical school places has gone up from something like 3,500 to just over 6,000. We monitor this all the time and we did create more places, as Liam referred to, at the time of Lord Warner. I think we have got it about right.

Q915 Dr Naysmith: Given that we are looking at training places in six years' time it is pretty difficult to predict exactly what the situation is going to be. Maybe Ms Chapman might have an idea about that. Do you think it is possible to do that?

Ms Chapman: I think that the Select Committee's report on workforce planning and also the work that we have done as part of the Lord Darzi next stage review has shown that we are very good at planning supply, but we are far less articulate at planning demand. One of the things that are being looked at as a result of the clinical vision being looked at for the service is making sure that we build two things into that. One is the workforce implications of the service redesign and, secondly, the financial implications of the service redesign so that you are bringing service design, finance and workforce planning in line. Do I think that is possible? Usually when there are changes, about 80% stays fairly static and about 20% has got the discontinuities, so the challenge is spotting where the discontinuities are so you can plan for them.

Q916 Dr Naysmith: You will accept that in this situation that we are talking about this afternoon we have got major changes taking place, like cutting off largely the supply from outside the European Economic Area, plus admitting you do not know what is going to happen. If there is some sort of vacuum in this country of medical graduates then what will happen in the EEA is that more graduates will apply.

Ms Chapman: I think two things have happened as, again, was made clear in the Select Committee's report. Since 1997 there have been over 250,000 more people brought into the service as capacity was built and over 35,000 more doctors. I think what we have seen during that period of time is a big increase in the capacity of doctors and also some adjustments in terms of the service that is being delivered, so looking forward I do not expect there to be such a massive increase in capacity and, therefore, the predictions we have currently got with the medical schools looks adequate. I do think it is going to be critical, as was mentioned before, that we look at what are the service design implications coming out of the Lord Darzi work.

Q917 Dr Naysmith: Do you have an optimum level of competition for training places? Do you have an optimum that you are aiming for? For instance, should we aim to produce 5% more medical graduates than training posts? Does that figure in your calculations?

Ms Chapman: The devil is in the detail. When you start to look at the detail by specialty there are some very hard to fill specialty areas and that is where you would want very different resourcing strategies from those specialties which are very popular and in very popular parts of the country. My reaction is yes, you would want some principles but they would need to be specialty specific.

Q918 Mr Bone: Can I just come in on that because that is an interesting point. If there is a hard to fill area would we be turning down graduates who might be qualified in that area from outside the EEA?

Ms Chapman: No. Firstly, there would be the opportunity for graduates from English medical schools to fill the vacancies and where that is not possible we would be bringing in talent and expertise from outside.

Q919 Mr Bone: This ban in 2009 would not apply to that?

Ms Chapman: We would still be able to do that.

Q920 Jim Dowd: How do we square the circle of maintaining quality practitioners against the obvious expectation that anybody who gets a place at medical school will ultimately get a job working within the NHS?

Ms Chapman: Say that again.

Q921 Jim Dowd: Is there an expectation that anybody at medical school will ultimately become a practising doctor within the NHS and if there is then how on earth can we ensure that we are actually getting the best?

Alan Johnson: That is a very good point actually because we are just getting to the level of self-sufficiency. Previously it was a case of trying to get doctors from wherever we could but now we are coming through to self-sufficiency. There is a view that says why should the medical profession be different from any other profession. Nobody who trains to be a lawyer is guaranteed a lawyer's job at the end of it and no-one who trains to be a plumber is guaranteed a plumber's job at the end of it, why should you have a guarantee that there is a job at the end of medical training. I think it is quite important to get the balance right, not least of all because we are spending about a quarter of a million pounds on training undergraduates to be doctors. I really think we have to try and get it just about right. I would not personally go for an over-supply issue, but there are many people out there who would say that if you do that you get better quality. I think our quality can be guaranteed through other means rather than by a market forces way but, nevertheless, that is an interesting argument and we are only just having it because we are only just talking about self-sufficiency.

Q922 Jim Dowd: Good. As a variation on that as well, there are recent figures from the Department of whatever it is called these days that looks after universities and the rest about the numbers of applicants to universities generally, they are going up, but there is still this perennial problem of those from "non-traditional" backgrounds. I saw a release from the BMA not long ago saying that the most socially exclusive higher education course in the country is actually veterinary medicine, not human medicine, but it is closely followed by human medicine. It is still very much a preserve of those from more prosperous backgrounds, certainly those from traditional backgrounds, sons and daughters of doctors who become doctors, et cetera. What is being done to address that?

