HL Deb 04 April 2003 vol 646 cc1636-56

2.44 p.m.

Baroness Andrews rose to move, That the draft order laid before the House on 3rd March be approved [13th Report from the Joint Committee]

The noble Baroness said: My Lords, I beg to move that the draft order laid before the House on 3rd March be approved.

The order has already been considered and passed by the Scottish Parliament, on 20th March. That was required because some of the matters covered are devolved. The devolved administrations are, for the first time, given the power to appoint members to the UK body that supervises postgraduate medical education. The order has also completed its stages in another place, and it now falls to this House to consider it. In my view the draft order is compatible with the convention rights.

I turn first to what the order will achieve. Noble Lords may not all be aware of just how complex postgraduate medical education actually is. Many organisations are involved at different stages. At present, there is a lot of potential for confusion. I hope to clear some of that confusion away.

Noble Lords may, however, be aware that the Joint Committee on Postgraduate Training for General Practice has formally supervised general practice training since 1981. Since 1995, the Specialist Training Authority of the medical Royal Colleges has been responsible for supervising specialist training. My noble friend Lord Turnberg and the noble Lord, Lord Patel, have served with great distinction as chairmen of the STA. Both bodies have made a significant contribution to the development of medical education and training. They have done as much as they could within the current limits of the regulatory system. I want to place on record my appreciation of their work over the years.

This order represents the fruit of three years hard work and close consultation at every stage between the Government and the medical profession. It establishes a new body which will reform the way in which we train and educate the doctors of the future so that they are better able to meet the needs of both patients and the NHS. This body will act independently of government. It will be a professional and authoritative body, fully in keeping with the principle of professional self-regulation. Government will have a limited role in the formative process. They will ensure that the board is set up and appointed, then step back to allow the board to get on with its work.

There are default provisions, but I stress that they can only be used should the board ever fail to perform a function. Default powers exist in the current legislation. They have never been used and we do not anticipate having to make use of them in any ordinary circumstances. We confidently hope and expect that this will be the case with the default powers in this order.

Perhaps I may also illustrate the limits to the Secretary of State's power. At various times it has been asked whether the Secretary of State for Health could compel the board to include or remove specific training requirements if he so wished. The Secretary of State would, and is required by ordinary administrative law principles, exercise his powers reasonably. Any decision that the board had failed to perform a function that it should have performed would have to satisfy this principle. It would not therefore be open to the Secretary of State to exercise his default powers where the board had considered and with good reasons decided on specific training requirements.

The reforms will introduce a more flexible system for regulating the education and training of doctors, in which the medical Royal Colleges will play a leading role. The new body will ensure that standards are maintained and developed for training doctors for independent medical practice in NHS primary and secondary care. However, a major change, in keeping with the changing public emphases, is that for the first time the NHS and the public will be well represented.

Other significant changes achieved by this order will be that arrangements for training general practitioners and specialists will be brought together in one organisation; that there will be a new GP register to sit alongside the specialist register; and that faster, fairer and more effective processes will be introduced, which will assess doctors on the practical demonstration of their competencies, in addition to their medical knowledge and their qualifications.

I emphasise what that last important change will mean. For the first time, these assessment processes will address properly the needs of specialist doctors who are not European Economic Area nationals and have qualified or trained outside the EEA. This will benefit thousands of doctors already working in the NHS—many of whom are in the staff and service grades—and are prevented front progressing in their careers because the current system does not allow their experience to be taken into account, together with their training and qualifications, in determining whether a particular doctor has met the required standard.

Doctors are very well aware already of the benefits that this new legislation will bring. As a recent national conference of staff and service grade doctors demonstrated, we have received many supportive responses to our consultations from individual doctors—the majority of whom have undertaken specialist training or have been awarded specialist qualifications outside the EEA. All are already working in the NHS in the staff and service grades. All are currently restricted in developing their careers because the current system does not allow their experience to be taken into account. This will change under the order.

We will have a fairer and a more transparent system. It will ensure that our already high standards in medical education are maintained and developed. And, finally, the order itself is a more flexible and adaptable piece of legislation which will make it easier to make any future improvement to the system of postgraduate medical education and training in the UK. Any such changes will of course be a matter for the board itself to determine.

Why do we need these changes? Let me briefly set out the background. Our medical training system is rightly admired across the world, but this order recognises that it is now right to develop it further to ensure that our future doctors are able to deliver quality services in the ways that they and their patients want. This must be done in partnership with other members of the healthcare team. Furthermore, the medical education and training system must be flexible and adaptable, and capable of responding quickly to changes in the NHS and to developments in education—for example, in improvements to methods of assessment and training.

I mentioned earlier that the system is already very complex. Let me try to pick out the key elements of the new system—one which will be less confusing. The new board will set standards and formally supervise the entire system—ensuring that the doctors it certifies have been trained to the standards it has set. But it will not be responsible for managing, funding or organising the training. That job is, and will continue to be, handled largely by the postgraduate deans in the NHS. Indeed, the system would not work without their invaluable contribution. But the board is the standard-setter, and it will rely heavily in this respect on the work of the Royal Colleges. It will be for the board, based on the advice received, to grant or withdraw approval from training programmes, and to award certificates to individual doctors. That will bring together both general practice training and specialist training. There will be one certificate for both types of doctor.

This is not change for change's sake. We recognise that we must not lose the many excellent features of our current training system. The order will ensure that this does not happen. For example, it clearly recognises the established role and expertise of the Royal Colleges. It ensures that the board and the GMC will co-operate closely with each other. But we should change those aspects of the present arrangements which do not work as well; for example, the current separation of general practice from the rest of medical training and the way that colleges sometimes work almost in isolation from each other.

