House of Commons - Education, training and workforce planning

Education, training and workforce planning - Health Committee Contents

3 Organisation of education, training and workforce planning

The Secretary of State

86. The Government made clear in Equity and Excellence (July 2010) that "In future, the Department will have a progressively reducing role in overseeing education and training."[120] This was elaborated on as follows in Developing the Healthcare Workforce (December 2010):

The role of the Department of Health is changing fundamentally. The forthcoming Health Bill will formalise the relationship between the Department and the NHS, to improve transparency and increase stability while maintaining appropriate accountability. In future it will have progressively less direct involvement in planning and development of the healthcare workforce, except for the public health services.[121]

At the same time, the consultation document also envisaged that the Secretary of State would have a role in holding to account HEE as regards "mid- to long-term system viability", and meeting national workforce needs and strategic commissioning intentions.[122]

87. In its response to the Future Forum in June 2011, the Government promised that "To reinforce its importance, we will introduce an explicit duty for the Secretary of State to maintain a system for professional education and training as part of the comprehensive health service."[123] The Health and Social Care Bill was amended accordingly.[124]

88. The response to the Future Forum also announced that the DH would "develop a national education and training outcomes framework, setting out the outcomes that HEE would expect providers to meet".[125] In evidence to us, the Department indicated that this would provide "metrics and indicators" to allow HEE to hold providers to account;[126] but it was not made clear or explicit what role the Outcomes Framework would play in the Secretary of State holding HEE to account. Ms Outram, the Senior Responsible Officer for HEE, told us that HEE would be "accountable to the Secretary of State" through "a mandate—an agreement—with the Department that will be reviewed, over time, to deliver certain things."[127]

89. The Department subsequently affirmed, in From Design to Delivery (January 2012), that "The education and training system will remain accountable to the Secretary of State." He "already has broad powers for education and training" and his new statutory duty in this regard was "not to grant new powers to intervene." Rather, the "aim is to ensure the new education and training system is set up to deliver a greater level of local accountability and responsibility for decision-making: a system that aspires to excellence and supports the values of the NHS."[128] HEE would be "accountable to the Secretary of State" from the outset and would remain so.[129]

90. Regarding the Education Outcomes Framework, the Secretary of State's own introduction to From Design to Delivery explained that this:

will directly link education and learning to improvements in patient outcomes. By providing a clear line of sight and improvement to patient outcomes, it will help address variation in standards and ensure excellence in innovation through high quality education and training.[130]

The document itself further explained:

Working with employers, clinicians and education providers, the Department, LETBs and HEE will develop a suite of metrics so that the system can demonstrate at all levels education quality outcomes as they impact on patient experience, care and safety.[131]

Outcomes would be organised into the five following "key domains":[132]

Excellent education;
Competent and capable staff;
Adaptable and flexible workforce;
NHS values and behaviours, and
Widening participation.

Conclusions and recommendations

91. We welcome the inclusion in the Health and Social Care Act 2012 of an explicit duty on the Secretary of State to secure an effective system of education and training. However we are concerned that there continues to be insufficient clarity about how the Secretary of State intends to discharge this duty. In particular, we seek reassurance that the Secretary of State shares our view that the effectiveness of the new system will be fatally undermined if it is not built upon a more accountable and transparent system of workforce planning.

92. We also welcome the fact that the Secretary of State will have a clear responsibility for holding to account Health Education England. The Department must, though, spell out how exactly this will be done—including the part that the planned Education Outcomes Framework will play.

Health Education England

93. In Professor Tooke's 2008 report on postgraduate medical education and training, Aspiring to Excellence, he recommended the creation of a new national body, NHS Medical Education England (NHS:MEE). This was intended to act as a single overarching education, training and workforce planning body for this section of the workforce, with control of a ring-fenced budget and engagement from the medical profession.[133]

94. Later the same year, in A High Quality Workforce, it was announced that an independent body, to be called just MEE, would be created—but it would only be advisory in nature, without control of budgets. In addition, its remit would extend beyond doctors to include dentists, healthcare scientists, pharmacists and low-volume specialties.[134] MEE was established on this basis in 2009 as an Advisory Non-Departmental Public Body (NDPB), with engagement from the professions facilitated through four separate Programme Boards for doctors, dentists, healthcare scientists and pharmacists. Similar Professional Advisory Boards (PABs), sitting outside MEE, were subsequently set up: the Nursing and Midwifery PAB, and the National Allied Health Professional Advisory Board (AHP-PAB).

