Memorandum by Professor Sir John Tooke
(MMC 61)
MODERNISING MEDICAL CAREERS
I appreciate that the Committee has now completed
its collection of oral evidence but hope that you will admit some
summary written observations in the light of the published transcripts.
1. THE ROLE
OF THE
DOCTOR
Everyone accepts that contemporary healthcare
depends upon a multi professional team approach, with different
professionals bringing particular attributes to the team. Each
professional "cluster" needs particular educational
foundations (in the case of medicine a deep and challenging education
with a strong science base to support the development of clinical
reasoning skills, upon which diagnosis and the capacity to deal
effectively with ambiguity and uncertainty rely).
Notwithstanding the need to develop shared understanding
about roles with the other members of the healthcare team, for
a variety of reasons, listed below, medicine does have to be treated
differently:
Medical education is much more expensive
than that of other healthcare professionals, reflecting the key
requirements of the role.
The length of training cannot be
determined locallyit is set in stone by EU directives.
There cannot be wholesale revision
of curricula to meet perceived local imperatives. The curricula
apply across the UK and have to be approved by external regulators.
Medical trainees subserve other key
national interests being crucial, for example to the biomedical
research that supports UK plc, and are not just NHS service personnel.
The training content and structure needs to be sensitive to such
issues. This aspect does not impinge on the other professions
to anywhere near the same extent.
Whereas the Final Report proposed the creation
of NHS:MEE (reflecting the fact that our remit was medicine) the
Panel supports the concept of NHS Education England, embracing
the needs of the various professional clusters. However the current
crisis in PGMET needs to be urgently resolved, so important is
such training for the future health needs of the population. The
national significance of the medical professional contribution
in a variety of domains makes it imperative that there is national
oversight and scrutiny of PGMET.
2. FOUNDATION
TRAINING
The Inquiry proposed splitting years one and
two of Foundation, principally to ensure UK medical graduates
achieve full registration with the GMC. Failure to guarantee such
status would lead to legal challenge to Universities, would be
a profound injustice to new graduates with tens of thousands of
pounds of debt, and would deter the socio-economically disadvantaged
from applying to study medicine just at the time when medical
schools' widening participation programmes are beginning to achieve
traction.
The Inquiry Panel is yet to see convincing legal
opinion that such protection can be afforded in ways other than
splitting F1 and F2 in an employment sense. Persisting with a
two year Foundation programme will shorten and impact negatively
on core training. Three years of core training is key to flexibility
and future workforce redesignand is necessary to help provide
trainees with adequate time to develop the relevant specialty
experience and skills in the face of EWTD.
Thus from an education and flexible workforce
perspective we strongly urge that a themed "F2" is incorporated
into "core", and split, in an employment sense, from
F1. It is a fragile argument to say the current Foundation programme
has not run long enough to change. All good curricula are responsive
to the required outcomes (ie the health needs to be addressed)
and should be subject to continued review and evolution.
We have already written to you with additional
evidence of strong professional and organisational support for
this move. The only voice of discord was heard from those directly
involved in the current provision, keen to maintain the status
quo.
3. HARNESSING
ACADEMIA
Our Interim Report pointed out the steady erosion
of the Health:Education sector partnership in recent years. Such
partnership was a founding principle of the NHS. Harnessing academia
for the benefit of health is a mechanism adopted by most developed
nations to drive up health care quality and innovation, and is
crucial if the UK is to achieve its stated goal of being a strong
knowledge-based economy.
We suggested a variety of ways in which better
links can be fostered including:
Incentivisation of Trusts to engage
in education and research.
Scrutiny of SHAs regarding the local
academic relationships they have fostered, and the use of PGMET
funds.
Review of the relationship between
Postgraduate Deaneries, Medical Schools and service including
the trialling of graduate schools.
Clear accountability at Trust Board
level for PGMET.
4. NHS:MEE
The consultation response showed that a mere
12 people1.3% of respondeeshad any measure of disagreement
with the suggestion that there should be a "National Institute
for Health Education" (Recommendation 12).
Our belief that such a body is necessary stems
from a fundamental lack of confidence by the medical profession
in the Department of Health's ability to manage the implementation
of changes in PGMET, and the clear need to separate policy from
implementation. Devolution of complete responsibility to SHA level
engenders even less confidence, given the current lack of workforce
planning and commissioning capacity, the lack of labour market
intelligence and the very recent history of education and training
budgets being raided to meet service pressures. The Panel believes
that local ownership and demand led solutions, informed by service
are key to success; nonetheless the national dimension must not
be ignored and without a body such as NHS:MEE to provide scrutiny,
the national interest is at severe risk. Such risk takes a number
of forms:
Lack of integration of the local
with the overall requirement for medical workforce.
Poor provision of subspecialty expertise,
not required in every SHA.
An erosion of an integrated approach
to development of the clinical academic workforce, crucial to
UK plc.
Inequity of specialist service provision,
striking at a fundamental principle of the NHS.
In addition NHS MEE would address the following
deficiencies identified by the Inquiry:
Provide coherent professional advice
on PGMET to policy makers.
Develop and act as the guardian of
the principles underpinning PGMET and the evolving role of the
doctor.
Integrate curricula requirements
(service and professional viewpoints) and interface with the Regulator.
Scrutinise the allocation of PGMET
resources both centrally and at SHA level.
Act as the commissioning agent for
certain small volume, highly specialised areas of medicine.
Act as the point of reference in
England to facilitate UK-wide collaboration on matters relating
to PGMET.
In any complex system transition imposes risk.
The Health Select Committee revealed deficient central workforce
planning. We believe the transition to demand led, local input
should be managed over a number of years during which time, adequate
local labour market intelligence is developed, central agreement
on professional roles is secured and new PGMET structures become
embedded.
5. SUPPORT
We have recently sent evidence to the Committee
regarding the degree of support for the Inquiry's final recommendations.
We should emphasise the overwhelming support for all our Recommendations
from the medical profession. Even where some Postgraduate Deans
and Foundation School Directors naturally feel unable to support
us, the vast majority of the profession, including the trainees,
wish to see full implementation. We owe it to tomorrow's doctorsand
to the nationto harness their aspirations. It is the profound
expectation of the medical profession that the Inquiry's recommendations
will be adopted in full. Such a response would maximise engagement
in resolving the difficult challenges ahead, which is in the best
interest of patients.
Professor Sir John Tooke
Chair
MMC Inquiry
21 February 2008
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