Reforms of the magnitude in this order need to rest on the broadest possible support. We have had that support from the profession itself as well as the patients and the wider public. We have consulted twice on these reforms. It has been a three-year process. The issues raised in the responses received—there have been more than 300 in total—have helped to shape the details of our policy. As a result of these two consultation exercises, we have probably made well over 100 changes in total. Involving colleges and other stakeholders in our working groups has been designed to achieve this consensus and has informed those changes.

The response to consultation showed a clear consensus that change was needed. We have, I believe, met the concerns which were initially expressed by the medical Royal Colleges and others. This is clearly demonstrated in the recent memorandum of understanding agreed between the Department of Health and the Academy of the Medical Royal Colleges in January. It marks a significant step forward in this direction. The colleges agree that there is no need for each and every one of them, and their faculties, to be represented on the board itself. They know that they will be strongly represented on the committees and sub-committees which the board will set up to tackle the detailed work in relation to each medical specialty.

We are profoundly appreciative of the hard work and of the support of the professional and academic medical leaders. Professor Peter Hutton, chairman of the academy, is a firm supporter of these proposals. He recently said that, sensible negotiation has resulted in a very practical piece of legislation … the way in which this exercise has progressed forms a good model for future working between the Department of Health and the Colleges". His view is backed by the other college presidents, six of whom are on departmental working groups helping to do some of the preliminary work to implement the order.

Let us look at what has been said by the colleges and the medical profession. The Academy of the Medical Royal Colleges, which represents all the colleges in the UK, states that it, strongly supports the philosophy", behind these changes and confirms that, all the colleges, without dissent, are in agreement". The colleges in Scotland have put on record, that the Order offers a framework for continued constructive collaboration to maintain, and improve, the standard of health care in the UK … there are now opportunities for us to develop Scottish initiatives contributing to an overall UK framework". The GMC has said that: We support the Government's commitment to reform postgraduate medical education and training. The creation of PMETB offers an opportunity for significant progress towards ensuring that both the training and service needs are met". The Royal College of General Practitioners has said: We believe that the PMETB offers real opportunities and benefits for the development of medical training".

The order is now clearly recognised and accepted as an important step forward in the system of medical education and training in the UK and will build on a great deal of developmental work which has already been taken forward by the profession—for example, on examinations and assessments—and on better ways of quality assuring training. It is in the wider public interest that this close working relationship is further developed and strengthened as the board is established. We will do all we can to ensure that this happens.

One of the key features of these reforms is that, in future, patients and the NHS will have a greater contribution in determining the standards of education and training for doctors. That wider representation will also be reflected in the board's committees where the detailed work will be done. This will ensure that the broader competencies required of modern doctors, such as team working and communication skills, are also included in training curricula alongside the detailed clinical knowledge which they clearly need. In this important respect, the order will help to support all our efforts to improve the quality of care in the National Health Service.

The provisions before your Lordships' House will contribute to the implementation of the major programme of reform we have announced to modernise medical careers, bringing more structure and coherence to the early stages of postgraduate training. We need to ensure that doctors in training grades and in service posts are well supported, and able to plan and develop their careers in the NHS. The board will be crucial to the success of these wider reforms to medical careers.

In addition to making improvements to the system, we are also making a number of other changes that are particularly important to career prospects within the profession itself.

I mentioned earlier how individual doctors in the NHS have welcomed the proposals because they will help them to develop their careers. Questions have been raised in another place about whether these proposals will actually help doctors who are already contributing to the NHS in the staff and service grades, but who want to advance further in their careers. I want to say very clearly today that we have set out to assist these doctors, and that is what the order does. In particular, the order will help many doctors currently working in the NHS with qualifications obtained outside the European Economic Area. They cannot progress to consultant positions in their careers because the current legislative system does not take all factors into account.

The fact that they may have completed additional training, or have years of senior experience in the United Kingdom, makes no difference. If the qualification is not determined to be equivalent to the UK specialist qualification, that is the end of the matter and the individual cannot have his or her name included in the specialist register. Many therefore have no chance of ever becoming a consultant and the NHS is deprived of the benefit that the full contribution of these doctors could make. This cannot he allowed to continue.

The order therefore provides for all training, experience and qualifications—wherever obtained—to be taken into account by the board when assessing the eligibility of applications to go on to the specialist register. If a doctor does not meet the required standard at the first application, that is no longer the end of the story. Doctors will be able to top up their training to meet the requirements. They cannot do this at present.

Training must no longer be seen as a one-off opportunity which ends at a certain point in a doctor's career. The whole point of medical education and professional development is that it needs to be a well-managed continuum throughout a doctor's professional life. That is why, in parallel with the regulatory reforms, we are modernising medical careers, taking forward the proposals set out in the Chief Medical Officer's consultation paper Unfinished Business to develop a more structured system of education early in a junior doctor's career, immediately following registration with the GMC.

Our proposals will deliver a new foundation programme, which will be followed by well-managed and structured programmes, supervised by the board, for all trainees, whether they become consultants or general practitioners. This will include programmes designed for doctors moving back into training from a staff or service grade post. We are taking an all-embracing approach which will include competency-based assessment and encourage that to thrive. This will see all doctors in training working against clear, agreed goals.

Both of these new developments demonstrate the importance of the current competence of a doctor to deliver quality services to NHS patients. The new system will ensure that all doctors will have a fair chance of demonstrating how they meet the high standards that we rightly require of our doctors. I should make one point very clear. This is not about lowering standards but about providing a fairer opportunity to doctors to show how they meet our existing standards.