95. In its original "vision" for NHS education and training, in Equity and Excellence (July 2010), the Coalition Government envisaged that:

Education commissioning will be led locally and nationally by the healthcare professions, through Medical Education England for doctors, dentists, healthcare scientists and pharmacists. Similar mechanisms will be put in place for nurses and midwives and the allied health professions.[135]

However, in Developing the Healthcare Workforce (December 2010) it was proposed to create a new body, with executive powers, which would supersede both MEE and the PABs—namely HEE. It was explained that HEE would be "a lean and expert organisation, free from day-to-day political interference"[136] and that its role would mirror that of the NHS Commissioning Board in relation to commissioning healthcare services, in that it would perform functions that could only be undertaken at the national level. It would "have national oversight of education and training, whilst leaving healthcare providers with a high level of autonomy"; and it would "work with the Department of Health to address the planning and development of the public health workforce".[137]

96. The need, in HEE's relationship with the skills networks (as LETBs were then being called), to achieve "the right balance of strategic oversight, whilst giving healthcare providers greater freedom for education commissioning" was noted.[138] HEE might need to commission at the national level education "for smaller professional groups, for example for healthcare scientists"; and where national priorities might have to override the aggregate of local plans, this "would need to be an evidence-based, fair and transparent process".[139] In discharging these responsibilities, HEE would be accountable to the Secretary of State for:

mid- to long-term system viability and ensuring that at a national level there are sufficient future healthcare professionals with the right skills and training to meet future healthcare needs and respond to national strategic commissioning intentions[.][140]

97. The timetable set out by the Government at this stage envisaged HEE becoming "established in shadow form in 2011 and as a special health authority to go live in April 2012, with the issue of its longer-term form being "revisited after April 2012".[141] As it turned out, however, matters proved rather more long drawn-out than this.

98. In June 2011 the DH put back to April 2013 the date at which HEE would become operational—in line with the decision to delay the abolition of Strategic Health Authorities (SHAs) to that date. At the same time, it promised to "ensure that HEE is in place quickly",[142] as a Special Health Authority "in shadow form, without full functions", during 2012.[143]

99. In July 2011 Sir David Nicholson announced that a Senior Responsible Officer for HEE would be appointed, to accelerate the process for setting up the new body. In October 2011 the appointment of Ms Outram to this post (in combination with her existing post of Chief Executive of MEE) was announced.[144]

100. In autumn 2011 the Government promised that draft primary legislation "to support the continuing development of the education and training system, including establishing Health Education England as a non-departmental public body" would be brought forward for pre-legislative scrutiny in the new Parliamentary session, beginning in 2012.[145]

101. When we took evidence from the DH in November 2011, Mr Rentoul explained that HEE would establish "national leadership and focus […] rather than having a set of functions sitting betwixt the Department of Health and strategic health authorities"[146] By encompassing all healthcare professions and controlling funding (unlike MEE), HEE would provide "grit in the system in terms of outcomes achieved".[147]

102. We heard in addition from Ms Outram, as the person "leading on the set-up of [HEE]".[148] She explained the sort of functions that would have to be undertaken by HEE at the national level. These included commissioning for "very small specialties, for example, where branches of some of the professions need very few people—types of medicine where you might need about 10 people across the country". Another example was "the recruitment of junior doctors for the different specialty training paths", where "There is an understanding that, to get that planning right, you need to take a national view".[149] HEE's relationships with the NHS Commissioning Board and Public Health England (the planned new dedicated national public health service) would be "particularly important".[150]

103. Ms Outram also told us about her intention "to ensure a smooth transition" of the functions of the Programme Boards and PABs into HEE.[151] We further heard about transitional arrangements from Kate Lampard, the Chair of the HEE Steering Group, which she explained was designed to "get the involvement and the perspective of a wide group of stakeholders" as early as possible. The group would:

be providing the leadership to ensure that we set up the new system, the new architecture, appropriately, so that it takes account of the views of the stakeholders, and to offer support, encouragement and challenge to the staff as they set up Health Education England. In due course, we will hand over, to a formal board, Health Education England.[152]

104. Subsequently, in From Design to Delivery (January 2012), the Department stated that HEE would now "be established as a Special Health Authority (SpHA) in June 2012, taking on some functions in October 2012 and ready to take on full operational functions from April 2013."[153] It confirmed that establishment as an NDPB would happen after pre-legislative scrutiny in the coming Parliamentary session (2012-13) and legislation "as soon as Parliamentary time allows".[154] (The website for HEE now states that it will be established in July 2012.)[155]

105. The key national functions for HEE were recast as follows:

providing national leadership on planning and developing the healthcare and public health workforce;
authorising and supporting the development of LETBs;
promoting high quality education and training responsive to the changing needs of patients and local communities […];
allocating and accounting for NHS education and training resources and the outcomes achieved; and
ensuring the security of supply of the professionally qualified clinical workforce.[156]

