Health CommitteeWritten evidence from The Academy of Medical Royal Colleges (ETWP 20)

Introduction

1. The Academy’s membership comprises the Medical Royal Colleges and Faculties across the UK. This submission represents a combined view across Colleges and has been endorsed by members. Individual Colleges and Faculties may, of course, submit their own evidence which will highlight their particular concerns or issues.

2. The primary interests of Colleges and Faculties are postgraduate medical education and training (PMET) and standards of clinical practice, but they also have a general interest in healthcare policy. The topic of this Inquiry is, therefore, an issue of core concern to the Academy and its members. Comments focus on the medical workforce and medical education.

The Academy’s vision and principles for postgraduate medical education and training across the UK

3. The Academy has very recently agreed a short statement setting out its vision for PMET which underpins our submission:

Principles

The Academy believes:

The quality of future medical care is critically dependent on the quality of current postgraduate medical training.

Medical training must continually adapt to the changing needs of patients and services to train doctors who meet the highest clinical standards set by the profession based on research, audit and involvement from patients.

Good medical training requires doctors to have practical experience of delivering care, making diagnoses, undertaking procedures and managing patients and the opportunity to develop leadership skills, and engage in research and audit.

Rigorous patient safety standards must exist in the design and delivery of training programmes.

Training must be provided by organisations and individuals committed to achieving excellence in training as a core objective rather than a by-product of service provision or an add-on to their clinical duties.

Being a trainee doctor brings both rights and responsibilities as set out in the AoMRC Trainee Doctors Group 2011 statement of principles and, of course, Good Medical Practice.

Funding for medical training must be identified, protected and not diverted into service provision or any other use.

Medical training must be independently quality assured using robust professionally developed quality indices applicable across the UK.

Vision

The Academy sees a post-graduate medical education system of the future where:

Doctors in training are in part “supernumerary” in a service where care is mainly consultant delivered and so not dependent on trainees to maintain services.

Those who train doctors have time to train, supervise and assess their trainees and themselves are appropriately trained to deliver high quality training and assessment.

Trainees and trainers work together to provide stability and continuity of training.

Formal postgraduate medical training is only provided in organisations committed to achieving excellence in training as a core objective and so there may be organisations or components of organisations which choose not to train or do not meet the standards to train.

Where training is judged not to meet externally quality assured standards, the relevant professional bodies should help Trusts achieve these standards failing which the right of an organisation to undertake training could be withdrawn.

Whilst not all NHS organisations may be appropriate training environments, all organisations using doctors should be contributing to the cost of their training.

Organisations which do train should be properly funded to do so which is recognised appropriately in commissioning contracts.

The role of Colleges in postgraduate medical education

See Section 8 for fuller explanation.

Context

4. The Academy pointed out in its initial response to the Government’s consultation document Developing the Healthcare Workforce earlier in the year1 that these changes have been required primarily as a consequence of other parts of the Government’s reform programme—explicitly the abolition of SHAs. Whilst the Academy has consistently identified a series of improvements it would wish to see in post-graduate medical education and workforce planning there has never been a clear articulation of the problems this wholesale re-organisation of education and training arrangements is seeking to resolve.

5. Therefore, whilst medical education and training can be improved it is important to recognise it is already generally of a very high standard in the UK. This is not a system that is dysfunctional and broken but rather a system that must be improved and further adapted to fit the needs of patients, the changing demography of disease, developing NHS patterns of service delivery and the requirements of trainees.

6. Our original submission also set out a number of principles that we felt should underpin any changes:

Workforce planning and the commissioning of medical education and training cannot be left to market mechanisms alone and co-ordination and planning is required to continue to deliver the right quantity and quality of future healthcare staff.

It is essential that clinicians and Colleges are fully engaged at all levels in discussions and decisions about clinical workforce planning and education commissioning and provide the professional leadership required in the process.

The functions currently carried out by Postgraduate Medical Deaneries are extremely important. They need to be retained in the new system, although there are a variety of ways in which this could be done.