Secondly, we are creating a new GP register. In future, all GPs will need to be on this register. General practice is strongly supportive of this initiative—it has been for some time—and it is supported by the medical profession as a whole. No one currently eligible to work in general practice in the NHS will be excluded; there is no threat to anyone's livelihood. We believe that the GP register will make a big difference to patients and employers. For example, they will easily be able to check a doctor's registration online. Doctors' standards will be visible and accessible to patients.

Finally, the new system is designed to work more efficiently. The board and the GMC will be required in future to give decisions about eligibility for registration of both GPs and specialists within three months of receiving a full application. At present, doctors—particularly those applying from outside the EEA—must often wait for considerable lengths of time for a decision.

Let me quickly go through the order itself. The order creates the board and two statutory committees—the training committee and the assessment committee (Article 3). The board will be responsible for supervising the system of postgraduate medical education and training in the UK, setting standards and ensuring that these standards are applied (Articles 4, 5 and 6). The statutory committees will report to the board and be accountable to it. The board will be able to set up sub-committees to deal with levels of detail. Royal Colleges will be appropriately represented on these committees and sub-committees.

Much of the detail of how the new education system will operate is intentionally not included in the legislation. Let me use this opportunity to again reinforce the independence of the board. The board will draw up its own rules and it will be able to change them to respond to changing training needs. While the board will be able to delegate work and decisions to its committees, it will not be permitted to delegate any of its rule-making powers. This is entirely consistent with the principles of independence and autonomy which have been the hallmarks of our system of postgraduate education and training. These principles are carried forward in the order.

There will be 25 board members, with a medical majority. The chair may be either medically qualified or a lay person. Appointments to the board will formally be made by the Secretary of State for Health and by Ministers in each of the devolved administrations. Each of the devolved administrations will make two appointments—one medical, one lay— and the Secretary of State will make the remainder.

At least six of the medical appointments will be drawn from a list supplied by a body representing the medical Royal Colleges in the UK. At present this is the Academy of Medical Royal Colleges. At least one appointment—lay or medical—will be made from a list supplied by the GMC. This ensures the essential professional input as well as proper representation of patients and employers.

I have gone into some detail because it is a complicated order which has taken a long time to prepare and it is important to get the details right. It has taken us almost three years' hard work to reach this point. The order has been designed in consultation with stakeholders to be flexible and adaptable. It will permit improvements to be made to the system of postgraduate medical education and training.

We are very glad that our proposals have the support of medical organisations and of individual doctors. We believe that they will be of direct benefit to the NHS and to patients because they will help us to produce not only more doctors but better-trained doctors. I commend the order to the House.

Moved, That the draft order laid before the House on 3rd March be approved [13th Report from the Joint Committee].—(Baroness Andrews.)

3 p.m.

Earl Howe

My Lords, I thank the noble Baroness for introducing this important order and for the clear way in which she did so. I wish to be entirely constructive in my approach to these proposals. I am the first to acknowledge that the Government have not only consulted widely on them but have taken account of many of the concerns raised by those who responded, not least the medical Royal Colleges and the GMC. What we have here, nevertheless, is a piece of major reform, and it is right that we should spend a few minutes in examining its implications.

I think we can probably all agree on several positive features. First, the order greatly simplifies what many would regard as a baffling array of regulations currently governing postgraduate medical training and, in so doing, it makes the underlying legal framework a lot less opaque. It also brings together under one statutory umbrella both specialist and GP training, a change which is, I believe, very welcome, as is the creation of a new GP register.

The other main change to be applauded is the way in which medical training is assessed. It is no longer a question of how long a person has trained in a particular discipline, but whether he or she is competent in that skill. Assessing someone's competency carries important implications for who will be able to apply to join the specialist register. As the Minister has just explained, Article 14 contains a provision which will allow for doctors who have gained qualifications outside the European economic area to be assessed here, on the basis of their competency and experience and, if found to meet the prescribed standards, admitted to the specialist register. I welcome that change. Quite a number of doctors practising in the UK cannot currently make this career progression. Both they and the NHS are the worse for that.

As I read it, we will ultimately have a much more flexible system than we do at the moment, but it will require appropriate mechanisms to be put in place to ensure that people's qualifications, training and experience can be properly assessed. The criteria used must be very clear and very tight. That task has to be put in hand. In fact, the practical aspects of these reforms have excited some comment and it would be helpful if the Minister could say something in her reply about a few of them. For example, there will be doctors in the SAS grades who are assessed but are then found to require further training. How exactly is it intended to provide this top-up training, and how will those doctors access the established training programmes? To what extent will an assessor be held responsible for the subsequent professional performance of the person who is assessed?

The other practical issue I want to raise relates to the interaction between the new board, the GMC and the medical Royal Colleges. In the report on the consultation published in February, there is a specific reference in paragraph 28 to the need for all three bodies to work together closely if the new system is to work effectively and well, particularly as regards processing applications for doctors' certification and registration. I agree with that, of course, but it is also self-evident that to have the highest and best standards of medicine in this country, the medical Royal Colleges have to be closely involved in determining the standards of postgraduate medical training.

Equally, doctors who qualify and are admitted to either of the registers will have to submit themselves to revalidation during the course of their career. Revalidating doctors is a responsibility of the GMC. If the standards of attainment in both training and revalidation are to correspond and cohere, clearly the GMC, alongside the Royal Colleges, has a locus in helping to oversee and shape the work of the new board. It is pleasing, therefore, to see that the board membership will include nominees of both the GMC and the medical Royal Colleges, and that this provision is now written into the order.

