Evidence submitted by the General Medical
Council (WP 68)
1. The GMC welcomes the opportunity to assist
the Health Select Committee in its Inquiry into workforce needs
and planning for the health service.
2. The GMC's remit does not extend to workforce
planning or employment issues. However, the GMC is an important
component of the medical workforce supply chain and we believe
it would be helpful to clarify our roles in registration and in
the education and training of UK doctors.
STATUTORY PURPOSE
3. Under the Medical Act 1983, the GMC's
purpose is to protect, promote and maintain the health and safety
of the public by ensuring proper standards in the practice of
medicine.
4. In support of this purpose, the GMC has
four main functions:
a. Registering doctors, who meet the required
standards, for medical practice in the UK.
b. Defining the outcomes to be achieved through,
and assuring the standards of, basic medical education; and promoting
high standards in, and coordinating all stages of, medical education.
c. Setting the standards of practice, standards
of performance, and ethics that society and the profession expect
of doctors throughout their working lives.
d. Dealing firmly and fairly with doctors
whose fitness to practise may be impaired.
REGISTRATION
5. Doctors who wish to practise in the UK
must be registered with the GMC.
6. There are three main routes to registration:
a. For doctors who qualified at a UK medical
school.
b. For doctors who qualified within the European
Economic Area and are EEA citizens or have European Community
rights.
c. For international medical graduates who
qualified outside the EEA or who qualified within the EEA and
do not benefit from European Community rights.
7. Table 1 shows the total number of new
registrations each year from 2002-05, subdivided across the three
main routes. Please note that this information is not necessarily
indicative of the number of doctors entering the workforce in
the UK. For historical reasons many doctors have held GMC registration,
though they remain resident in another jurisdiction. In 2003 for
example the closure of a former direct route to registration (without
an assessment of medical knowledge and skills) for doctors qualifying
from seven countries ceased. Several thousand International Medical
Graduates (IMGs) secured registration prior to the closure of
the route though there is no evidence that they planned to come
to the UK in the foreseeable future.
Table 1
| |
| | |
Year |
UK doctors
|
EEA doctors |
IMGs
| Total new
registrations |
| |
| | |
| 2005 | 32% | 16%
| 52% | 14,835 |
| 2004 | 32% | 24%
| 44% | 14,737 |
| 2003 | 25% | 10%
| 65% | 18,684 |
| 2002 | 39% | 14%
| 47% | 11,235 |
| |
| | |
| |
| | |
EEA doctors
8. The surge in EEA registrations in 2004 was the result
of the expansion of the EEA through the addition of the EU accession
countries.
9. The numbers of newly registered EEA doctors may not
provide a reliable indicator of the doctors who joined the UK
workforce for the first time. Although all EEA doctors must now
complete the registration process in the UK, we are aware that
a proportion of EEA doctors secure registration in advance of
deciding to practise here.
International medical graduates
10. Table 1 shows that IMGs represent the largest proportion
of new registrations, ranging from 44% in 2004 to 65% in 2003.
11. The surge in IMG registrations in 2003 was stimulated
by the impending withdrawal of the special recognition, for historical
reasons, of qualifications from seven countries—Australia,
Hong Kong, New Zealand, Singapore, South Africa, the West Indies,
Singapore and Malaysia. Qualifications from those countries are
now treated on the same basis as other countries outside the EEA.
12. From 2004 onward, the numbers of newly registered
IMGs provide a reasonably reliable indicator of the doctors who
joined the UK workforce for the first time. IMGs must complete
the registration process in the UK and registration is granted
only when they have secured an offer of employment. This was less
true prior to 2004, for example because of special recognition
explained above.
13. Most IMGs secure registration having demonstrated
their knowledge and skills by passing the Professional and Linguistic
Assessments Board (PLAB) test. The PLAB test is in two parts,
with Part 2 being available only in the UK. Doctors must pass
Part 1 before taking Part 2. The great majority of IMGs who secure
registration are seeking employment in training grades, not as
specialists.
14. The number of PLAB test applicants rose steadily
from 2000, when about 3,400 doctors took Part 1, to a peak in
2004, when about 12,600 doctors took Part 1. The numbers taking
Part 2 rose correspondingly, from about 1,349 in 2000 to about
8,200 in 2004.
15. There has been widespread concern that the numbers
of IMGs who have passed Part 2, and are in the UK seeking work,
greatly exceed the number of posts available. Among other things,
this led to calls that the GMC should ration test places, particularly
for Part 2, on the basis that this would help to secure a better
match between demand for, and supply of, jobs. This, however,
would be unlawful.
16. We have, however, sought to work with the Department
of Health and others to improve the information available to IMGs
who are considering coming to the UK and to ensure that they understood
that passing the PLAB test did not guarantee employment. For example:
a. In 2004 we began a regular survey of IMGs who had passed
the PLAB test, to collect information about their employment experience
in the UK. The results are published on our website. We would
be pleased to supply a copy of the most recent survey results
if that would be helpful.
b. We recruited, as advisers, a group of doctors who had
taken the test, to assist in rewriting the information we provide.
It includes fuller information on job prospects, on finding work,
and on life in the UK. Doctors must confirm that they have read
the relevant sections of the guidance before booking a Part 1
test place.
c. We work with others to try to provide a picture of
the UK job market. However, there is undoubtedly room for further
improvement.
d. In 2005, in conjunction with the Department of Health
and the BMA, we commissioned a survey that looked at the employment
experience of recently qualified UK doctors. We would be pleased
to supply a copy of the survey results if that would be helpful.
It can also be viewed on our website at www.gmc-uk.org/doctors/employment—surveys/index.asp.
