Health CommitteeSupplementary written evidence from the Royal College of Physicians (ETWP 113A)

Summary

The Royal College of Physicians (RCP) submitted evidence to the Health Select Committee’s Inquiry into Education, training and workforce in December 2011.

The government published Liberating the NHS: Developing the healthcare workforce—from design to delivery on 10 January in response to the Future Forum’s report on education and training. The RCP has some considerable concerns with the government’s proposals and have therefore decided to submit supplementary evidence to the Health Select Committee.

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

(a)National standards.

(b)National planning.

(c)Ring-fenced funding.

(d)Independent quality management and assurance.

The RCP is concerned that the government’s proposals

do not commit to adequate and necessary national planning of the medical workforce;

do not recognise the need for or commit to independent quality assurance;

relies on basic minimum standards for quality and fails to establish a system that will continually improve medical education; and

fails to recognise the need for the professions and royal colleges to be formally embedded in the governance structures of both national and local bodies responsible for medical education and training.

The RCP’s suggestions that we believe will improve the government’s proposals are below.

RCP’s Concerns with Medical Education and Training Proposals and Suggestions for Improvement

Lack of national planning

1. 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. 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.

2. The career path of doctors must be set nationally, drawing on national planning and horizon scanning data from bodies such as the Centre for Workforce Intelligence and royal colleges. The responsibility for setting and reviewing the medical career path must lie centrally, with HEE.

3. The education and training proposals argue that the current model of postgraduate medical training drives a degree of specialisation that does not fit with the needs of a population that is living longer with more long-term disease and co-morbidities. The RCP welcomes the government’s recognition that a more flexible model for postgraduate training may be more appropriate, with more training in the community. The RCP would also agree that 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 and generalist skills must be valued. However, developing generalist skills must not be at the expense of training highly skilled specialists who are often best placed to make difficult diagnoses and provide the best care for chronically ill patients.

4. From design to delivery suggests that the Centre for Workforce Intelligence (CfWI) will play a key role in using workforce information to provide expert advice and support on workforce planning at a national and local level. The RCP produces an annual census which provides data on the register and consultant physician workforce. We are therefore able to provide robust data that supplements CfWI’s work, which will allow the medical workforce to be nationally planned.

Lack of independent quality assurance

5. The RCP is concerned that quality control will be the responsibility of local education and training boards (LETBs), which will have conflicts of interest. From design and delivery states that LETBs’ governance should reinforce collaborative, provider-led arrangements. The RCP welcomes a collaborative approach, but is concerned that providers cannot quality assure the training they deliver. The RCP is not confident that greater levels of transparency on quality and cost together and/or evidenced metrics will help manage any perceived conflicts of interest and the appointment of an independent chair will adequately deal with any conflicts of interest, as From design to delivery suggests.

6. The RCP believes 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. We believe HEE should appoint a Director of Medical Education England and the postgraduate deans should report directly to them. The Director of Education and Quality, which HEE and LETBs will employ, should be a Board member, medically qualified and ideally should also be the postgraduate dean.

Role of royal colleges in setting both minimum and aspirational educational standards

7. The RCP welcomes the introduction of on education outcomes framework (EOF). We believe this will be a valuable tool for education providers. Royal colleges, who set the curriculum, must be fully involved in developing the EOF.

8. However, the RCP is concerned that there will not be a body responsible for continuous quality improvement in education and training. The RCP believes it is crucial that standards throughout every aspect of health care are continually improved. While we welcome the EOF as a tool to ensure minimum standards in education and training are met, we suggest that royal colleges are well placed to fill the gap in setting aspirational quality standards and accrediting providers.

9. This is a model RCP currently use for raising clinical standards. We run a wide range of specific programmes focused on measuring and improving quality—including developing and delivering clinical audits, clinical guidelines, service accreditation and quality improvement support. This includes accrediting services—a formal process using agreed national standards with the aim of improving quality—and undertaking Invited Service Reviews (ISRs) to provide independent advice on issues that are proving difficult to resolve in trusts. We propose that this model is applied to education and training. This would ensure that independent quality management and assurance are embedded into the medical education and training system.

Royal colleges must have a formal role at the top of Health Education England’s (HEE) and LETB’s governance structures

10. From design to delivery states that HEE will set up advisory structures to provide professional input and bring together all the stakeholder groups and that HEE will have relationships with national bodies including the royal colleges. This is welcome, but the RCP stresses that royal colleges and the professions must have formal input mechanisms at the highest structural levels of HEE and LETBs. We suggest that there be a reserved place for a doctor on the board of HEE and that HEE’s Professional Advisory Board should include the royal colleges. The boards of LETBs must also include a doctor.

Positive aspects of the proposed education and training system

11. The RCP welcomes some other aspects of the proposed changes to medical education and training. These are detailed below.

Flexibility of the Medical Career Path

12. The RCP is pleased the government has welcomed the need to increase the flexibility of the medical career path. We believe that 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.

13. The RCP produced a report, Women and Medicine in 2009, which can be referred to for best practice for the medical profession that has increasing numbers of female entrants.

Funding

14. The RCP welcomes the commitment that the MPET budget should be confined to funding education and training for the next generation of clinical and professional staff only. The budget for education and training should not be siphoned off to pay for service delivery. We believe that funding should flow directly from the national commissioner to deaneries, medical schools and other Higher Education Institutions.

15. We are pleased in principle that there will be an education levy. However, experience tells us that it is difficult to establish the true cost of training doctors and it is too easily underestimated. The levy must be constantly monitored and reviewed to ensure this is not the case.

16. The RCP believes there needs to be national oversight to ensure that enough commissioning contracts are awarded to providers that offer sufficient medical training. We welcome the commitment in From design to delivery that the education and training system should be responsive to strategic commissioning ambitions, but believe clinical commissioning groups (CCGs)and the NHS Commissioning Board (NCB) should have 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. The RCP also believes that Monitor should be required to consider education and training when licensing providers.

January 2012

Prepared 22nd May 2012