I have to ask the Minister, however, about paragraph 1(14) of Schedule 2. It says: On a proposal from the Board or otherwise, the Secretary of State may by order vary the size or composition of the Board". The only provisos to the exercise of the power are that the medical majority on the board has to be preserved and the appointment rights of the three regional departments are safeguarded. In other words, the nomination rights of the GMC and medical Royal Colleges, to which both bodies attach great significance, are not set in stone.

The words "or otherwise" concern me, however. In what circumstances might the Secretary of State be minded to say that nominees of the professional bodies should no longer sit as members of the board? Even the theoretical prospect of that happening fills me with some alarm. I say that especially in the broader context of the Secretary of State's wider powers, which I shall talk about in a moment. Now that the Government have agreed to include the nomination rights in the order, why is that get-out provision there at all?

The Minister will know that the BMA is disappointed that it is not represented on the board. I have considerable sympathy with its view that practising doctors should sit as members to represent the key groups of hospital and general practice, as well as training and career grades. There is no guarantee that the nominees of the GMC or the medical Royal Colleges will be practising doctors with direct experience of workforce planning, assessment and appraisal and implementing working hours agreements. The BMA Junior Doctors Committee is particularly ideally placed to provide that sort of knowledge.

There is also a strong case for GP representation on the board, given the fact that an increasing quantity of service and education is undertaken in primary care settings. Alongside GPs, the BMA has emphasised to me the particular significance of the staff and associate specialist group of doctors, whose needs are very individual and will undoubtedly have to be taken into account by the board. There is a good argument that a doctor from that group should be included in the board membership.

The underlying issue is that doctors must be fit for purpose. That point has been recognised by the fact of enabling the Secretary of State to ensure that NHS interest is represented on the board. I, for one, do not have a problem with that idea. However, I have a problem with the extent to which politicians, especially the Secretary of State, have influence over the composition and actions of the board. We all recognise the importance of professional self-regulation, and I am the first to recognise that the medical majority on the board preserves the essence of that principle. Yet the fact is that the appointments process is largely in the hands of politicians.

Why does the Minister believe that that is necessary? There should be some political appointees—yes; but should they all be? I am uncomfortable with that. Surely, politicians do not need to appoint all the members to achieve parliamentary accountability for the work of the board or for public money spent.

I have a similar concern in relation to the powers granted to the Secretary of State in paragraph 26 of the order. I understand completely that they are billed as "default powers", to be exercised only if the board has, in the opinion of the Secretary of State, failed to perform any of its functions. In that situation, the Secretary of State may issue directions to the board; if the board fails to comply, the Secretary of State may himself give effect to his direction. That means, in practice, that he will step into the board's shoes.

That is an extraordinary provision, and it is slightly difficult to imagine what the process would involve. We are all used to default powers in other contexts—usually in situations where it is essential for a matter to be expedited for the public good. I would not have thought that the work of a board responsible for postgraduate medical education and training fell into that category. If, by some awful contingency, the board were to fall seriously short in the performance of its functions, the remedy surely does not lie in the Secretary of State taking over in the form of direct rule. Surely, he should consult members of the profession—the GMC, the Royal Colleges, and other interested bodies—and propose arrangements that would serve to upgrade or replace the PMETB and remedy its failings. The role of the Secretary of State should be essentially as a facilitator, not as a protagonist. But that is not what the order provides for.

One then has to wonder what kind of circumstances might lead to the Secretary of State's default powers. That exercise depends, as I said, on his being satisfied that the board is failing to perform any of its functions. The board's functions are set out clearly in Article 3. However, paragraph (11) of that article allows the Secretary of State, On a proposal from the Board or otherwise"— note "or otherwise"—to, create a new statutory committee and confer functions on it; or … vary the functions of the statutory committees". I have to ask the Minister what exactly that entitles the Secretary of State to do. What we cannot have under any circumstances is the remit of the board, and therefore the standards governing postgraduate medical education, becoming the subject of a political agenda. I hope that she can reassure me that there is no means of that being permitted to happen via the backdoor with the order as it is worded.

I note what the Minister said about reasonableness. It might he thought reasonable for the Secretary of State in the interests of the NHS to influence, and indeed amend, the nature and scope of the board's functions and the bodies with which it is required to co-operate. However, such amendments might not necessarily advance the central objective of postgraduate medical education and training, which is to make doctors fit for purpose and to instil in them the highest standards of practice. I hope that she can reassure me on that.

I end with a question about the timetable for the establishment of the board. Should the House approve the order, I understand that it is likely to be made by the Privy Council at its meeting in mid-May. Advertising for the board members would take place in that event immediately afterwards. If so, the first board meeting is expected sometime in the autumn. However, there will have to be a transitional period during which the specialist training authority will continue its decision-making process about access to the specialist register. Can the Minister tell me when it is expected that the new decision-making process will formally pass to the PMETB?

Once again I thank the Minister for her explanation of the order, and I look forward to her reply.

3.15 p.m.

Lord Clement-Jones

My Lords, I join the noble Earl, Lord Howe, in thanking the Minister for her very comprehensive introduction which I think answered in advance many of the questions that we on these Benches would have liked to ask. We also give a broad welcome to the new board which I think is eagerly anticipated by the medical profession generally. It is the result of some extremely comprehensive consultations which we also welcome. The consultation certainly gave rise to a large pile of documentation which many of us have been reading through in the past few days. The outcome, which I very much welcome, is a series of quite carefully constructed compromises. The board itself will be a competent authority for the purposes of the EU directive on the free movement of doctors. Consequently, we have no great desire to disturb any of the quite carefully constructed architecture in the order itself.

