Examination of Witnesses (Questions 560-579)
MR PAUL
STREETS, PROFESSOR
ELISABETH PAICE,
MR BERNARD
RIBEIRO AND
PROFESSOR DAVID
GORDON
29 JUNE 2006
Q560 Dr Naysmith: The same survey
found that, as a result of Modernising Medical Careers,
63% of junior doctors felt that the quality of training had worsened.
Is that something that you are prepared to address? What do you
think of that? The junior doctors themselves felt that training
had worsened?
Professor Paice: Yet, Modernising
Medical Careers is not yet implemented. The Foundation Two
programmes start in August, the new run-through grades start in
August 2007.
Q561 Dr Naysmith: So what we are
talking about is really things that have happened that have got
nothing to do with changing medical careers?
Professor Paice: I am not sure
what they were referring to.
Q562 Sandra Gidley: My question is
to Mr Streets. There has been a change in the way doctors train,
and you now have the two-year foundation course split into the
F1 and the F2 year, F1 controlled by the GMC and F2 under PMETB.
Would it be more sensible to have the whole lot organised by one
organisation?
Mr Streets: You could take that
view. There is a logic behind what has been proposed, because
the GMC is responsible for the registration of doctors and doctors
are registered at the end of F1 (Foundation Programme One). PMETB
is responsible for all specialist training that takes place after
that, and that is where the cut takes place. What is important
is that we work closely with the GMC, and we have a joint group
working with the GMC, for example, looking at how we get a quality-assured
foundation programme. We also have a joint group which is looking
at how the outcomes of foundation training will be looked as a
whole. I would like to reassure you that we are working very closely
with the GMC. It might be better if it was one or other of us,
but there are reasons why, from a statutory perspective, the GMC
needs to be responsible for the first year of foundation programmes
where people are signed off.
Q563 Sandra Gidley: Could you clarify
why the GMC does need to be involved at that stage?
Mr Streets: It is about the registration
process for doctors. Doctors are registered at the end of their
first year post medical school.
Q564 Sandra Gidley: Why does that
mean that they have to completely oversee? Why can they not just
assess what has gone on, or is it just easier to do the two alongside?
Mr Streets: Professor Gordon may
want to come in on this because it is very much his territory
in terms of what happens after medical school.
Professor Gordon: The position
is that the Medical Act defines the responsibilities of the GMC
and then the PMETB takes over thereafter, but the delivery of
medical education up to qualification, normally five years from
admission to medical school, is directly what we do, but we remain
responsible for our students to ensure that they are getting good
experience and training and education for that next year until
they are fully registered. We are very happy to have that responsibility,
because we believe very strongly that there needs to be a continuum
in the medical education process from admission to medical school
right through to higher training and, indeed, to continuous professional
development. I think it is a pity that we have divisions at any
point, but obviously one body cannot deal with everything right
the way through. There is another important point in there, and
that is that in the development of the foundation programme and
the later stages of MMC there has been a lot of thought put into
the educational content of the curriculum, but some of our students
have commented that maybe that has not been as joined up as it
might have been. They have found themselves in the first foundation
year being taught about things that they felt had adequately been
covered in medical school. So, I think, yes, there needs to be
much better "joinedupness".
Mr Streets: It might help the
Committee to know that the Chair of the GMC Education Committee,
which is responsible for this, is also the Chair of PMETB, and
that is Professor Ruben, so in that sense it does help in terms
of coordination between the two bodies.
Q565 Sandra Gidley: Does he get paid
twice?
Mr Streets: You would have to
ask him that.
Q566 Sandra Gidley: Mr Ribeiro, there
has been some comment that the additional training requirements
of the new foundation programmes actually put a further strain
on consultant time. Is this a justified comment?
Mr Ribeiro: I was actually in
the north-east yesterday talking to some consultants, and I asked
them that very question because they had got some foundation trainees
with them, and I got two different answers, which was that there
were some consultants who felt that they put an inordinate amount
of strain on them in terms of the extra time to do the assessments,
and so forth, and others, who clearly have had some training in
this, who were able to organise their work in such a way that
they felt that they could accommodate it in the time that is available.