Alan Johnson: I am glad you have raised this as the former Higher Education Minister who introduced tuition fees and you alluded to the statistics which show not just a big increase in those applying to university but a big increase in the lower social classes, so this argument that fees was going to work contrary to that is not the case. This is the key profession in terms of attracting people from poorer backgrounds. There is no profession worse than the medical profession. You have just pointed out veterinary medicine, which I was unaware of, but when I was Higher Education Minister all of our efforts were to get poor kids, bright kids, to go into medicine because it was not seen as anything that they would be comfortable with. It was not just a problem of getting them to university, it was a problem of once they were at university of saying, "Why not go into medicine?" As Liam just pointed out to me, getting a medical school in a city like Hull, for instance, jointly with York and having medical schools in places like that does at least signal to youngsters in some of the deprived areas that there is a place nearby where they can train to be a doctor if they get the required qualifications. I think it does help the education system, which is key to all this of course, to build up the aspirations of youngsters to go into medicine.

Q923 Jim Dowd: What about the length of some of the courses to go into medicine? Does this not militate against those who do not have quite sufficient independent financial means?

Alan Johnson: That is true, but there are bursaries and grants. The new system introduces a bursary of �3,000 from the Government matched on many occasions by another �3,000 from the university itself. It is a long course in medicine as it is in disciplines like architecture, et cetera, but there is help available. The premium on that investment in education is huge in medicine more than many other professions.

Q924 Chairman: Could I just say on that basis, Secretary of State, I know you live quite close to my constituency and one of my secondary schools is visited annually by Sheffield Medical School to look at the brightest people there to talk to them and their families about whether or not they would like to go into medicine. Would you like to see something like that throughout places like Hull and South Yorkshire?

Alan Johnson: There is a lot going on out there and I think one of the problems is we have not brought this together. Perhaps we could do a piece of work with John Denham's Department to actually look at this. I was in Birmingham when I was at Education where they take kids from primary school and introduce them to things like first aid and take them to a hospital and gradually as they go to secondary school they become more and more interested. Some of them go on to be paramedics, some go on to be nurses, but the message to them is they can go wherever they want to go if they are interested in medicine, and they have got structures in place to help that. I am really interested in the initiative in your constituency and perhaps we ought to look at this, and perhaps they are doing this work, together with the Royal Colleges and everyone involved in this as a specific piece of work to see how we can learn from that best practice and introduce it much more widely.

Q925 Dr Taylor: Can I go back to the question of the number of applicants per place. Overall it is three applicants per place. Professor Douglas, when he came to us about a fortnight ago, said very clearly that there were 1,200 excess jobs at ST1, 1,300 too many jobs at ST2 but a huge deficiency of jobs at ST3. Is there not a tremendous danger that we are going to pull in non-EEA graduates to fill the spare places at ST1 and ST2 and then the problem at ST3 is going to be even worse when, from what you have been saying, we have pretty well promised them that they can finish their training, so we are going to have far, far too many people for the few posts at ST3. Is that accurate? I am quoting Professor Douglas' figures.

Ms Chapman: I do believe that is what Professor Douglas believes. There are two things worth saying here. One is ST3 has always been the level where there has been greatest competition so we need to be careful what is related to MMC and what actually has always been the case and, therefore, is amplified through MMC.

Q926 Dr Taylor: Is it possible to actually look at what it was before and what it is now?

Ms Chapman: We will not be able to look with as much accuracy at what it has been over previous years because obviously we do not have the quality of data that we have now got through last year. I am sure that we could produce something to show that the toughest competition has always been at ST3. The other point is there is no point in creating false expectations by putting a lot more roles in at ST3 than we need because what you end up doing is creating a dead end for people. It is a case of balancing it. At ST1 and ST2 what is very important is that we are creating the right number of roles to reflect the number of people coming out of Foundation Programmes, et cetera, so it has been carefully balanced. Because we have got multiple pulses of recruitment that will go on, if we do find that we have significantly under-represented one of the levels we do get the opportunity to come back and recommend to ministers that we adjust it.

Q927 Dr Taylor: Do you agree that there is a risk of sucking in non-EEA ones at ST1 and ST2 and making the problem even worse at ST3?

Ms Chapman: That is one view. It is certainly something that we should keep under consideration, but we do know how many people are coming out of Foundation and how many people are coming out of ST1 and, therefore, it is important that we provide the right number of opportunities to keep the doctors progressing.

