Health CommitteeWritten evidence from Professor David Black, Sir David Melville and Mr Duncan Selbie (ETWP 04)

EXPERIENCE OF A SUCCESSFUL INNOVATIVE MODEL OF POSTGRADUATE MEDICAL EDUCATION DELIVERY

1. Summary

1.1 This paper sets out a straightforward and cost effective model that has been developed in the south east coast for the organisation of postgraduate medical education.

1.2 It argues that a postgraduate deanery is a comprehensive provider of postgraduate medical education in the same way that an undergraduate medical school does the same job for undergraduate medicine.

1.3 Medicine should be nationally commissioned with opportunities to develop important inter-professional training issues at a regional level.

1.4 It is possible to put in place a nearly virtual board to oversee the education functions and as a model suggest that Local Education and Training Boards should be nearly virtual in operation.

1.5 It demonstrates that it is possible to have a hosting arrangement which allows the deanery to continue working equitably across the whole geographical patch.

1.6 The Postgraduate Deans in England should be primarily managerially accountable to the Director of Medical Education (England).

2. How is medical education structured?

2.1 The Royal Colleges write the curriculum for each medical specialty. The curriculum contains the syllabus (what has to be learnt), the way the syllabus will be taught and how it will be assessed. The writing of a curriculum is a slow and complex process which involves taking many factors into account obviously including the predicted future needs of the service.

2.2 The GMC is now the competent authority for medicine and must approve all curricula. The GMC is also the body for both undergraduate and postgraduate medicine that quality assures that the curricula are being delivered to a national standard.

2.3 Deaneries are charged at a “regional level” with ensuring that the curricula are actually delivered. Postgraduate medicine is largely learnt by experiential learning in the workplace. For every specialty and level of training the deanery has to ensure that appropriate doctors have been recruited; that they rotate through planned posts in hospital and the community where they will gather appropriate experience mapped to the curriculum; that the doctors who are training them are properly trained; that every doctor in every specialty is assessed as to whether they are making adequate progress every year; that all aspects of the curriculum have been covered (including issues such as clinical leadership); that doctors who are struggling are properly identified and managed and, important issues such as maternity leave and part-time training are planned for and accommodated. The average deanery is probably managing around 3,000 doctors at various stages of training at any one time.

3. How is a Deanery structured?

3.1 The simplest way to consider a deanery is as a postgraduate medical school (see Table A).

3.2 A deanery is composed of a number of specialty schools (eg Paediatrics, GP) that are led by a clinician in that specialty and the school takes responsibility for all trainees within that specialty. The Head of School (HoS) is normally appointed by the deanery and the Royal College jointly, but is managerially responsible to the deanery for local delivery. The HoS also have a significant role within their own Royal Colleges in ensuring standards and helping plan curricula for the future based on local experience of delivery.

3.3 The deanery integrates all of the schools into a single business unit. The deanery ensures single systems for managing the Annual Review of Competency Progression (ARCP), single systems for managing trainees in difficulty, single systems for training the trainers, single systems for developments that cross specialty such as clinical leadership and simulation. The heads of school also develop cross specialty programmes together such as Acute Care Common Stem which is a generic core training that allows people to enter Anaesthesia, Acute Medicine or Emergency Medicine.

3.4 The deanery coordinates all the posts and placements and the recruitment activities across all the schools taking into the account the progression and educational needs of all the trainees currently in each specialty programme.

3.5 A fundamental role of the deanery is its quality management activities. There are an integrated series of activities to ensure that trainees are receiving proper education to allow them to progress and ensuring that the needs of the service while being met are not preventing adequate educational progress. This is a continual iterative “total quality management” type activity to maintain standards, to improve standards and to fire fight crises. The service is constantly changing in activity and structure so the placements and education opportunities must continually be reviewed as education can only occur on the basis of current service.

The GMC quality assures postgraduate medical education and oversees the work of quality management activities of the deanery to ensure that they meet national standards.

Medical education is a national (England and the devolved nations) activity.

4. Commissioning and provision in Postgraduate Medical Education

4.1 There has been a considerable misunderstanding about the role of commissioning and provision in postgraduate medical education.