Several changes were made by Ministers as a result of the consultation. For example, initially the chairman was going to be appointed solely by the Secretary of State and not by the board. Now, at least after the initial period, the board will have the right to appoint. We welcome that, although we have some questions about whether five years is the right period.

There have obviously been changes as regards the use of default powers and the duty to co-operate with a body that appears, representative of the medical royal colleges". That co-operation by the board with the medical colleges enshrined in the order is wholly positive.

Generally the move to competency-based assessments away from the time served basis is greatly to be welcomed. The medical profession and those in the SAS grades mentioned by the noble Earl, Lord Howe, will welcome that. Medical experience will be recognised.

We welcome the new GP register alongside the specialist register and the more flexible admission to the specialist register. However, I refer to the question—the Minister went some way to answering it by way of an assurance, but chapter and verse is needed—of whether it is only academic or research knowledge and experience that make a doctor in the grades that we are discussing eligible for consideration. That point was raised by my honourable friend Dr Harris in Standing Committee in another place. I think that due to lack of time the Minister, Mr Hutton, said that he would write to my honourable friend. However, it would be useful to be given further clarification. On the face of it—perhaps I have not read every jot and tittle of the order—it seems that academic research rather than practical skills confers eligibility. It would be useful to hear more detail on that matter from the Minister.

We very much welcome—this has resulted from the way in which the board was set up—the apparent streamlining of the system of hospital visits by the Royal Colleges. It has long been a grouse of mine that over 28 bodies are now entitled to visit, inspect and audit acute hospitals. The more we can boil down the number of visits that are made, the better. It would be useful if the Minister could shed a little light on how that process will operate. Clearly, the board itself, as the regulator in these circumstances, will carry out that process on behalf of the Royal Colleges, but what residual responsibility will the Royal Colleges feel that they have in that regard? How will the process work out in practice? After all, the Royal Colleges will have some delegated responsibilities. They will have membership of some of the committees. Will they feel obliged to carry out inspections as well?

The noble Earl, Lord Howe, described the measure as a radical set of proposals. Perhaps my perspective is rather different. I believe that the setting up of the board is a significant step but I do not see it as a very radical move in many respects because the responsibilities of the NHS, the universities and the postgraduate deans for implementing training and performing to standards remain largely undisturbed. Accountabilities for different aspects of training seem, certainly to the uninformed onlooker, rather confusing.

The Minister told us that the funding and implementation of the training would be carried out by the postgraduate deans. There is the whole new "unfinished business" agenda announced by the health Minister which will be implemented not by the board, as that is the regulator, but essentially by the postgraduate deans and the NHS itself, as I understand it. Accountabilities will be extremely important in judging whether that extremely hefty agenda is successful and whether there is sufficient clarity of responsibility. Will the board have the ability to influence how "unfinished business" is put into practice? Certainly, the borders are unclear at the moment.

How do the responsibilities of the board fit in with workforce planning by the NHS? We have seen great improvements in that regard but it is crucial to delivery within the NHS. Also important is that perennial old chestnut, training numbers. The NHS has grappled with that over a number of years, and it is still a huge issue. In passing, I wonder whether the department is trying to do too much in the current circumstances. The agenda is massive, grappling not only with the implications of the working time directive, but changing the whole system of training junior doctors, instituting the board and so on. That is biting off a huge amount of reform in one go.

Having said all that, I have doubts on some individual areas, but the Minister can satisfy them in her reply. The noble Earl, Lord Howe, raised a large number of them and I certainly do not intend to repeat them all. The independence of the board is absolutely crucial, as is self-regulation, the principle that the Minister enunciated. I very much welcome the fact that there will be a majority of doctors on the board. The model of the GMC, which is responsible to the Privy Council, could however have been adopted in the case of the board, and I would very much like to hear the Minister explain why that model was not followed.

The noble Earl went into the use of the Secretary of State's default powers in great detail and very effectively. They are extremely important. The Minister more or less gave us the kind of judicial review test, saying that the Secretary of State will be reasonable in the actions that he takes in exercising his powers under article 26 and other default powers. Some examples of where in practice the Secretary of State would exercise his powers would be extremely useful, because they are very wide. The legislation states, has failed to perform any function". That is fairly draconian. Some assurances on the record to the effect that they will not be used lightly would be very helpful.

The question of nomination of board members is very important. As we know, for "special health authority" in the order, one needs to read "NHS Appointments Commission". I assume that that is the regular way in which nominations will be made. The Minister's assurance on that point would be extremely welcome.

The noble Earl talked about GP representation on the board. We place great emphasis and importance on having practising doctors on the board, whether they are indeed official representatives of the BMA or not. We also believe that junior doctors should be represented. A range of practising doctors should be represented, to ensure that they can give a proper perspective to the type of training that they are responsible for regulating. We share the noble Earl's concerns on the timing of the establishment of the boards.

My final point is on the issue of delegation to the Royal Colleges. It would be useful for the Minister to explain what will happen in practice, as well as explaining the relationship with the GMC, which the noble Earl mentioned. I welcome the fact that the GMC and the board are joined at the hip, so to speak. A little clarification about how that relationship will work is extremely important, and I look forward to the Minister's reply.