That is a foundation programme. Once you add the Modernising
Medical Careers group, which will start in 2007, to it, I
think Professor Paice actually has the figures of what it actually
means in terms of time, but we do anticipate that for the assessments
that will need to be done, and there are a series of work-placed
assessments that do need to be done, it will add extra time to
a consultant's working. What we have been trying to do, working
with the deans, is to develop a framework that will allow to us
have regional schools of surgery for us and for medicine and for
the other specialties, and within these frameworks we will actually
define the responsibility of the various people who are going
to undertake training, and it may be that not every single consultant
will have a responsibility for training per se. I think
all consultants have an obligation to train, but in terms of responsibility
for supervising and organising the training and the assessment
of trainees, this may have to be done by consultants who have
been selected, trained and picked to do it. I do not think it
is just a matter of every consultant having to have that responsibility;
that is one of supervision.
Q567 Sandra Gidley: You have just
mentioned in terms of assessment as to how much extra time it
would be. Are you able to quantify that?
Mr Ribeiro: This is what I hope
the Postgraduate Medical Deans will be able to tell you, because
they did actually do that sum before they made the bid for extra
monies for the foundation programme.
Professor Paice: We certainly
did look at how much it would cost or at least how much time it
would take to do the various assessments, and I will apologise,
I do not have the figures in my head but I am happy to send them
along. I would actually say the trouble is when you think about
the future in terms of the now, you some time get things wrong.
Yesterday I went to a presentation by the National E-learning
Alliance, which really opened my eyes to what modernising education
should look like and already does look like for radiology, where
you join an on-line learning management system, where the things
that you need to learn, the films, et cetera, are brought up to
your own laptop in the comfort of your own home. You do a lot
of the training in your own time and the outcome so far appears
to be that trainees who have this available to them are volunteering
to take the exams a year early, passing them, moving ahead at
a far greater rate and also going into the clinical environment
(and this is the important bit) to meet with their consultant
already well prepared, well informed, having had the opportunity
to do some virtual learning and are then able to benefit from
that expertise, and that is very expensive specialist time, rather
than the old apprenticeship model. What we need to do is modernise,
not just medical careers but modernise the content and the delivery
of education, and that is expensive, but by no means unaffordable,
as an overall vision for the way we train specialists in the future
without just simply doing one-to-one teaching.
Q568 Sandra Gidley: Is the consultant
as trainer model slightly outmoded then, because it seems we are
expecting them to be trainers, managers and clinicians and you
cannot necessarily expect everybody to have all three of those
qualities?
Professor Paice: Not only that,
but you need huge opportunities for people to practice skills
which are not everyday skills. The high fidelity simulator environment
where you have everything which looks jolly like the real thing
and you are faced with emergencies, five emergencies in one day
that might take you five years to experience in real life and
have someone observe how you carry out everything from the procedures,
to the thinking, to the team working, to the resource management,
to the human factors. That is the kind of learning which is available,
and I think patients would be surprised to discover that it is
not available for every trainee on a regular basis.
Mr Streets: Professor Ribeiro
is probably right that not all consultants in the future will
train, and it is interesting perhaps for the Committee to juxtaposition
general practice training where GPs are selected as trainers and
remunerated as trainers compared to hospital training where that
is not the case. Clearly, there is an issue here about how trainers
are incentivised to be trainers and, indeed, how trusts are incentivised
to provide training. This Committee previously has looked at ISTCs,
for example. The first wave of ISTCs were not rewarded for training,
the second wave will be, and that is very important from our perspective;
but what is more important in all of this is that there is a culture
of training and education embedded in the NHS. That is actually
pretty important to us because that is the only way that consultants
will be released for this work, and that means chief executives
being measured just as much on their ability to provide a workforce
for the future as delivery today, and that is one of the central
problems that we have to address as we move forward in implementing
MMC.
Professor Gordon: Just a small
point, I noted your expression of surprise at this degree of multi-skilling
amongst the consultant workforce.
Q569 Sandra Gidley: It is not just
surprise, it is disbelief.
Professor Gordon: You have to
have to remember that 7% of all hospital doctors are actually
clinical academic staff employed by universities and they, in
addition to doing clinical work, at the highest level and, of
course, patient safety is paramount, also teach and do research,
and we expect their research to be of international quality as
well, so there are a lot of people working very hard.