4.2 The discussion in section 3 make a clear case to consider a deanery and its activities in exactly the same light as an undergraduate medical school, as a comprehensive provider unit of medical education. The main difference being the largely virtual nature of the postgraduate campus and the far greater focus on service rather than research. It is also crucially important to understand that most of MADEL is used for salary support for trainees (see Enclosure 1).

4.3 Most aspects of postgraduate medical education are nationally determined, this includes the number of posts that can be recruited to in each specialty in each year in each locality, the curriculum are national and the regulator is national. The allocation (MADEL) was originally based on the number of training posts but this has now become a historical anachronism and there appears to be no direct relationship between MADEL and the size of the population or the number of training posts.

4.4 There is a considerable variation of funding for higher specialty training historically by SHA (see Enclosure 2). There is also huge variation in the number of training posts that are entirely funded by local trusts again based on historic differences (see Enclosure 3).

4.5 The funding issue has also been complicated in that MADEL comes down as part of a bundle of funds to the SHAs, which then individually decided how much can be used for medical education and how much should be diverted to other activities. The old South East Coast SHA has been one of a small number of SHAs that have continued to pass all MADEL through for postgraduate medical education because of the relative local underfunding.

While postgraduate medical education in the community in General Practice has always been seen and funded as a “supernumerary” experience, in secondary care postgraduate education is completed integrated into the service. It is extremely difficult to move posts and finance around the system which has driven the intensive work on deanery quality management.

4.6 The arguments over the last three years about commissioning and provision have been complex and often unhelpful. The funding and numbers are nationally determined so presumably this is national commissioning. The amount of money that each SHA will allow to go into medical education is then decided at SHA level so this is presumably regional commissioning. The deaneries allocate funding for salary support and educational infrastructure support to trusts so this is presumably deanery commissioning, however the system as described above is much more complex and interdependent. Certainly whatever model is implemented in the future must surely increase transparency, increase equality of funding and rewarding excellence for meeting educational standards, yet not destabilise service in a time of great strain.

5. The South East Coast model

5.1 In 2010, the South East Coast SHA came to the conclusion that the postgraduate deanery was a comprehensive provider of postgraduate medical education for the South East Coast SHA and it wished to separate the provider function of the deanery from what was seen as the commissioning function of the SHA.

5.2 The deanery, through a tendering process, was put out for hosting by any NHS organisation within the South East Coast. A critical part was for the hosting organisation to propose mechanisms that would allow the deanery to thrive in its mission of ensuring the highest quality of postgraduate medical education across the South East Coast.

5.3 Following five expressions of interest and two formal bids, Brighton and Sussex University Hospitals made a successful bid to host the deanery. The crucial part of this bid was that it was very clear that hosting was about supporting the generic functions of the deanery (Finance, HR, IT) for which a fee would be paid. But the work of the deanery would be overseen and supported by a Deanery Board that was completely independent of the host organisation with an independent chair.

5.4 From April 2011, the KSS Deanery has been hosted by Brighton and Sussex University Hospitals and the Deanery Board has been set up and implemented. The SHA and Brighton and Sussex University Hospitals appointed in open competition an independent chair (Sir David Melville) and the independent board was appointed to forthwith. This has representation from acute and mental health providers across KSS, PCTs, HEIs, the medical school and the SHA. The terms of reference and membership of the Deanery Board are set out as Enclosures 4 and 5.

5.5 Brighton and Sussex University Hospitals have a three year contract to host the deanery and the deanery has key performance indicators that it must be meet for the SHA on top of the requirement to meet the standards of all the national regulators. There are quarterly contract review meetings between the SHA and the deanery when all the key performance indicators and the financial performance of the deanery is reviewed.

6. What has been achieved?

6.1 The full support and buy-in of the only university hospital in KSS as well as much closer collaboration with the medical school.

6.2 Far greater involvement of Chief Executives from local education providers in postgraduate medical education. Significant competition for membership of the Deanery Board.

6.3 Much better understanding of the roles of HEIs in the work of the deanery. The potential to get HEIs to work together with the deanery schools across the whole of the geography of KSS.

