Health CommitteeWritten evidence from the Wellcome Trust (ETWP 24)

Key Points

1. The Wellcome Trust funds a range of activities to relating clinical research, including research fellowships that support clinicians at all career stages and major investment to develop the UK Clinical Research Facilities. Our key messages:

We have major concerns about the Government’s proposals for the delivery of training and education for the healthcare workforce, particularly the proposed governance model for Local Education and Training Boards. These proposals fail to take into account the vital role that universities must play in a world-class education and training system.

We support a system where Health Education England (HEE) offers clear national leadership, with local partnerships between higher education institutions and healthcare organisations delivering education and training. The governance arrangements must ensure a clear, central role for universities, maintaining essential links with research and innovation and undergraduate medical education.

The education and training system must support research and the adoption of new technologies by incentivising healthcare professionals and providing them with sufficient education, training, time and resources.

Introduction

2. We are pleased to have the opportunity to submit evidence to the Health Committee’s inquiry and we welcome scrutiny of the Government’s proposals to reform the education and training system for healthcare professionals, as part of the wider reforms outlined in the Health and Social Care Bill. Given the Wellcome Trust’s remit, our comments focus primarily on the interactions between research, innovation, education and training.

3. We agree with a statement made in the NHS Chief Executive’s Review, Innovation: Health and Wealth, that “innovation is central to the future of the NHS”.1 The Review recognises the importance of the workforce in realising this ambition and we consider it essential that this is reflected in reforms of the education and training system. In order to ensure that new technologies such as genomics and stratified medicines are deployed effectively in the NHS, it is essential that healthcare professionals are given the education, training, time and resources needed to support research and innovation.

4. Improvements to the education and training system for healthcare professionals must be piloted and evaluated to ensure a smooth transition to an effective new system.

Career Pathways and Curricula Development

5. The current career pathway for clinicians is highly inflexible. This lack of flexibility makes it difficult for young clinicians to develop a fully rounded set of skills and devote time to activities away from the bedside, such as research. The career pathway and curricula for clinicians must be reformed to ensure that they are clear but flexible, and avoid over-specialisation. The system must be designed to enable collaboration between academia and service providers in the development of curricula, to ensure that the workforce is fit for purpose. Furthermore, sufficient support and recognition for activities such as research must be embedded within the system and it is important that National Institute of Health Research (NIHR) funding for academic posts and Clinical Excellence Awards are maintained.

6. Healthcare provision is continually changing as new technologies and innovations emerge and the profile and health of the population changes. As such, it is essential that the healthcare system fosters a culture of lifelong learning for healthcare professionals.

A Model for a Reformed Education and Training System

7. We consider that the Government’s proposed model for reform of the education and training system is unnecessarily complicated and lacking in clarity. It should begin with a clear vision of the goals of education and training, and this vision should then inform the development of a new system of delivery. Form should follow function, rather than the other way round. We would argue that the goal is to educate, train, recruit and retain a diverse workforce that can deliver a first class health service. There are three key elements in achieving this goal:

The NHS requires a well-educated and trained workforce that is flexible and capable of responding to evolving healthcare needs at both local and national levels.

The best intelligence on educational and training needs must be gathered at local and national levels in order to match supply to need as closely as possible.

There must be clarity around the responsibilities and accountabilities of the many staff that provide and oversee education, training and continuing development across the workforce.

8. We think this vision is best delivered through a system where Health Education England (HEE) offers clear national leadership, with local partnerships of higher education institutions and healthcare organisations delivering education and training. For the system to provide the best quality education; keep pace with advances in healthcare; and clearly define the roles of staff in education and training, it is essential that universities play a central role. The system must also minimise conflicts of interest and ensure clear lines of accountability between national and local components. The following sections set out the model that we consider would work most effectively.

National Coordination

9. It is essential that HEE is empowered to provide national coordination for the education and training system, with this role including quality assurance and standardisation. In a complex system such as the NHS, national priorities and needs must be able to shape local education and training plans. HEE also must provide national-level engagement with key stakeholders in the education and training landscape, such as the Higher Education Funding Council for England, the General Medical Council and the Medical Royal Colleges.

