Health CommitteeWritten evidence from the Royal College of Physicians (ETWP 113)

The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. As an independent body representing over 26,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

Summary of the RCP’s Response

The RCP believes the following fundamental principles should underpin medical education and training:

National standards.

National planning.

Ring-fenced funding.

Independent quality management and assurance.

The RCP believes that the roles and responsibilities of bodies in new structure should be as follows:

Health Education England should lead the national planning process for all postgraduate medical education, working closely with the medical royal colleges and the Centre for Workforce Intelligence (CfWI).

Postgraduate deaneries should be responsible for independent quality management of medical education and training and trainee management.

Local Education and Training Boards (LETBs) should advise HEE and bring together the local health and social care community.

The RCP is calling for the health service reforms to have stronger safeguards to protect medical education and training. Commissioners, both local and national, should be required to consider education and training and it should be part of Monitor’s licensing conditions. To prevent problems with transition HEE should be established under the Health and Social Care Bill.

The delivery and content of medical education and training should be reviewed. While there should be improved inter-professional education, the RCP is concerned that trainee medical specialists have particular education needs which would not be met in multidisciplinary training sessions. We also want time for work that contributes to the wider NHS to be recognised and respected by employers, as recommended by the Future Forum.

The RCP is aware that there are changing workforce demands and requirements. The RCP is establishing a Commission on the Future Hospital in early 2012 that will explore issues such as generalism, providing a consultant delivered service, medical career paths and improving the flexibility of rotas to mediate against problems caused by EWTD and the New Deal.

Fundamental Principles that should Underpin Medical Education and Training

1. The RCP believes the following fundamental principles must underpin medical education and training structures.

National Standards

2. Medical education and training must adhere to national standards. We must be able to trust that doctors trained in different parts of the country are able to deliver the same high standard of care. This will prevent variation in standards and facilitate movement of doctors working around the UK.

3. Specialist societies must have a central role in setting and developing the curriculum for training doctors in their specialty. This must be centrally planned. As the umbrella body for 31 medical specialties, the RCP can act as the conduit for this work. The RCP will work to develop strong links with HEE to develop strong national standards for medical education and training.

National Planning

4. The medical workforce must be nationally planned. Training must consider both service needs and the whole pathway of medical school to specialism, which is often 15 years or more. Medical training is expensive, and the right balance must be achieved between specialties. Experience tells us that this requires constant national supervision and intervention. This is most obviously the case for smaller specialties, but it is clear that planning for all medical specialties, such as cardiology, requires long term vision. The number of trainee placements for medical specialties should be set at a national level, with scope for flexibility in local implementation. HEE should be responsible for approving local plans and have sufficient powers to take action where necessary.

5. National planning requires good quality data. Attempts to plan the medical workforce in recent years have been hampered by the lack of reliable information about the numbers and location of doctors in training.1 The RCP supports the further development of the Centre for Workforce Intelligence (CfWI) and the promotion of more integrated ways of working. The RCP’s Medical Workforce Unit currently works with the CfWi to improve the data available to facilitate workforce planning.2

6. There are currently challenges facing the medical workforce that illustrate the need to nationally plan based on good quality data. There is currently an oversupply of trainees in some medical specialities. Renal medicine is the worst affected, but gastroenterology, respiratory and cardiology are “at risk”. Conversely, there is also an undersupply of consultants in small specialties such as audiovestibular medicine and some large specialties such as dermatology. This has created a large variation in service provision across the UK. Under and over supply of both trainees and consultants has exacerbated the variation in medical staffing levels both at junior and senior levels throughout the country.3

Ring Fenced Funding

7. Funding should flow directly from the national commissioner to deaneries, medical schools and other Higher Education Institutions. This ensures that as far as possible funds allocated centrally for education reach regional education bodies intact and are not, for example, siphoned off for service.