Lord Turnberg

My Lords, in welcoming the order, I have to express an interest as a past president of the Royal College of Physicians and past chairman of the Specialist Training Authority. May I also say how much I appreciate the way in which my noble friend and her officials have explained the detail of the order to me, and how the department and its officials have consulted all and sundry in reaching what I believe is a very satisfactory order.

I particularly welcome the bringing together of the Specialist Training Authority and the authority that regulates general practitioner training. I welcome the facility to take on board experience as part of the ability to assess individual doctors, and the encouragement to look at overseas doctors, who have sometimes had a difficult job getting into the system. Of course, the increase in lay and NHS representation is to the good. I believe all those things are very valuable.

As my noble friend said, concerns have been raised about the powers of the Secretary of State. I think that I am reassured by the suggestion that he or she will have to demonstrate reasonableness in bringing the board to order. I was particularly concerned at one point about medical Royal College representation on the board. I am moderately reassured and I believe that the colleges are moderately reassured.

I want to comment briefly on why it is important that the colleges are adequately represented. The colleges are, and have been for very many years, responsible for developing all the various curricula for all the various specialties, as well as general practitioner training. They set up the training programmes and have a number of specialist training courses.

One has only to visit the Royal College of Surgeons or the Royal College of Obstetricians and Gynaecologists and to see the special training methods they have adopted, which allow young surgeons to practise on inanimate models before being let loose on the public, to recognise how valuable all that is. They ensure that trainees go through all the programmes; they set the exams; they run the examination process; and they assess all the competences.

Incidentally, the colleges are already assessing competences. That will not be new for them; it will be a continuation overseen by the board. Therefore, it is not absolutely new. The colleges visit all the establishments concerned with training—all the hospitals and so on—and ensure that they are up to standard.

The colleges will also welcome the ability to assess experience. The Specialist Training Authority was very constrained by the European directive in its ability to assess experience. It seems that this new order will help to get round that problem. In all that, the colleges work very hard. My own old college, the Royal College of Physicians, ran 28 different specialty training programmes: cardiology, gastroenterology, neurology and all the "ologies" were involved.

All that vital experience should not he lost and should be used in the new board. It is helpful that six places will be available to the colleges. I hope that my noble friend will be able to reassure us that that is a minimum figure and that at least that number will be representatives.

I want to raise another point concerning the responsibilities of the board with regard to the supervision of training. It is hard to imagine how that responsibility will be fulfilled without the board being able to delegate it to colleges and to postgraduate deans. I make a similar point in relation to visiting. I cannot imagine that the board will visit establishments where training takes place. It will have to delegate that responsibility. Therefore, I would welcome a reassurance from the Minister about the ability to delegate responsibilities.

3.30 p.m.

Lord Patel

My Lords, I, too, welcome the order that brings postgraduate medical education in general practice and specialties under one statutory organisation. Like my noble friend, in a true sense, Lord Turnberg, I also declare an interest. I am the immediate past chairman of the Specialist Training Authority—a body that will be replaced by the new board. I have also been president of the Royal College of Obstetricians and Gynaecologists and chairman of both the Scottish and United Kingdom Academies of Medical Royal Colleges and faculties. All those organisations are concerned primarily with promoting and establishing medical education.

The order creates an opportunity to bring some fresh thinking to the way doctors are trained to meet the needs of the health service and to change the way that medical care is delivered in this country from much of care today, particularly emergency care, being delivered by doctors in training to care being provided by doctors who are fully competent to provide it, and who have gone through a structured competency-based training and assessment.

To be able to bring about the changes proposed in the order, the board must be independent of government and organisations primarily concerned with devising and delivering programmes of medical education. At the same time, the board must work closely with and support organisations such as the Royal Colleges which are, in the main, as all noble Lords have said, responsible for postgraduate medical education.

While there have been anxieties about appropriate Royal College representation on the board—that has been mentioned several times—several of the college presidents who have spoken to me recently are content with the proposed arrangements and are looking forward to the establishment of the board. Yes, they have concerns that appropriate representation will also be maintained, and significantly so in the various committees. I, too, support the comments of the noble Lord, Lord Turnberg, that the colleges are important and we should ensure that they are well represented on the committee.

It is right that the board and its committees should have significant lay representation. That is lacking on the current board of the STA, which has representatives from all the medical Royal Colleges, two representatives from the GMC, two lay representatives and one postgraduate dean. On many occasions during my chairmanship of the STA, the dominance of the Royal College representation on the board slowed the progress towards reforming curricula, introducing competency-based curricula, competency-based assessments, further training of doctors in non-consultant career grades and reform of so-called hospital visiting. My hair has turned grey trying to bring uniformity to hospital visiting processes that could be adopted by all the colleges. I exclude here the Royal College of General Practitioners, which has a very good system.

I do not criticise colleges for that; I merely give an example of how the board, working in a co-ordinated way, could bring about changes that would benefit medical education and training. The independence of the board should help to strengthen its role in those areas. The board should also be independent of the Government. The Minister's assurance on that would be comforting to the colleges.

Having said that, I believe it to be right that the Secretary of State has reserve and default powers to be used if the board is not discharging its function. I hope that those powers could be used only following a comprehensive external review of the board's work. The board has to be accountable.

Two other areas need clarification and reassurance. I hope the Minister will be able to give that. The current arrangements for recognising training undertaken outside the United Kingdom and EEA countries are not satisfactory. That has also been mentioned by all noble Lords. Thousands of doctors working at staff grade and associate specialist grade providing excellent care fail to get on to the specialist register and are disheartened, demoralised and feel discriminated against. At the initiation of the STA, over 3,500 doctors applied for entry to try to have their training and qualifications recognised. Over 50 per cent failed to do so.