An annually updated Strategic Education Operating Framework for HEE would "set out the medium and long-term context for the development of the health and public health workforce".[157]

106. We heard in evidence from NHS Employers the view that "HEE must be employer led and patient focused."[158] Mr Royles, of NHS Employers, explained to us that, since HEE was being set up over employer-led LETBs:

we need employer representation, employer led, with Health Education England so that if there are disputes, conflicts or issues people have trust in that system. That might be about bringing people into Health Education England who have particular expertise in this area and who also happen to be employers and, maybe, medical directors, nursing directors, HR directors and chief executives.[159]

However, the Minister did not recognise this conception of HEE when we asked him about it.[160] Mr Rentoul of the DH explained to us that HEE needed to carry not just the confidence of employers but also of "the education sector, professionals, patients, the commissioning system and, indeed, regulators […] This is about bringing together a range of different perspectives and making the system work effectively."[161]

107. Evidence that we received from COPMeD in February 2012 raised the concern that there would not be sufficient time in the new Parliamentary session to legislate in relation to HEE, as the Government intends. COPMeD proposed that clauses be added to the Health and Social Care Bill, setting out principles to which HEE must be obliged to adhere in relation to: national workforce planning; ring-fenced funding of education and training; independent quality management and assurance of education and training; and national standards for delivery and outcome, particularly in respect of medical education.[162]

108. The Government's reform proposals entail shifting at the national level from a body oriented towards certain professional groups (MEE) to one whose remit covers the entire healthcare workforce (HEE). This will bring the NHS in England into line with a number of other developed countries where a multi-professional approach to healthcare education, training and workforce planning is already well established. One such country is Scotland, where an equivalent body to HEE, NHS Education for Scotland, was established as long ago as 2002. We heard several times in evidence positive comments about the role of NHS Education for Scotland and its potential to serve as a model for HEE.[163]

109. In Developing the Healthcare Workforce (December 2010) the DH promised to consult with the devolved administrations "to ensure a UK-wide approach to […] workforce strategy within the new framework, where this is relevant".[164] We heard in written evidence from the Royal College of Surgeons of Edinburgh about the extent to which the wider workforce "moves freely from country to country within the United Kingdom".[165] When we took oral evidence from Ms Outram, the Senior Responsible Officer for HEE, in November 2011 she explained the UK aspect of HEE's role as it affected workforce planning:

I do not think HEE has to take a UK view, but it has to bear in mind that the labour force it is working with—the market it is operating in—is UK wide. For example, if it was to cut the number of healthcare scientists it was training, in my opinion, it should not do that without discussing it with the devolved Administrations.[166]

Mr Rentoul, of the DH, added that diminishing numbers of doctors trained in Scotland would have "a potential impact on England" and noted the need for an "exchange of information so that we each understand what is going on".[167] This point was elaborated for us by Professor Edwards, of MEE, who told us that "a UK wide perspective" was "absolutely vital".[168]

110. When we heard evidence from Professor Tooke, of UCL, he stressed the importance of "a central view and central intelligence […] to ensure that, for certain specialties, a national UK wide provision is protected."[169]

111. In From Design to Delivery (January 2012) the DH cited one of the underlying "design principles" for the new system as "supporting the development of the whole workforce, within a […] UK-wide context".[170] It reiterated that "HEE will work with the professional regulators and the authorities in other parts of the UK to ensure a UK wide approach to […] workforce strategy.[171]

Conclusions and recommendations

112. We welcome the plan to set up Health Education England as an executive body with overall responsibility for education, training and workforce planning, drawing input from all healthcare professions and other stakeholders. The creation of such a body is long overdue and has the potential to be a significant step forward.

113. However, we are concerned, given the centrality of this body to the Government's plans, that the Government has been slow in developing a coherent plan for the new organization. It is being set up in shadow form in July 2012 and will be fully operational in April 2013. There is an urgent requirement for the Government to publish a clear and detailed execution timetable.

114. In the absence of this timetable there continues to be a lack of clarity about the role, responsibilities, powers and structure of Health Education England. Fears have been expressed to us that Health Education England, growing out of Medical Education England, could be predominantly focused on the medical workforce, despite its multi-professional remit. The Government must show that it is addressing and allaying these fears.

115. Greater clarity is particularly needed about how Health Education England plans to ensure that it develops a dynamic view of the changing education requirements of the whole health and care sector.

116. Greater clarity is also needed regarding the role of Health Education England in relation to the professional regulators and to its counterpart organisations in other UK countries.