6.4 Greater clarity of funding and its usage.

6.5 Genuine discussion with the service when educational changes need to be made.

6.6 Genuine involvement of local education providers in strategic planning by the deanery.

7. Risks and opportunities in the future DH model

7.1 The current model allows the Government to state that a certain amount of money is being dedicated for postgraduate medical education by allowing the intermediate tier to completely ignore its allocations. This is confusing for both the service and the public. The Department of Health should determine the money to be spent on postgraduate medical education as this is a national endeavour and it should pass as directly as possible to the deaneries to use to deliver the national curriculum.

7.2 Having an intermediate tier of Local Education and Training Boards has the potential to interfere with those funding flows. The role of the Local Education and Training Board should be to work on the crucial areas of inter-professional learning (for example, communication, team working and leadership) but it should not be able to alter medical education funding without formal HEE approval.

7.3 The current model demonstrates that the important driver of getting service involvement in postgraduate medical education can be achieved at low cost in what is nearly a virtual organisational role. The only cost to the Deanery Board is three days a month of the chairman’s time. We suggest this is good practice that should underpin the formation of Local Education and Training Boards which in large part should be virtual organisations with the absolute minimum of appointed staff.

7.4 A major focus of Health Education England must be to ensure not only that medical education funding is spent on medical education but that it becomes more equitably distributed around the country wherever it can be demonstrated that national standards are being met. Much less of the curriculum now needs to be delivered in University hospitals compared with 10 or 15 years ago.

7.5 Medical education is a UK wide endeavour and as such the postgraduate deans of England should be managerial accountable to the Director of Medical Education for England.

7.6 It is crucial that educational bodies are hosted but not managerial integrated into employing organisations to ensure and be able to demonstrate a clear operational independence.

7.7 Although we have not presented the evidence here other specialties such as Pharmacy and Dentistry that are largely a postgraduate education based in clinical placement work extremely well within a Deanery model. In KSS these specialties are fully part of the same quality management and trainee in difficulty process as medicine.

Enclosure 1:

Overview of use of MADEL in KSS.

Enclosure 2:

Funded NTNs per 100,000 population by SHA.

Enclosure 3:

Trust funded specialty training posts as a proportion of total specialty post numbers by SHA.

Enclosure 4:

KSS Deanery Board—Membership and Terms of Reference.

Enclosure 5:

KSS Deanery Board Membership.

November 2011

Table A

Undergraduate

Postgraduate

1. Recruitment

Selects school leavers to start undergraduate education in medicine.

The deanery runs selection processes at various levels of training: undergraduate to foundation training, foundation to core training, core training into specialty training, foundation training into GP specialty training. Many of these local processes are part of national coordinated recruitment.

2. Recruitment buy in

Each medical school has its own culture and selects students with the best fit.

Clinicians who will work with, and train doctors, in postgraduate education are fully involved in selection to their own programmes.

3. Delivery of the curriculum

Significant taught programme including lectures and laboratory work with increasing experiential learning in the workplace throughout training.

Almost entirely experiential undertaking clinical work supervised by consultants or GPs. Some taught programmes and a large amount of self-directed learning.

4. Clinical placements

Medical school arranges clinical placements in the local trusts, surrounding hospitals and community. SIFT funding is used to pay for this.

Deanery sources and contracts for clinical placements including paying for a significant part of the salary of the doctors in training using MADEL funding.

5. Educational environment and infrastructure

Medical school infrastructure and some support for trusts providing undergraduate medical education funded through SIFT.

Postgraduate medical education centres, local medical education managers and some aspects of library services, some support for essential course for trainees (“study leave”) all funded through MADEL.

6. Assessment of progression

Multiple examinations and assessment throughout undergraduate training.

Exams arranged by Royal Colleges, Deanery managed annual review of progression (ARCP) against curriculum defined competencies for all trainees. There is external review to ensure national standardisation.

7. Quality assurance and management activities

The GMC quality assures undergraduate activities and medical schools undertake activities to assess placement quality.

The GMC quality assures the deanery process. The Deanery undertakes detailed quality management activities including routine visiting of all local education providers as well as trouble shooting exceptional problems. These processes involve external experts, trained lay input and trainee input.

8. Failure to progress

Medical schools provide remedial support wherever possible.

Systematic processes to help identify, support and remediate whenever possible trainees in difficulty. Also career guidance processes.

9. Training the trainers

Locally based systems.

Systematic training of all education supervisors required by GMC to national standards.

10. Research

A major focus of undergraduate teachers and medical school function.