10. HEE must be established with independent, non-executive members and be accountable to the NHS. The chair of HEE could sit on the National Commissioning Board to ensure coordination between national commissioning and education and training activities.

Local Delivery

11. We are very concerned by the proposals to establish Local NHS Education and Training Boards (LETBs) without balanced representation of both service and education providers. It is absolutely crucial that universities play a central role in the delivery of education and training, to maintain links both to the academic research environment and to ensure seamless provision of undergraduate medical education. We therefore consider that education and training would be delivered most effectively by partnerships between local higher education institutions (HEI) and healthcare providers. The governance structures of the LETBs must reflect this.

12. The UK is alone among the advanced nations in lacking strong formal links between higher education institutions and postgraduate medical education. These reforms present an excellent opportunity to address this deficit. This will enable UK universities to build on their existing strengths in undergraduate education and biomedical research, to ensure that our post-graduate education and training is also world-leading.

13. The Government’s current plans imply that higher education institutions have a conflict of interest with respect to postgraduate training, whereas healthcare providers do not. We disagree and consider that neither higher education institutions nor healthcare providers are truly independent. We therefore suggest that the most effective option would be to have both of these stakeholders represented on the board of LETBs.

14. We support the Future Forum’s recommendation that LETBs should be established with an independent chair. We also consider that LETBs should have independent, non-executive members that would play an important role in supporting and challenging the executive members and therefore help to address the inherent conflict of interest. The LETBs should be based on existing examples of good practice, for example the Academic Health Sciences Centres (AHSCs), where a similar model has been successfully implemented. Academic Health Sciences Networks, proposed in Innovation: Health and Wealth, provide an exciting opportunity to link education and training with research and innovation, building on strong partnerships between centres of academic excellence and healthcare providers across England.

15. Set up in the way we describe, and building on existing relationships, LETBs will be well-placed to play a key role in connecting healthcare provision with research and innovation, therefore strengthening the global competitiveness of the NHS. Furthermore, these partnerships would enable UK institutions to compete for the best international talent, ensuring a steady income stream for the partners and, crucially, improving service provision for patients.

16. LETBs must be accountable to HEE, and could be established as part of HEE itself. This approach would remove the need for further legislation to establish the LETBs as separate legal entities. It is important that there is flexibility in the arrangements for LETBs to ensure that they are suited to the local environment. This flexibility could be compromised if the governance mechanisms are enshrined in legislation.

17. We envisage that the LETBs would coordinate local information collection and feed this back to the Centre for Workforce Intelligence or directly to HEE. This will enable HEE to monitor and assess the quantity and quality of education and training provision and in turn LETBs must be responsive to the national priorities set by HEE in order to implement this.

Funding Distribution

18. It is essential that budgets for education and training are sufficient to ensure a high standard across the full range of professions within the workforce. HEE should hold a ring-fenced budget in order to ensure that this can be protected from other pressures. The budget should be allocated on the basis of quality and quantity of education and training and the successful NIHR approach to support for research could provide a useful model for this.

Migration of Health Professionals

19. As part of the Government’s policy to reduce net migration, the UK Border Agency (UKBA) has recently consulted on changes to the Tier 5 temporary workers immigration category. The NHS, with the support of the medical royal colleges, uses this immigration category to bring highly skilled, well-qualified and experienced doctors into the UK for up to 24 months, through a scheme known as the Medical Training Initiative (MTI). The MTI enables international medical and dental graduates to enter the UK to experience training and development in the NHS for up to two years, before returning to their home country. The MTI contributes to NHS service delivery through the placement of highly skilled international medical graduates; makes use of spare training capacity in the NHS; provides relevant work experience in the UK to doctors from low- or middle-income countries; and saves NHS trusts money by reducing reliance on locums.

20. The UKBA consultation proposed a number of restrictions on the Tier 5 category, including reducing the maximum length of stay from 24 to 12 months. This would seriously threaten the viability of the MTI scheme, and push doctors from overseas into training opportunities in other countries. In our response to the consultation, the Trust argued that the current flexibility to remain in the UK for up to 24 months must be retained.2

December 2011

1 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131299

2 http://www.wellcome.ac.uk/About-us/Policy/Consultation-responses/index.htm

Prepared 22nd May 2012