The proposals in the order that include recognition of medical experience along with qualification and training and considering doctors' eligibility to be put on specialist registers, together with the proposals relating to top up training in the United Kingdom, will allow for many of those excellent doctors to get on to a specialist register and obtain consultant positions. I do not think it is beyond the wit of man to find a way to provide this type of training in a proper institution where training is possible.

The board must make sure that that happens; otherwise it will fail in its duty. I hope that this will be one of several outputs by which the board will be judged in the review. While the order proposes that a review should be carried out after five years—and I agree with that—I hope that there will be some way to monitor the board's work on a more regular basis.

The recognition of qualification, training and experience should also make it possible for overseas doctors to come here and continue their training in order to get on to a specialist register. I agree with the noble Lord, Lord Clement-Jones, that that should not just apply to those in academic and research positions but to others in service positions.

The final area on which I want to comment relates to the board's responsibility for setting up an appeals panel. During my chairmanship of the Specialist Training Authority, on occasions the independence of the present appeals system was challenged. While none of the formal appeals succeeded, I hope that the Minister can give a reassurance that the proposed appeals panel system will provide for the establishment of an open and independent appeals system which can also demonstrate a clear separation of the appeals panel from the board.

Perhaps I may also comment on the subject mentioned by the Minister about a proposed new careers structure being developed—Unfinished Business. I look forward to it eagerly. I hope that I shall have a lot to say about the matter. The career structure for doctors, in particular in training, needs to be revisited. I hope that that will be simplified and not made more complicated.

In conclusion, apart from those areas that I have mentioned which require some further work by the board, I support the order and look forward to the establishment of the Post-graduate Medical Education and Training Board. I shall follow its work with great interest.

Baroness Andrews

My Lords, I hope that noble Lords will bear with me while I arrange my papers so that I can answer at least some of the questions raised this afternoon. First, perhaps I may say how grateful I am for the very warm welcome that the order has received. All credit should go to those who have worked so hard and with such great thought and conviction regarding the need for change in this respect.

Many detailed questions have been raised. I hope to answer as many as possible. Primarily, they appear to be grouped around issues. For example, there are issues regarding the independence of the board and the powers of the Secretary of State; and issues which deal with the representation of doctors and the needed assurances that there will be a medical majority with doctors being represented appropriately.

A number of issues were addressed by the noble Lords, Lord Patel and Lord Clement-Jones, and the noble Earl, Lord Howe, including the range of experience regarding the notion of competence and the necessary mechanisms in relation to it. There are issues that deal with the workforce and how what we are trying to do in order to expand and change the workforce of the NHS will reflect, impact on and be, as it were, regulated by the board itself. That brings in issues regarding visiting panels and so on and the delegation that the noble Lord, Lord Turnberg, talked about in relation to the power. The noble Earl, Lord Howe, raised the issue of the timetable. The noble Lord, Lord Patel, raised the issue of the appeals mechanism.

I shall try my best to give assurances on most if not all of those matters. I start with the issue of the board's independence and the assurances that noble Lords seek on the powers of the Secretary of State. We can give with total conviction the assurance that it will be an independent board. The Secretary of State will have the power to nominate the chair in the first instance. The nomination of other members of the board will be as has been agreed and which has come forward in a variety of ways.

There will be at least six places—there may be more—from the medical Royal Colleges, and at least one place from the General Medical Council. There will be six places via the devolved administrations; 19 appointments will therefore notionally be made by the Secretary of State but, in fact, they will be generated by the expert and devolved bodies in the field.

The process of advertisement and selection will be delegated to the NHS Appointments Commission. The reason why the Secretary of State has that role in the first instance is the need to ensure that the first board has balance and authority and is robust and representative.

I was asked why the board does not approximate more closely to, say, the GMC. In fact, that is a slight misreading of the powers of the GMC, because the Department of Health is not as much an arm's length body as it would appear from the fact that powers are located in the Privy Council. The Department of Health has a close link with the GMC through the Privy Council, so the GMC does not provide an appropriate model in this case.

On the question of powers held by the Secretary of State, it is important to reflect that his default powers are not new. They have been held in another form under the STA, which could give direction about administration. The powers in the order approximate to those held under the Medical Acts. So essentially, we have not invented anything in the order. The default powers are important because, should there be such exceptional circumstances as a failure of function—we have no examples to offer noble Lords, because such powers have never been used—or systems failure, we need those powers to rescue the board. We fervently hope that they would never be needed.

The noble Earl asked why the Secretary of State had power under Article 3(11) to create a new statutory committee. That article entitles the Secretary of State to vary the functions of the training or assessment committee or to create a new statutory committee, simply because the power must be exercised by statutory instrument, which is obviously subject to the negative parliamentary procedure. During consultation, many respondents felt that the functions of the statutory committees needed to be capable of being altered. So that is a safeguarding mechanism to allow change to be made without having to go through more elaborate or Draconian measures. In fact, it was the doctors' representatives who asked us to include such a power to avoid arbitrary or artificial limits on the committees' functions. The power allows us flexibility for the evolution of function.

The noble Earl also asked why there is power to vary the size and composition of the board. Again, we need the flexibility to do so. As he said, there will always be a medical majority and a requirement that the devolved administrations appoint one medical and one lay member. But we want to build flexibility into the procedures, so that if the board concludes that change is needed we do not have to make amendments via a Section 60 order of the primary Act. That has been agreed with the Royal Colleges and others in negotiation.

I hope that those reassurances reinforce the board's intention to operate independently and the Government's intention to ensure that it does.