There needs to be transparency about costs of undertaking postgraduate training and education and a proper price must be paid to all those who provide education and training.

7. The Academy is pleased to acknowledge that, to varying degrees, the current proposals have recognised these principles.

The role of Royal Colleges and Faculties in medical education, training and workforce planning

It may be helpful to explain the role that Colleges and Faculties currently have in PMET and workforce planning:

Curricula—Colleges and Faculties design and produce the curricula for each of the 61 specialties and, within these, 34 approved sub-specialty training programmes (including GP training) that doctors undertake to get their Certificate of Completion of Training (CCT). The curricula are approved by the GMC. The Academy, pulling together all the specialties, is responsible for the Foundation Programme Curriculum, Common Core training and the common competences across training.

Assessment—Colleges set and run national exams and College representatives undertake local assessments of trainees as they progress in order to quality assure doctors for the NHS.

Training of trainers—Colleges are responsible for ensuring that trainers and assessors have up to date specialist knowledge and skills to ensure they are able to train effectively.

Assuring quality—Colleges help assure the quality of training and Continuing Professional Development (CPD) content. The Academy believes that there is an important further role that Colleges can play in assuring education processes and delivery locally. Without establishing additional inspectorate machinery we believe College expertise could be used to better effect possibly through the development of accreditation.

CPD—Colleges have an important role in supporting and providing continuing professional development for doctors beyond formal training which will be essential for revalidation.

Clinical standards—Colleges are responsible for the development of the specialist clinical standards which are the core of medical training.

Workforce planning—Colleges probably have the most comprehensive and accurate information on workforce numbers in the specialties. This feeds into the Centre for Workforce Intelligence (CfWI). Colleges all input their professional expertise and judgement into decisions on specialty number requirements.

National level—At national level Colleges and the Academy work closely with the four UK Health Departments, GMC and Conference of Postgraduate Medical Deans (COPMeD) on training and education issues. The Academy has representatives on Medical Education England (MEE) and its Medical Programme Board (MPB).

Maintaining professional standards—Colleges review, advise and help departments and individuals that have issues with performance in any of a number of areas.

Transition

8. The Academy is concerned that, as in any re-organisation, uncertainty and individual anxiety leads to destabilisation and lack of focus. There is a balance to be achieved between the benefit of clarity of purpose and rapid progress, and the need for proper deliberation, effective involvement and agreement on long-term decision making.

9. The Academy believes it is important to progress as quickly as possible with the establishment of HEE and has welcomed the appointment of the Senior Responsible Officer and Chair of the Steering Group. The Academy is pleased to be represented on the Transition Steering Group and keen to begin discussions about the most effective structures for HEE.

10. The Academy believes the position at local level is less clear. The actual number of LETBs, let alone their organisational and governance structure, is unclear. The position for deanery staff is not resolved and we understand that some deaneries have had significant problems with the loss of staff. There are concerns as to whether arrangements can be effectively in place by April 2013.

11. Aside from the need to ensure that permanent structural arrangements are in place in 2013 the Academy would stress the importance of ensuring that the 2012 recruitment and rotation process for doctors in training is not destabilised because of lack of capacity or expertise in deaneries. That would cause significant problems to the NHS service, and directly to patients.

Future of postgraduate deaneries

12. The future of deaneries has consistently been a key concern for the Academy, and remains so. The Academy has strong views that in the reorganised training system Postgraduate Deans need to have significant independence from the LETBs, whilst working with them to deliver a multi-professional approach to patient care. This is for three main reasons:

Postgraduate Deans must be able to move trainees from locations where training is not meeting the expected standard to those where training is better. This ability is key to maintaining and driving up the quality of training and may be at variance with the priorities of service.

Postgraduate Deans have to be free to report to regulators when they have significant concerns either about the quality of training or about the quality of care. This again might not be seen by employers and service providers to be in the service’s best interests.