Mr Ribeiro: One of the issues
in the workforce is this question of consultant expansion, and
one of the reasons we have been very keen to drive that is because
we felt that we would be moving towards a consultant base rather
than a consultant-led service. So, we will inevitably end up with
many more consultants than trainees, and we have estimated that
the ratio would be something like five consultants to every one
trainee in the future. So, with that sort of ratio, it is inevitable
that consultants will have to develop different skills. Some will
develop skills as managers, some will develop skills as educators
and trainers, some will develop research and academic skills,
some will have technical skills that actually determine their
future and the trust will appoint people on the skills that they
actually present. On the question of the interaction between trainer
and trainee, one of the things that our colleges have been doing,
with support from the Department of Health, is to develop a new
web-based curriculum, and as regards the work on this our college,
which is an intercollegiate surgical web-based site. I think is
a first, and in fact there has been a lot of interest from countries
outside the United Kingdom in what we are doing. The intention
with this is actually to have a conversation, as Professor Paice
has said, through the web-base with your trainee to actually set
them objectives, see whether they will be able to meet those objectives
and then to critique it and decide how they are progressing. It
is not all about necessarily a face to face, and we must be aware
of technology. One of the things that we are criticised as a profession
is that we are obstructers of change. Actually the medical profession
has been one of the greatest innovators of change, and we have
actually undertaken this in the development of this new curriculum.
Q570 Dr Taylor: Going on with the
content of medical training, it is obvious that undergraduates
have got to have the scientific and the clinical training. Some
of you have mentioned other aspects of the NHS. How important
is it at student level (and really to Professor Gordon, I think,
first) that they are taught about the NHS itself, about relationships
with managers, with other professionals?
Professor Gordon: You have to
remember that we are educating medical students for a lifetime
career rather than just training them for a job, and that career
for most of our graduates, of course, will be in the UK but many
of them will work abroad, some of them will be overseas students
who, once they are fully trained, will return home. Education
for a lifetime career, potentially worldwide, means that the NHS
is a very important element, but it is not the sole element that
they need to understand. Nevertheless, it is very important that,
certainly before qualification, our students understand how the
NHS works and how they can interact with the service, more importantly,
how they interact with their professional colleagues in other
disciplines and learn to work together in a team. I think most
undergraduate medical curricula are quite well advanced in making
sure that that understanding is in place. The GMC Education Committee
would be on our backs if we did not.
Q571 Dr Taylor: So at undergraduate
level that happens. As one moves up the scale, on one of our visits
recently when we went to visit Kaiser Permanente, we learnt that
fairly early on they pick out what they call "emerging medical
leaders". At what stage does that happen in a career? Is
it left until somebody becomes a consultant or are there steps
before then?
Professor Gordon: It is a subject
of great interest to us, for a number of reasons, not least, for
example, that it is surprising that more people do not put themselves
forward to become deans of medical schools, and we are particularly
concerned that more women do not put themselves forward to become
deans of medical schools, and we are working with the Leadership
Foundation for Higher Education on that problem. We see it as
something that extends much earlier in people's careers and, indeed,
we are looking into ways in which, right down to medical student
level, there will be some people who will be interested in developing
their leadership skills, and there is some work being done at
the University of Leeds Medical School on this.
Q572 Dr Taylor: More and more doctors
have to be medical managers. What is the college doing about that?
Mr Ribeiro: Again, in the submission
that was given by both Professor Dame Carol Black and Sir Alan
Croft, reference was made to young emerging consultants, as you
have said, and also reference was made to the fact that the Academy
and the colleges are working very closely with the Institute for
Improvement and Innovation, because we see that one of the major
deficiencies, which I am sure you experienced when you became
a consultant, is that you were trained to be a physician and a
surgeon, and I was plainly trained to be a surgeon, you were not
trained to manage, and we picked that up during our early consulting
years. I remember having a three-day refresher course on how to
deal with managers and how to deal with management in the early
days. We would hope that that would be part of the curriculum,
and one of the things that has come in our curriculum is adopting
the GMC's seven principles, one of which does involve the acquisition
skills of management. So, within the training programme, we will
actually be teaching this and training in those skills.
Q573 Dr Taylor: You are talking about
the future. Is it there now?
Mr Ribeiro: Currently, it is there
in the curriculum that we have developed now. We would hope, and
we are encouraging our trainees, that all trainees in the current
Calman programme would be encouraged and move to the new curriculum.
We would certainly expect those Calman trainees who are in year
one to four to adopt the new curriculum. We cannot force them
to do so, they were appointed under different terms, but we would
certainly expect them to adopt those principles.
Q574 Dr Taylor: Would there be any
move to pick out people who show promise in this and push them
forward?
Mr Ribeiro: In what way?
Q575 Dr Taylor: To push them forward
to take on more of the management, more of the leadership role
if they looked to be the sort of people who would do that.