117. The Government has acknowledged the need to take account of the UK-wide dimension of education, training and workforce-planning policy. However, in that context we are concerned that there must be adequate emphasis on workforce planning in particular.

Local Education and Training Boards

STATUS, COMPOSITION, GOVERNANCE AND SIZE

118. The Government's view of the status, composition and size of LETBs changed significantly between July 2010 and January 2012. In July 2010 the Government indicated that, in future, "healthcare employers and their staff" would be responsible for deciding on plans and funding for education and training.[172]

119. In From Design to Delivery (January 2012), the DH was more prescriptive; it defined LETBs' purpose as being to:

Identify and agree local priorities for education and training to ensure security of supply of the skills and people providing health and public health services;
Plan and commission education and training on behalf of the local health community in the interests of sustainable, high quality service provision and health improvement;
Be a forum for developing the whole health and public health workforce.[173]

On this basis, a series of "core functions" for LETBs was set out.

120. Membership arrangements for LETBs "should provide fair representation across the range of healthcare and public health employers, including acute, mental health and community services, primary care and local government."[174] There would be a requirement to have "a formal, decision-making Board accountable to HEE that derives its membership from the full range of healthcare and public health providers so that all types of healthcare provider are fairly and proportionately represented."[175]

121. The size of LETBs was "a matter for local decision", but the DH suggested "a scale of enterprise not too dissimilar to the range of current [postgraduate medical] deaneries [which are organised at regional level]".[176] The Department would "establish the legal form for LETBs when we set up HEE".[177] LETBs would be established in the first instance, by April 2012, as Education and Training Sub-Committees within SHAs (now gathered together into supra-regional clusters, ahead of their planned abolition in April 2013). These would then become "precursor LETBs" (subject to authorisation by HEE) in April 2013.[178] It was further stated that "While the new NHS and public health system is taking shape and maturing the LETBs will be hosted by HEE from April 2013."[179]

122. Broad authorisation criteria were set out. LETBs would have to show "Proper constitutional and governance arrangements to manage competing interests, and allow secure exchange of commercially sensitive workforce information", but no indication was given of what these should be. LETBs would have to make provision for "Fair representation of local healthcare and public health employers, across sectors and including community and primary care employers, and private, voluntary and independent sector employers". As regards "the education sector and local government", they would only be required to have "Meaningful partnerships and engagement".[180]

123. Although the Government's views about LETBs have developed, their status and role continues to be the subject of considerable uncertainty. According to the DH, "Determining the detailed authorisation criteria, the accountability framework for allocating […] funding and establishing the authorisation process" for LETBs would all be "critical actions for HEE in its first year."[181]

124. When we took evidence from members of the Future Forum shortly after the publication of From Design to Delivery, they informed us that each LETB was now to have the status of "an outpost of HEE".[182] In the Forum's January 2012 report it noted there was "major support for common terms of reference and a single model for LETBs to promote consistency across the country".[183]

125. When we took further evidence from Mr Rentoul, of the DH, in March 2012, he developed this thought as follows:

The Local Education and Training Boards will be committees of Health Education England. Health Education England, subject to parliamentary approval, will be set up as a special health authority. The Local Education and Training Boards will be sub committees of that special health authority with formal schemes of delegation for what they are being asked to do.[184]

He explained that, in the DH's original plans, LETBs had been envisaged as "being autonomous bodies, whether statutory or hosted by another NHS body"; on that basis, a contractual relationship between HEE and the LETBs had been considered. However, now it was intended that LETB staff would be directly employed by HEE; and LETBs' relationship with HEE would be "more of a service level agreement and a formal scheme of delegation."[185] LETBs would be "formal sub committees of HEE with the level of delegation reflecting the authorisation process, again, with the intention of more delegated, devolved decision making."[186]

126. On the number of LETBs, Mr Rentoul reiterated the estimate he had previously given us ("something like 10 to 15 as a kind of estimate").[187] When this was qualified by the Minister ("The estimate is 12 to 16"), Mr Rentoul added: "There is quite a lot of active discussion locally on what they see as the right footprint, relationships, scale and leadership capability for them, and so on."[188]

127. The emergence of LETBs at the regional level has led to talk of the possibility of more localised "sub-LETBs".[189] Mr Royles, of NHS Employers, emphasised the need for local discretion for LETBs to "configure themselves to deliver for their local organisations and the patients in those areas". He explained that:

With the idea of a labour market in somewhere like South Yorkshire, for example, or places in the north west around Greater Manchester, where they share a variety of different higher education institutions, it makes perfect sense that that is where that relationship is carried out.[190]