8. The RCP supports the concept of an NHS training levy paid by all providers, including providers to the NHS, directly to HEE. This should include those providers who do not provide NHS services, but do use NHS trained staff, ie the independent sector. Experience tells us that it is difficult to establish the true cost of training doctors and it is too easily underestimated. Work must be started now, which engages a full range of bodies, including royal colleges, to establish the level of the levy. However, the RCP is concerned that the levy is not a sufficient safeguard to ensure that there is sufficient training provision in the health system to produce the amount and types of doctors that is required to meet the needs of the NHS (see the Health Service Reforms section for more detail).

9. The RCP supports the review of the Multi Professional Education and Training (MPET) budget and agrees that the current system should be reformed. Currently, the link between the quality and quantity of education and training, and the funding that pays for it, is weak. There are insufficient incentives for excellence, and inadequate, or non-existent, penalties for failing education providers. There must also be sufficient incentives to ensure that education and training are improved when outcomes are shown to be poor. The RCP suggests that HEE consider adopting a system of financial incentives for quality similar to the Commissioning for Quality and Innovation (CQUIN) payment system used within service commissioning.

Independent Quality Management and Assurance

10. Postgraduate and undergraduate deans must be the “responsible officer” for quality management of medical education. The GMC has a clear structure for holding deaneries accountable at a local/regional education training board level to ensure quality management, while individual providers undertake quality control. This is a strong and logical system that combines understanding of service pressures at a regional level and proper external scrutiny.

11. The RCP believes that personal contact with trainees can improve quality management and supplement the data generated from surveys. We believe it is crucial that quality management looks at supervision and training, and has the teeth to withdraw funding and trainees. Postgraduate deaneries must maintain sufficient independence and autonomy to undertake their quality management functions effectively, and should therefore not be part of LETBs (although the dean would sit on these boards).

12. Close contact with trainees also has the potential to detect wider safety and quality issues, which can be discussed/monitored/acted upon/referred to regulators, as appropriate. It is important that any changes to structures take account of the findings and recommendations from the Public Inquiry into Mid Staffordshire NHS Trust, due to report in spring 2012.

13. There has been much debate about metrics to support the development of medical education (or as a financial incentive). Measuring, publishing and incentivising quality is vital but new proposals must be piloted and subject to academic scrutiny, and proper prospective academic study. The RCP should be involved in developing this evaluative framework.

Roles and Responsibilities of Bodies in New Structure

14. To secure high quality medical education, the RCP suggests the following role for bodies in the new health system.

Health Education England

15. The national planning process for all postgraduate medical education should led by Health Education England (HEE), working closely with the medical royal colleges and the Centre for Workforce Intelligence (CfWI). The number of trainee placements for medical specialties should be set at a national level, with some scope for flexibility for local implementation. HEE should be responsible for approving local plans and have sufficient powers to take meaningful action where necessary. HEE must retain strong professional ownership and influence. The RCP strongly recommends the retention of the Medical Education England’s Medical Programme Board, which supports an inter-professional approach.

16. The professional advisory boards and MEE’s Programme Boards should be absorbed into HEE’s structure. This will ensure continuity throughout and beyond the period of transition. The Medical Programme Board will advise the main HEE Board on the development of their respective education and training arrangements and on workforce planning matters. It—together with the other programme boards—will play an essential role in scrutinising the local plans of provider networks and drawing attention, for instance, to any issues that may not be in the overall national interest of the right workforce supply.

17. The RCP recommends that the Medical Programme Board carry out the functions originally described in the Tooke report,4 which includes holding the ring-fenced budget for medical education and training for England and defining the principles underpinning postgraduate medical education and training (PGMET). There must also be lay involvement at a strategic level within HEE.

Postgraduate Deaneries

18. Postgraduate deaneries undertake crucial functions that cannot be delivered as effectively elsewhere in the system—including independent quality management function and trainee management—and must be retained. We welcome both the Future Forum’s and the government’s recognition of the importance of postgraduate deaneries. There has been growing partnership at regional level between royal colleges, deaneries and medical schools through the development of specialty schools. Developing academic training partnerships need to be fostered and enhanced.