A related aspect of independence is the composition of the board—why, for example, the British Medical Association will not be on it and whether there will be sufficient GPs. Essentially, the board's composition will be driven by the applicants. At least six people will be nominated through the Royal College, and at least one through the GMC. We will be extremely interested to see the range of specialities and health service representation that comes forward when we advertise the posts. We are confident that we will get the representation of doctors and of many of the groups that we wish to see. But much will be in the hands of the Academy of Medical Royal Colleges and the GMC in terms of nominations.

There is no reason why there could not be a specialist committee of the board simply for general practitioners. General practitioners and, indeed, many more members of the Royal Colleges will be represented on the sub-committees on training and assessment and any other committee that the board chooses to appoint.

The noble Lord, Lord Clement-Jones, asked about the links between the GMC and the Academy of Medical Royal Colleges. The order provides that there is a duty on the board to co-operate with the GMC and the Academy of Medical Royal Colleges as the representative body. There could not be a more explicit demonstration of the intention to work closely with the medical profession than including in the order that duty in what I hope are explicit and reassuring terms.

On the timetable, we hope that the Privy Council will pass the order at its next meeting. It will come into effect in October, when the board is set up. Advertisement and appointment will occupy the time between now and October. The board will run in parallel with the STA and the General Practitioners Training Committee for a year. We expect the full transfer of powers to take place some time at the end of next year. We know that the process is complex. We do not want it to be rushed or compromised, which is why additional resources have been put into making it as robust and effective as possible. The functions of the STA and the other training committee will continue in parallel, so there will be no discontinuity.

The noble Lord, Lord Clement-Jones, asked about workforce issues. As he said, it is a matter of agenda. Part of the order's function and significance is, not least, expanding the number of people who will be able to join the specialist register through an emphasis on competence. We will expand the number of people who can serve the health service in that way. But, as the noble Lord said, Unfinished Business on modernising medical careers looks to reforming the postgraduate medical curriculum in different ways, with a new foundation year, for example. But it also looks to building into it curriculum assessment and competencies. So we have two parallel processes in which the board will be closely involved as the regulator and the standard-setter. It will have a major job to do in regulating the process as it evolves over the next few years. That is a major, coherent change in medical education and training.

The noble Lord, Lord Clement-Jones, also asked about visiting panels. We are conscious of the great seriousness—I hesitate to use the word "burden"—of the process of visiting panels. But it is a very important process, which will continue and be reviewed. I am sure that the Royal Colleges and the board will discuss how best to manage that in future. A review is taking place at present.

The noble Lord, Lord Turnberg, asked whether the board would supervise training. He also asked about its delegation powers. The board is legally responsible for training. It may delegate activities and decisions to its committees or sub-committees, which may be Royal College-based, as I suggested. However, the requirement for designated competent authorities to supervise training emanates from EC Directive 93/16/ EEC. The board is the competent authority under that requirement for specialist training. The directive requires that the competent authority supervise specialist training. It is identical to the wording of the requirement in the European Specialist Medical Qualifications Order 1995.

We envisage that the board will fulfil its duty to supervise training by virtue of its standard-setting functions, its approval functions and its ability to organise visiting panels in respect of postgraduate medical education and training. It has the power to appoint persons to visiting panels and to make rules as to the composition of visiting panels.

The noble Lord, Lord Patel, asked a specific question about appeals. I can give the noble Lord the assurance that he seeks. The appeals panel will have to be independent. Doctors need an independent panel to handle appeals, and they must have confidence in that independence. No member of the board or its committees or sub-committees will be able to sit on an appeal panel. That is the guarantee of independence that the noble Lord seeks.

A major issue was raised about the opportunities presented for training. We are convinced that the order will make a major difference. To the noble Lord, Lord Clement-Jones, I say that, by "training", we mean practical training, not just academic training. All experience, wherever obtained, can and will be taken into account, together with qualifications and training. We are creating a level playing field for doctors with different sorts of experience.

As I understand it, doctors who are, at the moment, excluded from the specialist register because they do not have additional training or experience will be able to apply to the board and demonstrate how they reach the standards set in the new ways. The board will be able to assess doctors in terms of the standards that they have reached. Assessing experience is a particular skill that must be developed over many years. We look to the board to develop its rules on the basis of common sense. If the doctor is assessed as needing top-up training, he will be able to apply through the postgraduate deaneries for a suitable training programme. Those programmes will be different from traditional programmes. They must be designed to respond to the needs of the doctors who will come through different routes with different qualifications and experiences. We will look to the deaneries and the board to manage the process.

If I have neglected to answer any questions, I will be happy to write to noble Lords. In conclusion, I must say that doctors already understand the advantages of the new system. We have had the first application to the new board, even before the legislation has been passed and the board set up. That application came from a specialist doctor from the Indian sub-continent seeking entry to the specialist register. In his country of origin, he is an associate professor in his speciality. He has previous NHS experience and holds a fellowship from a medical Royal College in the UK. That is precisely the sort of benefit and bonus that we want to see for the NHS. We cannot and should not pre-judge board assessments of individual doctors, but we believe that there are many more in a similar position.

We have had overwhelming endorsement. Because it is one of several initiatives in postgraduate medical training, the board will set the standard for all postgraduate medical education, as we have described it. In that way, we hope to give the NHS doctor of the future a clear career path, to the benefit of all the things that we are trying to do to modernise and improve the NHS and to the particular benefit of patients. I am grateful to noble Lords.

On Question, Motion agreed to.

House adjourned at four o'clock.