128. As regards the membership of LETBs, the Minister told us:

They will derive their board membership from a range of healthcare and public health providers, so that all types of healthcare are included and their views can be considered. What the board will also have is representation from local education providers who will agree in the developing of local public health workforce and research, as well as local government […] They will set up advisory arrangements to reflect the breadth of local interest and ensure that the decisions that are taken are reflective of the needs of local communities.[191]

Mr Rentoul added that:

A number of them—[…] in their current development stage—have a board, which may be 12 to 15, but also a wider partnership council that involves the wider range of stakeholders, to make sure the range of interests is represented.[192]

129. The level of detail that is starting to emerge about the composition of LETBs does appear to be assuaging some concerns which had previously been expressed. This was apparent from evidence that we took from Dr Dolphin, of the BMA, in February 2012:

One of the concerns we had originally was that the LETBs looked like they were going to be too employer-dominated—too heavy on the employer side. The proposition that is currently on the table is a lot better in the balance that it achieves.[193]

130. However, significant unease continues to be expressed by higher-education bodies about the role that they will play in LETBs. Supplementary evidence that we received from million+ (a university think tank) in March 2012 reiterates the fear that "LETBs may include a majority—and possibly a monopoly of healthcare providers." On this basis, the organisation fears that there will be an overriding concern with "immediate or short-term workforce requirements" to the exclusion of considerations such as clinical academic workforce needs. Furthermore, there is a fear that "the LETBs will be dominated by the needs of acute providers" in particular. million+ also draws attention to what it sees as the potential for conflicts of interest to occur, with, for instance, "NHS providers in receipt of CPD funding […] able to award CPD training contracts to themselves^".[194]

131. There are also still issues concerning the involvement in, and representation on, LETBs of non-NHS providers, non-acute NHS providers (including GPs), and social-care commissioners and providers. We heard from Ms Taber, of Independent Healthcare Advisory Services, that involvement of the independent sector in a LETB was being piloted with the Midlands and East SHA cluster. Ms Taber felt "There must be, almost, a mandate for all the LETBs to have an independent sector representative on them."[195] She also told us that "The management of [the Midlands and East] LETB is going through Skills for Care to involve the social care side. There is a huge workforce out there that is not involved."[196] Mr Worskett, of the NHS Partners Network, noted the lack of any guarantee as regards LETBs engaging with the independent sector. He feared a replication of the current situation in respect of postgraduate medical deaneries, where independent-sector involvement had been "patchy".[197]

132. In written evidence in December 2011 the Royal College of General Practitioners told us it was "concerned that the new system may be dominated by secondary care providers such as Foundation Trusts". It contended that "Whilst GP-employed staff only account for 10% of the NHS workforce […], the College believes that as a minimum GP provider representation on LETBs should be in excess of 10%". This was because of: the complexity of general practice (with large numbers of heterogeneous providers); the fact that GP provision accounted for a disproportionate number of patient contacts in the NHS (90 per cent); and the fact that GPs were almost as numerous as hospital consultants.[198] However, the DH still has yet to set out what the arrangements will be for the representation of GPs on LETBs—beyond saying that primary care providers will (like all others) be "fairly and proportionately represented".[199]

Conclusions and recommendations

133. We welcome the Government's plan to create Local Education and Training Boards as provider-led bodies to take responsibility for education, training and workforce planning below the national level. We are concerned, however, at the Government's protracted failure to produce concrete plans in respect of the Boards, which poses a significant risk to their successful establishment.

134. Between July 2010 and January 2012 the Boards were conceived of as loosely defined non-statutory "legal entities", to be developed at local level. The Government has now concluded that they should be "outposts" of Health Education England. There is, however, still little central guidance about the requirements for authorization, despite the recommendation of the NHS Future Forum that there should be "common terms of reference and a single model […] to promote consistency across the country".

135. It is unsatisfactory that so much about the Boards still remains vague and indeterminate. Crucially, the precise extent of their autonomy, and the means by which they will be authorised and held accountable, are still worryingly opaque. This must be spelled out as a matter of urgency.

136. We welcome the Government's guidance that Local Education and Training Boards should be comprehensive bodies, not restricted to healthcare providers. However, concerns remain among higher-education institutions that their viewpoint will not be adequately heard. The Government should provide a definitive list of stakeholders which should be represented, as well as providing greater clarity on other aspects of governance—not least how potential conflicts of interest are to be addressed.

137. We are also concerned that the geographical basis of Local Education and Training Boards remains obscure. Evidence submitted to us that there will be "10 to 15" (or alternatively "12 to 16") calls into question their ability to reflect local conditions. There is a definite need for structures at the level of local health economies and the Department must make clear how these are to be facilitated.