Mr Ribeiro: The model I was suggesting
to people is that to be employable as consultants it is not good
enough just to have the skills of a doctor, they will have to,
at a point, demonstrate that they have added value to that trust,
because I think in the future what we as colleges have done is
produced a cohort of trainees with a certificate that says, "You
are accredited to practice as a consultant." We have not
armed them with anything else. What I think we now have to be
cognisant of is that we are in a market place now, and trusts
are going to function on the basis of contracts, commissioning,
PBR, all those things which will determine that they have a workforce
to deliver the agenda that they have been given, and I think we
have a responsibility as colleges now to develop that workforce.
Mr Streets: Your question was
broad on content but you fell specifically on medical management.
PMETB has said it will look at what the content and outcomes of
all curricular should be in order that we can look at the core
content, and one of the aspects that we will look at is medical
management. We have specifically indicated this. We think there
are three levels at which this needs to take place. There needs
to be a compulsory component of medical management which is within
the CCT itself for everyone, but also there needs to be the opportunity
for people to pursue medical management as a speciality post CCT,
and, as previous people giving evidence to this Committee have
said, we have encouraged the work of the National Institute for
Innovation and Improvement to look at this specifically, and also
potentially the opportunity for doctors to take time out to do,
for example, an MBA. Having just come from the NHS Confederation
Conference, there is great deal of talk about the need for clinical
engagement and clearly to date one of the issues has been clinical
engagement; but I think it is interesting that the Committee has
not looked at, which for me is one of the major drivers of content
in the future of medical education, at the different kinds of
relationships between patients and professionals as heralded by
things like a patient-led NHS, and if one looks at moves towards
the co-morbidity of patients in the future, older patients requiring
a very different kind of relationship with their doctors, I would
suggest to the Committee that that is perhaps the major change
that we need to look at in medical education and how we get that
right.
Q576 Dr Taylor: "A different
relationship with their doctors"?
Mr Streets: If I can use diabetes,
which is the example I know very well, good diabetes physicians
were moving to a model very much where it is a partnership between
patient and professional making joint decisions around care.
Dr Taylor: Thank you.
Q577 Dr Stoate: According to Mr Ribeiro,
Modernising Medical Careers is going to introduce for,
the first time, this idea of competences in the currency of medical
training. Do you think this will help to improve flexibility of
a consultant's career?
Mr Ribeiro: I think there have
been some who have felt that a trainee who has been proved to
be competent in one particular area, for example taking gall bladders
out, might be able to provide a service to the NHS by doing a
service list of gall bladders. I think you have to see it in context.
The training is the training in the whole, and just ticking a
box to say, "I am competent to do gall bladders", is
not what we are about. Certainly in general surgery we would expect
our trainees to end up being more than just competent to manage
the emergencies; they must be able to be competent in their own
speciality, plus the ability to manage the general emergencies,
and that is a big task because it involves expertise in all the
sub-specialties within general surgery.
Q578 Dr Stoate: I have got an even
bigger question. Given that the role of surgeons if likely to
change very radically over the next ten, 20 years, are we training
the surgeons now with the right competence to be flexible in the
future, given that their role is going to change enormously?
Mr Ribeiro: I have used the expression
that one has to learn to be light on one's feet, and I think that
we all know the dangers that came from Tagamet, the drug that
got rid of ulcer surgery, you will no doubt ask me questions about
cardiac surgery and drugs that get rid of the need for cardiac
surgery. You have got to be light on your feet. If you do not
have a good, broad base to your training, you will be never be
able to reposition yourself into another specialty.
Q579 Dr Stoate: Is the current training
under MMC going to do that or not?
Mr Ribeiro: This is one of the
things that we have done. We have started from a premise that
we were here to try and shorten training and improve training
educationally, and we felt that we could do that and the time-frame
for that was suggested that this could be done in six years, indicative
years. However, the confounding factors of the European Working
Time Directive and all those things made it absolutely clear that
this was not achievable in that time frame, and what we have in
surgery done is insisted that we have a core two years, what we
call a core specialty two years, where these generic foundation
skills and surgery will be learnt. I think it is very, very important
that people do not go straight into their specialty, but that
they do have exposure to other specialties in the first two years
of starting, because they will be coming out of a foundation programme,
many of them, with no exposure to surgery. It is quite possible
to apply for a surgical post, believe it or not, with the way
things are structured, without having done a surgical job other
than your first foundation year.
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