Government’s response to the Tooke inquiry into Modernising Medical Careers
Authors: Tony Delamothe
Journal: BMJ (2008)

Unhappy at the Catholic Church’s sale of indulgences, Martin Luther nailed his 95 theses to the door of the Castle Church in Wittenberg. While Rome eventually responded to some of his criticisms, it did not move fast enough to stall the protestant reformation.

At first glance, Sir John Tooke has been more successful than Luther, with England’s secretary of state for health immediately agreeing to half his 47 recommendations to reform postgraduate medical education and training.1 2 3 (Responses from Scotland, Wales, and Northern Ireland are awaited.) However, the vagueness of the government’s timescale for implementation has left every spokesperson for the medical profession—starting with Sir John himself—unhappy. The government might want to reflect on the lessons of that church door.

Of Tooke’s 23 other recommendations, four are matters for other organisations, two are being considered as part of Lord Darzi’s next stage review of the NHS in England, and seven are consigned to the limbo of “further consideration.”

In this limbo are most of the recommendations to alter the structure of training—the “visible face” of Modernising Medical Careers.1 The rationale behind Tooke’s new structure was to reinstate the principles of broad based beginnings and flexibility,2 espoused in the chief medical officer for England’s consultation document on senior house officers, Unfinished Business,4 but eroded since then. Tooke recommended breaking the link between the two foundation years and incorporating the second foundation year as the first of three years of core specialty training. Higher specialty training would follow, with entry by competitive selection.5

Without an agreement on the early years, it is impossible to structure the remaining years of training. And until this is done, any new competitive selection process remains on hold. It was, of course, the very public failure of the competitive selection process, the medical training application service (MTAS), which triggered Tooke’s inquiry.

So it hardly needs emphasising that these matters should be resolved with some urgency. Yet the government has decided to maintain the current training structure for a further, undefined period.

For England, the lynchpin of Tooke’s recommendations was the formation of a new body, NHS: Medical Education England (NHS: MEE). Although it made its appearance only in the final version of Tooke’s report (published 8 January 2008), the new body was to be intimately involved in the delivery of more than a third of the 47 recommendations.

The government’s response was that the proposal for the new body needs to be considered alongside the work being done on workforce planning, education, and training as part of Lord Darzi’s next stage review of the NHS. As this is due for publication in June, and must now be virtually complete, it is hard to see how sufficiently detailed consideration of an NHS:MEE can have happened in the past two months.

Such a body could mitigate the effects of the government’s decision not to agree for England one of Tooke’s recommendations—that the chief medical officers should be the senior responsible officers for medical education. In England the senior responsible officer will report through the director general of workforce to a subcommittee of the Department of Health that includes the chief medical officer. In his report, Tooke had strongly regretted that service imperatives had trumped educational ones in the training of doctors. If the routing of medical education is to continue through workforce planning (where the prime interest is not medical education but workforce needs), then a body such as NHS:MEE could provide an important counterbalance.

The government has also been vague about when (and if) general practitioner training will be extended to five years. And the merging of the Postgraduate Medical Education and Training Board with the General Medical Council, which Tooke wanted “as quickly as possible,”2 won’t be happening until at least 2010, when the government is prepared to allocate legislative time to it.

In his response to the Tooke report, the secretary of state accounts for the pace of implementation by “the need for policy development and implementation to be evidence based, and for change to be implemented only after careful testing and following co-production with professional and other key stakeholders.” It will be fascinating to see whether the government holds to these tenets over the implementation of Lord Darzi’s recommendations.

In the meantime, as the government is forever exhorting doctors to behave in a more businesslike fashion, it should set an example by providing SMART targets (those that are specific, measurable, achievable, realistic, and time bound) for the implementation of Sir John’s recommendations. That would certainly banish any lingering suspicion that now that the hubbub over MTAS has subsided, the government is happy—as far as it can—to stick with the status quo.