19. Postgraduate deaneries should be made accountable to HEE at a national level, and continue to be accountable to the General Medical Council (GMC) for the delivery of the postgraduate medical curriculum. Postgraduate and undergraduate deans must be the “responsible officer” for quality management of medical education.

20. Local hosting arrangements for postgraduate deaneries will need to be set up following the abolition of Strategic Health Authorities (SHAs) in 2013. There are a number of potential models for the hosting of postgraduate deaneries, including as an autonomous, independent body hosted within universities, a teaching trust, academic healthcare centre or in sub-national HEE or NHS Commissioning Board structures. Hosting arrangements could be determined locally depending on local needs and relationships. However, the routes of accountability (to HEE) and funding (from HEE) should be common across the system, and postgraduate deaneries must maintain sufficient independence, control and autonomy to undertake their quality management functions effectively.

21. Royal colleges and deaneries have worked together recently to deliver deanery-based schools to create and effective visiting processes. Over the last three years, heads of school have become an enormous source of workforce knowledge and expertise at a regional level. They understand where the trainees are, they know the service pressures and they know the workforce undertaking the training. They should be one of the most powerful sources of local workforce expertise at a regional level to support local education and training boards in the future.

Local Education and Training Boards (LETBs)

22. It is vital that local needs are understood, and that providers are engaged in education and training. This information must influence the national commissioning programme if it is to make sense at a regional level. It is widely understood that it has been difficult to engage local education providers in either national or local workforce planning.

23. Local Education and Training Boards (LETBs) should provide information and advice to the national commissioner (HEE). In relation to postgraduate medical education, their role should be to advise the national commissioner, as well as acting to bring together the local health and social care community. In medicine, local needs tend to focus on months to a year. Training, however, must consider the whole pathway of medical school to specialism—often 15 years or more. There are already examples of inter-professional educational bodies, such as deaneries, being hosted outside Strategic Health Authorities helping to develop strategy and inform local delivery. We would advise learning from these non-bureaucratic solutions and can provide examples on request.

24. There needs to be greater clarity on the arrangements for ensuring that providers participate in LETBs. Developing the healthcare workforce suggested that Monitor is likely to have a role in ensuring provider participation in LETBs. There needs to be a clearer vision of the sanctions and action that will be available if providers do not participate. Likewise, there must be clear guidelines setting out what meaningful participation will look like.

Delivery and Content of Education and Training

Inter-professional training

25. There should be improved inter-professional education, and there is a role of LETBs in ensuring this happens. Developing clinical leadership, team working and a real focus on improving patient care is fundamental for the NHS. This is not, however, the same as multidisciplinary/multi-professional education. Multi-professional education at the undergraduate level, other than for groups requiring the same scientific basis to their studies or where there are certain shared needs, has not been demonstrated to have any impact or saving, for the different professions have different requirements. Trainee medical specialists have particular education needs which would not be met in multidisciplinary training sessions.

Time for work that contributes to development and the wider NHS

26. The RCP particularly welcomed the Future Forum’s recommendation that there be recognition of the importance of time for training and work that contributes to the wider NHS, including college work, such as curriculum development, training and the development of clinical standards. This should be formally recognised by the government.

Health service reforms

27. The RCP welcomes the government’s amendment to the Health and Social Care Bill that gave the secretary of state a duty to secure education and training, introduced in Committee stage in the House of Lords. However, the RCP believes that the Health and Social Care Bill should have further amendments to ensure education and training and the future workforce is safeguarded.

28. The RCP is concerned that the training levy will not be sufficient to ensure enough training is being provided to meet the future needs of the health service. There needs to be national oversight to ensure that enough commissioning contracts are awarded to providers that offer sufficient medical training. The RCP is therefore suggesting an amendment to clause 23 to give CCGs a duty to promote the education and training of the current and future health care workforce. This should also be a mandatory part of commissioning contracts. Similarly, the RCP also believes that the NHS Commissioning Board (NCB) should have a duty to promote education and training of the current and future healthcare workforce. We believe this should be a mandatory part of commissioning contracts. This would require an amendment to clause 20 of the Bill.