Independence of the Postgraduate Deans from service will add a major additional means of ensuring that monies are not vired from training to service.

13. We believe that the best solution would be for Deans to be accountable to HEE and retain responsibility for the placement (and removal) of trainees.

14. The Academy has consistently fed this view into all discussions about the proposals as well as to the Future Forum. The Chairman of the Academy together with the Chairman of COPMeD and the Chair of English Postgraduate Deans wrote to the Secretary of State in these terms on 25 November 2011.

15. Whilst there appears to be recognition of the validity of our concerns, to date there has been no satisfactory response. The Academy would urge the Health Committee to address this issue.

Role of HEE

16. The Academy supports the establishment of HEE. It will be essential that there is clarity in the relationship between HEE and LETBs. It is right that HEE must be able to hold LETBs to account for their performance but that authority must be real. Clearly the Academy would hope there is a constructive relationship but HEE must have the authority to ensure that high quality education and training is being commissioned and delivered.

17. Secondly, it has to be ensured that HEE’s structure delivers what is required at national level. The correct balance of patient, professional, employer and education interests has to be achieved.

LETBs

18. The Academy supports the more active engagement of employers in education and training. However there are genuine anxieties, not that employers are unconcerned about training and education, but that the immediate demands of service delivery and financial pressures could threaten education and training and its funding. This is why the independent judgement of Postgraduate Deans is so crucial.

19. It is also crucial that processes and structures at employer and LETB level genuinely involve clinicians who provide the expertise and leadership on education and training and workforce planning issues.

20. Alignment of LETBs with Academic Health Science Networks may be sensible but the specific tasks of commissioning and delivering education must not be subsumed.

National Education and Training Quality Outcomes Framework

21. The Academy is absolutely clear that good quality education and training has to be rewarded and incentivised and poor quality has to be improved or removed. This can only happen if the quality of training can be measured and assessed. The Academy, therefore, has been involved with and supports the development of an Education Outcomes Framework underpinned by robust metrics. We do not underestimate the complexity of the task and recognise that it is unlikely to be right at the first attempt. However this should not halt progress.

22. The Academy is aware that there are a number of initiatives developing or looking at metrics or indicators for education and training. It is essential that that this work is co-ordinated to produce a single set of metrics for common use across the UK otherwise effective judgements on quality will be impossible.

Engagement in the development of curricula

23. Colleges have the lead responsibility in terms of the development of curricula for postgraduate medical training and we are absolutely clear that they remain best placed to do this. This process does not currently happen in a vacuum. The GMC has to agree curricula and will usually have been engaged throughout the process as will have deaneries and higher education representatives as appropriate.

24. Experience has shown it is not easy to engage healthcare providers and commissioners in the detail of curriculum development. The Academy recognises that curricula must adapt to changing service needs and is happy to explore how service provider engagement can be improved.

25. The Academy was surprised that patient input to curricula was not cited by the Committee. The Academy believes this is an important and valuable component to the process and seeks to ensure that this happens consistently. The Academy’s Patient Liaison Group has made its own submission.

The public health workforce

26. The Academy believes that workforce planning and education and training proposals for the public health workforce need to be co-ordinated with NHS arrangements as well as local authorities. The training of public health doctors must remain integrated with wider medical training. Detailed comments will be submitted by the Faculty of Public Health.

Relation to healthcare, education, training and workforce planning in the other countries of the UK

27. The Academy believes that it is essential that there is consistency across the UK in medical education. Whilst exact delivery mechanisms may differ, variation in standards of training for doctors in the four countries would have unacceptable consequences on services and the quality of care for patients. It is therefore essential that there is co-ordination between the four nations. Colleges, Deaneries and the GMC do operate or co-ordinate on a UK basis and HEE must ensure that it works with the relevant bodies in the other administrations.

28. Similarly, there needs to be co-ordination over medical workforce planning across the UK.

December 2011

1 http://www.aomrc.org.uk/publications/statements.html

Prepared 22nd May 2012