POSTGRADUATE DEANERIES

138. Postgraduate medical deaneries, which are currently incorporated into the SHAs, have a crucial set of responsibilities. They oversee the quality of postgraduate medical education for all those who have completed their first year of (post-qualification) vocational training. They commission and manage the delivery of postgraduate education for all doctors in training, across all grades, specialties and modes of training. They ensure the availability of sufficient training places to meet the NHS's future needs and that recruitment to training places is rigorous and fair. Lastly, they advise SHAs on the distribution of funding for postgraduate training to providers (NHS Trusts, FTs and training GP practices) under Learning Development Agreements.

139. Deaneries liaise with the medical Royal Colleges and their Faculties. They also liaise with, and are accountable to, the GMC. At the national level, deaneries work together through COPMeD to ensure high standards and their consistent application throughout the UK. The Director of Medical Education for England at the DH (who reports to the NHS Medical Director) provides national professional leadership for the deans.

140. In Developing the Healthcare Workforce (2010) the DH indicated that the planned skills networks (i.e. LETBs) would take on the "functions" of the deaneries, as part of a multi-professional approach to postgraduate education and training.[200] However, nothing more was said about what the fate of the deaneries would be, leading to considerable anxiety on this score.

141. In November 2011, when we took evidence from the current Director of Medical Education at the DH, Dr Hamilton, we asked her about the future of the deaneries. She told us:

They are very important and their function is essential. We have done a lot to assure their continuation during transition and the intention is that they continue beyond transition with, probably, many of the same staff. We have to talk about functions rather than individuals, but those functions will continue into the new system architecture.[201]

142. She also said that "Deans and deaneries […] have an important role to play" and would be accountable to HEE in the new system.[202] Deaneries would "move out of the SHA aegis at the end of March 2013 and into the new system architecture", at that time becoming "truly multi-professional". There would also be "obvious economies of scale and economies to be made in back office functions being shared and so on" when the deaneries became part of the LETBs.[203] Within the LETBs, "The dean should be part of the board, because it is crucial that they represent the quality of education and training".[204]

143. Other evidence that we took in the autumn of 2011 reflected continuing anxiety about the future of the deaneries. Professor Sowden, of COPMeD, told us that the deaneries had to continue:

because they fulfil such an essential function at the moment. If they were not there, you would only have to reinvent them. Some countries around the world are in the process of inventing postgraduate deaneries by another name because they have had problems with systems that do not have postgraduate deaneries in them.[205]

He indicated that haemorrhaging of experienced staff was continuing. There was a:

huge gap with people thinking, "What are we going to do?" These people are a scarce resource. Other people want them. Some of them are going off into the private sector and elsewhere. It will be almost impossible to get their like again for several years because we have struggled with that skill set over the last decade or two.[206]

144. Sir Peter Rubin, of the GMC, explained why the specific role of postgraduate dean needed to continue:

The key thing is holding somebody, not a nebulous committee but a named person—nailing a named person—to account for the quality of postgraduate medical education in their area. That needs to be the postgraduate dean. The postgraduate dean needs to have the levers necessary to produce change when change is needed and those levers will usually be financial levers.[207]

145. In From Design to Delivery the DH stated that LETBs would need to "operate on sufficient scale to offer a safe transition for the enduring workforce functions of SHAs, including the deaneries". It was in consequence of this that "a scale of enterprise not too dissimilar to the range of current deaneries" was suggested for LETBs.[208] Their "executive structure and operational arrangements" would need to "ensure enduring deanery functions".[209] It was reaffirmed that deans and deaneries would provide "operational management" and "continuity" in their areas of responsibility during the transition period (up to April 2013).[210] The "principles of the Human Resources Transition Framework agreed to underpin the wider [NHS] system reforms" would apply to education and training staff in SHA clusters, which would support LETBs in retaining the skills of current staff, including those in deaneries.[211]

146. The Department also stated that LETBs would:

need to appoint a Director of Education and Quality, or equivalent position, to be accountable to the Board for the effective quality management of education and training programmes commissioned or provided by the LETB. The Director of Education and Quality may also be the Postgraduate Medical Dean.[212]

The "function" of postgraduate dean was described as "key" and "essential"; and it was stated that "There must be a Senior Responsible Officer (SRO) role for junior doctors"[213]—which position could be held by the Director of Education and Quality. Occupants of these roles must be accountable to HEE for "professional education leadership".[214]