29. The RCP also believes the Monitor should be required to consider education and training when licensing providers. Clause 93 of the Health and Social Care Bill should be amended to ensure that education and training is a mandatory licensing condition, with certain explicit exceptions.

30. To prevent transition problems, we also recommend that Health Education England is established under the Health and Social Care Bill, as are the four principles it will adhere to when carrying out its functions—namely there will be national standards for education and training, the workforce will be nationally planned, there will be ring-fenced funding and an independent quality management system.

Changing Workforce Demands and Requirements

31. The medical workforce must meet the need—and future need—of patients. The RCP will be launching a Commission on the Future Hospital in the New Year that will explore how address the issues raised above. The RCP will keep the health select committee informed of the progress of this work.

Generalism

32. We need to assess whether the current balance between physicians trained in a speciality and those trained in general internal medicine and/or geriatric medicine is right. Acute hospitals need a workforce appropriately trained to deal with the acute medical intake and aftercare of these patients. This means looking at who is best placed to look after the increasing number of complex patients who do not neatly fit within a single speciality. Generalist skills must be valued.

Flexibility of Medical Career Paths and Training

33. There needs to be greater flexibility in medical career paths. The medical specialty workforce needs to be more flexible to the needs of the NHS, and trainees need to be able to move between specialities more readily to facilitate this. There should also be flexibility (including in existing deaneries) for doctors to move from one specialty or region to another to meeting training needs. This could be hindered by increasing the amount of local planning. HEE could provide oversight of this and work with partners to ensure that curricula are not overly restrictive.

Consultant-delivered Service

34. RCP advocates consultant-delivered care and the provision of better out-of-hours care for hospital patients. We believe the mounting evidence of sub‐standard care delivered to patients who are admitted to hospital during these times is related to the difficulties in providing sufficient input to these patients from consultants. The lack of senior input at these times also adversely affects the supervision and training of junior doctors. There is an urgent need to review rotas and the structure of the entire medical team to ensure that inpatients receive direct input from consultant physicians seven days a week. Service reconfiguration will be necessary to achieve this goal. The RCP statement on care of medical patients out of hours in 2010 advocated hospitals undertaking the admission of acutely ill medical patients should have a consultant physician on‐site for at least 12 hours per day, seven days per week, at times related to peak admission periods. The consultant should have no other duties scheduled during this period.

EWTD and New Deal

35. Doctors’ working patterns have been significantly affected and working hours considerably reduced by both the European Working Time Directive (EWTD) and the New Deal for junior doctors. Although the RCP supports the aim of preventing doctors working excessively long hours, there has been an unintended increase in staffing pressures and other consequences that need to be addressed. The RCP is calling for greater flexibility of application of both the EWTD and New Deal as a solution to these problems.

December 2011

1 At present, the size of an individual workforce is decided based on the prediction of its needs by a specialty (as outlined in “Consultant Physicians Working With Patients”), the number of training posts decided by the Medical Education England (MEE) Medical Programme Board, the Workforce Availability Policy and Programme Implementation Group (WAPPIG), the deaneries and the local finances of trusts. Centre for Workforce Intelligence advises the Programme Board and WAPPIG, and was hoped to be a facilitator in the planning process.

2 In addition to our Medical Workforce Unit, which can continue to advise CfWI on numbers and measurement, we also have a well-developed regional system embedded in the Schools of Medicine and hospital trusts. This is well-placed to facilitate the provision of expert advice on medical specialties to any localised workforce planning functions.

3 These conclusions are drawn for data generated by the annual RCP Census. Please contact the RCP directly if you would like more information on the data available.

4 Professor Sir John Tooke. Aspiring to Excellence: Final Report of the Independent Inquiry into Modernising Medical Careers. MMC Inquiry, January 2008. Final Report of the Independent Inquiry into Modernising Medical Careers.

Prepared 22nd May 2012