A take on Tooke
Authors: Edward Peile
Journal: Journal of the Royal Society of Medicine (2008)

Modernising Medical Careers1 seemed benign enough at first; indeed, Sir John Tooke, in his foreword to the Inquiry report,2 refers to ‘an honest attempt to accelerate training’. However, the MTAS debacle was symptomatic of widespread cellular disorganization within NHS workforce planning for doctors, many of whom came to view MMC as a malignant process. It is to Tooke's lasting credit that he adopted the widest possible brief2 and successfully combined independence of vision with building consensus. A comprehensive and cohesive package of recommendations emerged after wide consultation on interim proposals. Only some of these are to be enacted.

Reflecting on the Secretary of State's response to the Tooke report,3 it is difficult not to share Sir John's view that postgraduate medical education and training is no subject for procrastination. His plea, following his diligent collation of available evidence, is now for decisiveness: ‘In medicine it is sometimes necessary to take decisions in the absence of optimal evidence in the interest of high quality outcomes.’4 He is right – parking many of the issues with the NHS ‘Next Stage Review’ could impact adversely on future training, and ultimately on patient care, if policy cohesiveness becomes a victim of politicians' cherry-picking.

Some benefit will derive from the inquiry's solid workable proposals for mechanisms of consultation, decision-making and accountability in relation to medical education. The Secretary of State must now be accountable for delivering the processes to stabilize and enhance the future training of doctors. The level of detailed, coherent thinking that the inquiry team delivered should make this an easier task than some previous scrambles to roll out NHS policy in the wake of soundbites.

There are big disappointments in the ministerial response. Tooke's new commissioning body for higher specialist training – NHS Medical Education England (NHS:MEE) – looks likely to be kicked into the long grass. Weasel-words around the recommendation requiring ‘very careful consideration to ensure that decisions are informed by evidence and evaluation before DH responds fully’ are worthy of sceptical enquiry about political motives.

The minister puts faith in the ability of the MMC England Programme Board to bring order out of chaos in the planning and governance of education and training. This contrasts with the view of the Academy of Medical Sciences that there was a need for an arms-length co-ordinating body to act as ‘honest broker’, and agree a coherent, co-ordinated approach to medical education.5 If existing processes fail to re-engage those who have been disillusioned by MMC failures, then ministerial fence-sitting will be seen to be costly. Consistent partnership working between deanery fiefdoms, fifty-seven specialties, seventeen Colleges and numerous other interested bodies has so far been elusive.

As to the specifics of Tooke's new thinking, much that was welcomed by the profession has been sidelined by Department of Health. Medical Schools Council (MSC) reported ‘strong and universal support’ amongst medical schools for uncoupling F1 from F2.6 The idea was that newly qualified graduates, emerging from their fully linked-in medical schools, would commence life as Provisionally Registered Doctors, their workplace-based learning for the first year being a continuum of the curriculum of their medical school. Alan Johnson's failure to adopt this proposal means that medical students forego the gain in assured placements and connected learning. They face prolongation of the uncertainty over their future lives.

Likewise, the broadly welcomed concept of incorporating F2 into Core Speciality Training is on the minister's wait-and-see list. Another missed opportunity is the failure to commit expeditiously to the five-year general practice training programme, which had been strongly supported. The ministerial responses to the specific Tooke proposals to develop the postgraduate training structure are so hedged around with circuitous further steps that it is doubtful that many will see the light of day.

My take is that the final recommendations of the Tooke Inquiry were worthy of adopting as a cohesive package, rather than tinkering at the edges. Given the extent of consultation that the Tooke team managed, it is unlikely that the Department of Health could come up with anything much better. Is there a hidden agenda here? Could deferring to the NHS Next Stage Review impede rather than facilitate change?

Applicants per training post are mounting in 2008 and trainees will continue to face an uncertain future until we get a better thought-out system in place. The longer the delay before implementation, the more problems will mount, given that NHS bodies thrive on indecision and planning blights.