147. When we took evidence from members of the NHS Future Forum in January 2012, Dame Julie Moore emphasised "the importance of not losing expertise and experience". She argued that "If the [Director of Education and Quality] is not the postgraduate dean, then there must be medical representation on that [LETB] board."[215]

148. Another Forum member, Professor Tooke, thought it was important to ensure "that the postgraduate deanery function is informed by educational expertise that resides within our universities".[216] He thought the new system would help address the fact that the deanery function had become "divorced from higher education". We were "the only system in the developed world that has done that and, I would suggest, at a cost, so that we are not linking in educational expertise with the training of that important professional group [i.e. doctors]".[217]

149. Professor Tooke's Future Forum colleague Dr Nightingale, of the Royal College of Anaesthetists, wanted the Royal Colleges to be more involved in controlling the quality of training, "as opposed to the GMC working with the old deanery function".[218] (This appears, however, to run counter to the second Future Forum report, which seemed to suggest that the extent of the Royal Colleges' role was a factor in the system being overly complex.)[219]

150. The issue of how consistent national (i.e. UK) standards will be maintained across deaneries seems still to be contentious. Written evidence that we received from COPMeD in February 2012 argued that From Design to Delivery "does not provide sufficient assurance on this topic". There seemed to COPMeD to be "a genuine risk that local variation could be permitted at a level which might undermine national standards, and it is unclear to COPMeD as to how Colleges and Faculties will input into either national or local arrangements". Also, the interface between HEE and the GMC in this regard seemed uncertain.[220]

151. COPMeD had additional concerns about "the necessary independence of quality management and assurance functions, particularly at the level of the LETBs with regard to PG [postgraduate] Deans and Deaneries". It suggested "that more work needs to be done on this aspect of the proposed arrangements, ensuring that there is greater independent professional input from both PG Deans and specialties".[221]

152. When we took evidence in February 2012 from Dr Dolphin, of the BMA, he told us that the Association would prefer deans to be employed by HEE and seconded to LETBs, as that would allow the deans:

to remain independent with regard to enforcing the quality of training. They would be able to act without fear or favour when they go to the different employers, without having to worry that their employment status might affect their judgment.[222]

It actually appears from what we later heard from the Department that this will be the case, as all LETB staff are to be employed by HEE.[223] Moreover, in the same evidence session, Dr Hamilton told us that the need for an independent challenge to the quality of medical training made it "very important to preserve the function of the deans":

We would expect the LETBs to be able to demonstrate that the dean can act independently of the conflicts of interest that may arise, particularly with service and training, in making sure the quality of training is preserved and not sacrificed to service and yet not compromising service either so we get that balance right.[224]

She reiterated several times the important role that the deans and deaneries were envisaged as playing in the new system within LETBs, both in respect of medical training and in their intended new multi-disciplinary role.[225]

153. The Government's intention that all the deaneries will become "truly multi-professional"[226] within the new system is a significant policy innovation. Professor Sowden, of COPMeD, was confident that this could be achieved—provided that existing expertise could be retained:

The multi-professional bit is not difficult. It requires a different mindset and approach, but it is perfectly possible to achieve. We need to ensure that we secure the expertise we have within the system at the moment. Within a multi professional deanery setting, that will be the existing postgraduate deanery staff together with those people in strategic health authorities who run education commissioning—so they are commissioning for the other healthcare professional groups—and workforce planning and development. Without those two bits together, you cannot create a multi-professional deanery.[227]

154. Some deaneries are in fact already operating on a multi-professional basis. One example is the East of England Multi-Professional Deanery. Another was the former Trent Multiprofessional Deanery, which merged in 2007 with the Leicestershire, Northamptonshire and Rutland Healthcare Workforce Deanery to form the East Midlands Healthcare Workforce Deanery.[228] The new East Midlands Deanery was initially constituted on a multi-professional basis too,[229] but Professor Sowden, who was himself the Dean, told us that it had actually reverted to being only a medical deanery.[230]He explained in subsequent written evidence that this had come about as a result of the requirement to effect a purchaser / provider split in respect of deaneries. The multi-professional education and training functions of his deanery were transferred to the SHA Workforce Directorate, as part of the commissioning role, leaving Professor Sowden with a postgraduate medical deanery constituted as a provider unit.[231]

Conclusions and recommendations

155. The integration of the postgraduate deaneries into the new system will be crucial to its success. We regret the fact that the Government allowed uncertainty about the future position of the deaneries to persist for so long. Although there is now greater clarity of intention, the period of uncertainty led to a regrettable loss of experienced staff.