Service is the main focus of postgraduate teachers. There is some research into postgraduate educational activity.

Enclosure 1

Enclosure 2

Enclosure 3

Enclosure 4

DEANERY BOARD

MEMBERSHIP AND TERMS OF REFERENCE

The Deanery Board will:

(i)promote excellence and innovation in postgraduate education and encourage and develop educational research including development and evaluation of assessment and learning;

(ii)oversee the business planning process for the Deanery as a provider within the context of SHA commissioning of postgraduate medical and dental education, undergraduate and post graduate pharmacy education and possible future national commissioning;

(iii)add value to and promote the success of the Deanery as an organisation both nationally and regionally;

(iv)assure all stakeholders that work with the Deanery on a regional basis that the work of the Deanery is equitable, in particular, in its allocation of finances, quality management processes and operational contracting with Local Education Providers;

(v)assist the Dean Director in setting strategic direction and effective educational management capacity and capability;

(vi)oversee the Deanery communication strategy in order to ensure engagement of all stakeholders;

(vii)take a lead role in the appointment of the senior staff; and

(viii)review the overall performance element of the evidence required by the commissioner to meet national regulatory standards and local key performance indicators.

Its Principal Functions are to:

(i)receive reports from the Dean Director and other Deans;

(ii)consider and approve the Deanery strategic direction and business plan;

(iii)approve and review the Deanery financial plan;

(iv)receive and comment on the national workforce plans;

(v)receive and approve the Deanery quality management reports;

(vi)receive and comment on GMC and other national reports;

(vii)appoint Appeals Committees as required; and

(viii)receive and comment on the risk register and escalate any risks to the Brighton and Sussex University Hospitals (BSUH) Board of Directors.

The Chair will be responsible for the operation of the Deanery Board, ensuring that it makes an effective contribution to the governance of the Deanery and its pursuit of quality and excellence. The Chair will work closely with the Dean Director and the Secretary of the Deanery Board and will ensure that key and appropriate issues are discussed by the Deanery Board in a timely manner and that relevant information and advice is made available to the Deanery Board to inform the debate and decision-making process.

Membership of the Deanery Board

The membership of the Deanery Board will comprise:

From the Deanery: the Dean Director, the GP Dean and the Chief Operating Officer.

From the Brighton and Sussex Medical School: the Dean or designated representative.

From the SHA: the director responsible for commissioning postgraduate medical, dental and pharmacy education.

From a Higher Education Institute: two representatives elected from the HEI college arrangement with a minimum of one place to be reserved for either the University of Kent or the University of Surrey.

From local acute Education Providers: three representatives elected through the LEP college arrangement based on the three counties of Kent, Surrey and Sussex.

From the three county based Mental Health Trusts: one representative.

From the three new county based PCT clusters: one representative.

An independent Educationalist.

The Deanery Board will meet monthly in the first instance.

The Membership of the Deanery Board will be based on the principle of no substitutes.

Enclosure 5

KSS DEANERY BOARD

Board Membership

Sir David Melville
Independent Chair

Professor David Black
Dean Director, KSS Deanery

Professor Abdol Tavabie
GP Dean and Deputy Dean Director, KSS Deanery

Mr Chris Bird
Chief Operating Officer, KSS Deanery

Professor Zoe Playdon
Head of Education, KSS Deanery

Professor Jon Cohen
Dean, Brighton and Sussex Medical School

Dr Judy Curson
Clinical Lead for Medical Education Commissioning, NHS South of England (East)

Professor Shirley Price
Associate Dean of Learning and Teaching Division of Biochemical Sciences, Faculty of Health and Medical Sciences, University of Surrey

Professor Julian Crampton
Vice Chancellor, University of Brighton

Mrs Susan Acott
Chief Executive, Dartford and Gravesham NHS Trust (Kent)

Mr Andrew Liles
Chief Executive, Ashford & St Peter’s Hospitals NHS Trust (Surrey)

Mr Phil Barnes
Medical Director, Western Sussex Hospitals NHS Trust (Sussex)

Dr Rachel Hennessy
Medical Director, Surrey and Borders Partnership NHS Foundation Trust

Dr Robert Stewart
Medical Director and Director of Clinical Commissioning, NHS Eastern and Coastal Kent

Prepared 22nd May 2012