17. The steps we and others have taken to improve the
availability of information, combined with feedback through IMG
networks, have led to a sharp drop in applications for Part 1
of the PLAB test, from about 12,600 in 2004 to about 9,100 in
2005. This downward trend has continued in the first two months
of 2006.
18. While further analysis would be required, the experience
of recent years appears to demonstrate that the supply of IMGs
who wish to work and train in the UK can be stimulated and depressed
through the availability of good quality information about the
market.
19. On 7 March 2006, the Home Office announced that all
IMGs wishing to work in the UK would be required to have a work
permit from July 2006. We are communicating this to potential
candidates via our website. We foresee that this will lead to
a further drop in the numbers of applicants.
MEDICAL EDUCATION
AND TRAINING
21. Under the 1983 Act, our Education Committee has the
general function of promoting high standards of medical education
and coordinating all stages of medical education. The 1983 Act
lays down specific roles for the Education Committee in relation
to undergraduate education and training for doctors with provisional
registration. Doctors are granted provisional registration, usually
for one year, on completion of their medical degree to enable
them to continue their training in a managed environment.
22. The Postgraduate Medical Education and Training Board
(PMETB) has functions relating to postgraduate medical education
and training, set out in the General and Specialist Medical Practice
(Education, Training and Qualifications) Order 2003. Effective
medical education and training requires doctors with the time
and the skills to deliver it in the workplace.
23. Neither the GMC nor PMETB has a remit to set the
number of medical students and trainees. In England, medical schools
are funded through the Higher Education Funding Council for England
(HEFCE) and the Joint Implementation Group of HEFCE and the Department
of Health makes decisions on student numbers. The funding of medical
school numbers in the devolved nations is similarly a matter for
the health departments and analogues to HEFCE.
24. In relation to undergraduate medical education, the
GMC Education Committee determines the "knowledge and skills"
and the "standard of proficiency" required on graduation
from a UK medical school and we also set standards for medical
schools. The guidance is set out in Tomorrow's Doctors which is
available on the GMC website www.gmc-uk.org. We would be pleased
to supply a copy if that would be helpful.
25. The GMC Education Committee ensures that undergraduate
medical education is appropriate but does not attempt to define
the workforce or other resources needed. In Tomorrow's Doctors
we state that medical schools must make sure that their staff
follow our guidance and are provided with the necessary training
(paragraph 97). The UK health departments must make facilities
available for students to receive training and decide how students
may have access to patients (paragraphs 99 to 100). "Doctors
with particular responsibility for teaching students must develop
the skills, attitudes and practices of a competent teacher. They
must also make sure that students are properly supervised,"
(paragraph 103).
26. To develop appropriate knowledge, skills, attitudes
and behaviour, medical students should have contact with patients
throughout their undergraduate courses. Tomorrow's Doctors states,
"From the start, students must have opportunities to interact
with people from a range of social, cultural and ethnic backgrounds
. . . Such contact with patients encourages students to gain confidence
in communicating with a wide range of people, and can help develop
their ability to take patients' histories and examine patients,"
(paragraph 50).
27. Medical schools therefore place students in a variety
of NHS settings. It is important that workforce planning adequately
takes into account the need for doctors to find the time appropriately
to train and assess medical students, without detriment to NHS
services. Training inevitably reduces the number of procedures
that can be carried out in the NHS, as doctors must take the time
to show students what to do. It is essential that workforce planning
takes into account this relationship between training and throughput.
28. In addition, doctors and other health service staff
are involved in teaching medical students on university premises
and in associated research. Workforce planning therefore needs
to reflect the requirements of medical schools with their expanding
student rolls.
29. Following medical school, graduates now enter the
two-year Foundation Programme, which takes place within the NHS.
The GMC Education Committee has responsibility for the first year.
To enter the second year, graduates need to secure full registration
with the GMC. Thereafter, PMETB is responsible for postgraduate
medical education and training, incorporating the second year
of the Foundation Programme and subsequent GP and other specialist
training. We are working closely with PMETB to ensure that the
outcomes required of doctors in the Foundation Programme, and
the standards required of those providing that training, are clear
and coherent.
30. The New Doctor sets out our guidance for the first
year of the Foundation Programme. The current edition, published
in 2005, is transitional, in preparation for expected changes
in the Medical Act to modernise the legal structure for training.
The current edition states that the health departments should
make sure that NHS organisations work with universities and must
make facilities available (paragraphs 135-136). Health service
organisations must "put in place appropriate structures for
making sure that high quality training is provided," (paragraph
137). "Doctors with particular responsibility for supervising
PRHOs [Pre-Registration House Officers, that is, doctors in the
first year of the Foundation Programme] must develop the skills,
attitudes and practices of a competent teacher. They must also
make sure that PRHOs are properly supervised," (paragraph
140). It is important therefore that workforce planning reflects
the need for doctors to have the skills and finds the time to
train and assess Foundation Programme trainees.
31. Alongside the Education Committee's interest in workforce
planning that takes full account of the requirements of medical
education and training, the GMC is keen to ensure that the knowledge,
skills, attitudes and behaviour required of doctors remain appropriate.
During 2005, we held an international conference and conducted
a full-scale formal consultation on strategic options for undergraduate
medical education. This covered themes that should be reflected
in the next edition of Tomorrow's Doctors (scheduled for publication
in 2008) alongside consideration of changes to the present arrangements
for assessment and for consideration of students' fitness to practise.
The Education Committee has a stream of work to consider how medical
practice could develop in the decades ahead. Separately, the GMC
Standards Committee is reviewing Good Medical Practice, our key
guidance for doctors.
General Medical Council
March 2006
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