156. There continues to be an urgent need for more precision about how the deaneries will operate in future. The distinct position of postgraduate dean should continue to exist to provide an independent professional voice. There needs to be greater clarity about relationships with the General Medical Council, the Director of Medical Education and Health Education England. Finally, there must be a convincing plan to realise the Government's stated aspiration for deaneries to become "truly multi-professional" in their new role.

INNOVATION BODIES

157. In From Design to Delivery (January 2012) the DH stated that LETBs would need to "build alliances with" Health Innovation and Education Clusters (HIECs), Academic Health Science Centres (AHSCs) and Academic Health Science Networks (AHSNs) "to promote research and innovation, benchmarking and co-ordinating approaches to improve workforce productivity".[232] LETB Boards would have to work with AHSNs in respect of the public health workforce; and "work with and be advised by academic health science systems so that local decisions are informed by the latest research and thinking about innovation and entrepreneurship".[233] Boards would also need to "take account of the developing AHSNs to ensure the synergies in embedding research and innovation can be realised".[234] LETBs would:

be key partners in promoting and ensuring integration of innovation and leading practice in both training and service delivery in line with the precepts set out in the recent report Innovation, Health and Wealth. Further work is needed on the best alignment and mechanisms for collaboration with the Academic Health Science Networks as they evolve.

Existing structures that could "facilitate this interface during transition" included the National Institute for Health Research (NIHR), AHSCs / Academic Health Science Systems, Clinical Networks, Clinical Senates, Clinical Research Networks and HIECs.[235]

158. When we questioned Professor Tooke about the relationship between the various bodies in the NHS "innovation landscape" he told us he saw it "quite simply". The five existing AHSCs were "major centres of biomedical science expertise and have a diffusion mechanism to translate research into practice". The AHSNs would take on the diffusion role, which needed to be undertaken throughout the country at regional level. At the same time, some AHSNs would be "doing substantive amounts of biomedical research and they may qualify for academic health science centre status in the future.^{"
Overall, though, he envisaged "}a model of a relatively small number of globally competitive AHSCs and then a regional panoply of networks that is a diffusion vehicle for the NHS.^"[236]

159. Dame Julie Moore emphasised to us the Future Forum's view that there needed to be geographical coterminosity of education and academic research.[237] (In its January 2012 report the Future Forum referred to the "number of players in the system" generally as a complicating factor.)[238] We heard similarly in written evidence from Ed Macalister-Smith, the Interim Independent Chair of the shadow LETB for NHS South Central (South of England). He saw the need for the roll-out of AHSNs:

to be accompanied by a de-cluttering of related and overlapping organisational structures, in a process that needs to be led preferably at [Chief Executive Officer] (or Executive Director) level in every provider organisation. The geographic footprints of LETBs could usefully be co-terminous with AHSNs, and could incorporate HIECs and [Collaborations for Leadership in Applied Health Research and Care].

At the same time, there was a need to avoid rationalisation leading to the stifling of local initiatives, take-over by particular sectors (e.g. universities, FTs or particular professions) or bureaucratisation.[239]

Conclusions and recommendations

160. We welcome the Department's intention to continue within the new system the work done in recent years—through the Health Innovation and Education Clusters and Academic Health Science Centres—to link innovation with education and training. We also welcome the intention to build on this through the creation of Academic Health Science Networks. However, there is a risk, through creating a yet more complicated landscape of Boards, Clusters, Centres / Systems, Networks and Collaborations, that the resulting arrangements could be incoherent and ineffective. The Department must develop a plan to rationalise these bodies and structures, to bring about as much de-cluttering and geographical coterminosity as possible without limiting local initiative and creativity.

161. The same point applies to the planned new education, training and workforce planning system as a whole. The NHS Future Forum has rightly referred to the "number of players in the system" as a complicating factor. Nothing we have heard suggests that the new arrangements will be any less overpopulated with stakeholders, sometimes with overlapping or unclear responsibilities. If this is not addressed, it will be a serious shortcoming in the Government's reforms.

120 Department of Health, Equity and Excellence: Liberating the NHS, Cm 7881, July 2010, para 4.33 Back

121 Department of Health, Developing the Healthcare Workforce - A consultation on proposals, December 2010, para 1.8, cf. para 1.4 Back

122 Ibid., para 6.8 Back

123 Department of Health, Government response to the NHS Future Forum report, Cm 8113, June 2011, para 6.1 Back

124 Health and Social Care Act 2012, section 7 Back

125 Department of Health, Cm 8113, June 2011, para. 6.18 Back

126 Qq 457, 519 Back

127 Q 59 Back

128 Department of Health, From Design to Delivery, January 2012, para 6 Back

129 Ibid., paras 37, 47 Back

130 Ibid., p 5 Back

131 Ibid., para 14 Back