Q928 Dr Taylor: Professor Douglas really felt extremely strongly about this and in our evidence he said: "I took this problem to ministers that day. We wrote to all the appropriate channels and made full recommendations as to what I suggested they could do to try to rebalance the situation just a little bit. Despite taking the papers I had written to ministers I was getting the impression that there was just no room for movement on this."

Ms Chapman: I think there are two things. Since then the Programme Board have discussed this issue and we have put, I cannot remember the exact numbers, about 156 new ST3 posts in place, so there was a recognition that we needed to take some action and we have taken some action. This was discussed at the last Programme Board and our conclusion was that what we needed to do was to recognise it as a risk and make sure that as we get the results from this next round of recruitment we look to see whether it is an issue. What we will do is continue to talk with Professor Douglas and the Programme Board about the facts that we are finding.

Q929 Dr Taylor: Those 150 extra are not going to overload the potential consultant posts?

Ms Chapman: A good question. There is sufficient capacity within the service to provide both the training for those extra roles and also we believe, because we have worked with the Royal Colleges, we have actually put the extra roles in places where we know the service has got need.

Q930 Dr Taylor: Just to follow on from that, we were rather distressed in the first session with the Immigration Departments to hear that there are still doctors coming from abroad not going on to actual training programmes, presumably filling in pure service, possibly dead-end jobs. Do you see an end to that?

Ms Chapman: I am sure the CMO would want to comment, but I do not think that doing service jobs are dead-end jobs on the basis that these are trained doctors and trained doctors doing very important roles within the service. We will continue to have overseas doctors coming in to fill ---

Q931 Dr Taylor: They are trained to a certain degree but their training in some of these jobs will actually stop. Tooke suggests that Staff Grades could have access to continued development and continued training.

Ms Chapman: Indeed, and that is being looked at.

Sir Liam Donaldson: If you look at the figures from last year, quite a substantial number, albeit the minority, of doctors in those sorts of posts did get on to the full-blown training schemes which in my view, although we have not got data from the past, was a rarity in the past.

Q932 Dr Taylor: So you would try and find us figures to show that the competition was pretty well as tough before as it is now?

Ms Chapman: No, my point was different from that, which was we should recognise that competition has always been toughest at ST3. Whether the percentage of competition ratios has increased, I am sure it has bearing in mind that what we have had is a transition year.

Q933 Jim Dowd: Ms Chapman, this is for you. Immediately before we undertook this inquiry we concluded one into workforce planning in the Health Service and also during the course of this inquiry many of the witnesses we have had have criticised the lack of planning for the overall medical workforce. Do you accept that planning has been poor? Whilst obviously the focus, certainly of this inquiry, is on the medical frontline, if you like, the National Health Service has a wide variety of specialties and disciplines and although doctors have an unerring ability to generate the most attention and get the most attention devoted to them, they are just one significant part of an overall pattern that we need to address. Do you think that we are actually addressing it adequately now?

Ms Chapman: I think I am probably going to repeat the evidence I gave last time. An increase in a workforce of over 250,000 since 1997 is certainly the largest increase of workforce that I have seen anywhere else in the world. There have been difficulties with that and they were well-documented as part of the Select Committee's report. In terms of both Sir John Tooke's findings as well as our own review as part of the Lord Darzi work, I do think there is evidence that the service has been good at doing the supply side of the planning but I think what it has been poor at doing is the demand side. Just over a year ago the demand side of planning was made the accountability of the strategic health authorities and they have been in the process over the last year of actually building capability to do that demand side planning much more. Certainly that has been the focus as part of the Lord Darzi work. There is more work to do and specific focus on improving demand side planning.

Q934 Jim Dowd: What about getting the balance between medical training and the wider workforce?

Ms Chapman: Again, when you look at the increase in nursing and other clinical areas what you have seen is a lot of those commissions actually get done not centrally but within regions. The evidence is that those commissions are far more effective the closer they are to where the people are needed. I do not think that there has been a distraction because they are done differently and done at different places within the service.

Jim Dowd: Do you think we need to break the link between training places and consultant posts? Do you think that is misleading us? We can wait for the Tooke Report and you can put it in there if you want.

Q935 Mr Bone: Take the Fifth!

Ms Chapman: It does get covered as part of that. What is very important is there is a connection between the number of training places and the supply and demand assessments that go on as part of the service planning. That is the key bit of analysis that needs to get done.

Q936 Jim Dowd: Sure, but my question was do you think we need to break that link? The purpose of training places is to keep consultant numbers at the levels they are at.

Ms Chapman: And GPs. To be honest, I am not sure I entirely follow your logic, which is why I am not sure that I am giving you a correct answer.