Health CommitteeWritten evidence from the Royal College of Surgeons of Edinburgh (ETWP 30)

The Royal College of Surgeons of Edinburgh wishes to submit the following written response to the select committee focusing on the items outlined in your invitation and confining our comments in the main, to the surgical aspect of each item unless declared otherwise. Our fellowship and membership of 18,000 is spread across the United Kingdom and indeed globally. Surgical education and training and the implication for workforce planning within the United Kingdom are central to our purpose and actions; our structure, function and influence is directly relevant to surgical practice and patient care across the entire UK. A pan UK approach to training and education is essential in order to avoid potential differing educational provision and standards for a workforce that moves freely from country to country within the United Kingdom. Political and geographic boundaries should not be given the potential to translate into differences in quality of patient care.

An invitation to contribute to your deliberations failed to reach us directly despite the fact that our membership extends throughout the UK. The failure to appreciate the significance of contribution to and influence of the medical Royal Colleges based in Scotland to educational standards and process is an indictment of the approach to planning of both workforce and education strategies for British medicine. Whilst implementation of healthcare is devolved, we do not believe that there should be a similar restriction on the strategic approach to education and training of our workforce, hence our wish to contribute to your work on this key matter which ultimately dictates the standard of care for our patients. We trust, therefore, that this submission is contributory and facilitates the planning process in these strategically important areas.

1.0 The numbers of appropriately qualified and trained healthcare staff at national, regional and local levels

1.1 We would anticipate that the established trend of increasing consultant numbers (the consultant workforce has doubled in England from 18,000 to 36,000 between 1994 and now) and the more recent trend of migrating numbers from the training and specialist grade in to the consultant workforce, will continue until such time as there is a steady state between recruitment into training and exit from the consultant workforce. The potential for a mismatch between the product of medical school education in terms of UK graduate numbers and recruitment into all specialty training is a concern for us however since the projected reduction in training numbers will exacerbate this mismatch year-on-year. Policy for manpower planning therefore must include entry into the profession as well as attrition and departures from it.

1.2 Distribution at national, regional and local level is a responsibility for each jurisdiction coordinated through the respective human resource departments. However, particular consideration has to be given to supra-regional services where there is a dependency upon a small number of consultants who are nonetheless crucial to provision of high-quality specialist care.

1.3 However, due notice must be taken of the cross-border migration of staff in both consultant and non-consultant grade. Neither England nor Scotland are self-sustaining in any but particularly smaller specialties and any policy which deals with workforce training and education must recognise the reality that exists in cross-border flow and must ensure that both strategic and operational policies accommodate this pattern such that there is no obstacle to its continuation. Additionally, note must be taken that some training programs are pan UK and a policy emanating from one country should not compromise that program.

2.0 The need for training curricula reflect the changing nature of healthcare delivery, including the medico-legal context

2.1 An increasing awareness of the presence of harm as a unintended consequence of patient care and a new emphasis on patient safety requires a specific addition to postgraduate curricula which will embrace the subject matter of human factors and improvement science as it relates to surgical practice. This college has a pre-eminent position in its contributions to both these fields witnessed by (a) the global success of our non-technical skills taxonomy developed with the University of Aberdeen (NoTSS), (b) our alliance with the NHS Institute in creating a Curriculum Creator Tool and (c) with our ongoing work to establish an in workplace assessment tool of non-technical skills (embracing behavioural aspects of surgical performance ) with the accompanying faculty training products. This underlines our commitment to maintaining a contemporary and “fit for purpose” approach for creating a surgical workforce for the future.

2.2 The medicolegal consequences of harm are best approached by a methodical and systematic study of its origins which we believe more likely to achieve mitigation than a policy based on a transactional top-down approach.

3.0 The contribution that providers and commissioners of healthcare (both NHS and non-NHS) play developing the future workforce

3.1 The role of providers and commissioners is key in that their support and commitment to education and training of the current and future workforce is obligate and anything short of complete commitment is prejudicial to the delivery of education and training,- (often delivered outwith contractual duties), but best developed with an endorsement from providers rather than in the face of apathy or frank opposition. The current lack of commitment to training and education by management results in it being undervalued and compromised. This contribution has to translate into more than an absence of objection, but must also call to account those who fail to declare and display ongoing commitment to education and upskilling of their successors.

3.2 Better and more robust contracts/MOUs/SLA’s need produced to underpin the relationships between educational bodies and the NHS and reduce the discretional approach taken by local management (often in response to short-term service pressures) which can compromise long-term investment in our workforce.

4.0 Multi-professional and multidisciplinary leadership and accountability (encompassing the full range of healthcare professions, specialties and grades) at all levels

4.1 We are committed to multidisciplinary and multiprofessional leadership. This college is currently piloting the development of the Faculty of Surgical Trainers specifically to look at the generic skills that need to be enhanced within the workforce in order to support the professional development of educational and teaching skills as well as improving the quality of patient care indirectly through this strategy.

4.2 The new faculty of Medical Leadership and Management instigated by the Academy of Medical Royal Colleges is indicative of the commitment of all colleges, to leadership and accountability. We would also highlight a number of our current and ongoing initiatives directed at multi-professional support eg development of non-technical skills in theatre scrub nurses (Splints) and our hosting of the Faculty of Prehospital Care which deals with the range of disciplines from the ambulance service, paramedic care, nursing, through to trauma surgery. We have additional educational provision for those working in remote situations (Diploma in Remote and Offshore Medicine)-all indicative of our commitment in this area.

5.0 High and consistent standards of education and training

5.1 This is amongst the highest of our priorities and responsibilities and a duty that we execute with care and diligence. As an equal partner within the intercollegiate network of surgical standards setting and examining across the United Kingdom (and farther afield,) we have a thorough and rigorous approach to summative and formative assessment such that through our joint committee structure, we are able to provide the General Medical Council with advice on the suitability of placement of a surgeon in training onto the specialist register.

5.2 Discontinuation of the visiting process carried out on behalf of all surgical colleges by the Specialty Advisory Committees (SACs) was a significant loss to the quality assurance of training as its prime goal and indirectly and by proxy an evaluation of the quality of the service. Recognising that this constituted a significant burden for deaneries and providers alike nonetheless has not been re-placed by a mechanism that approaches in any way the rigour, effectiveness and efficiency of that quality assurance process. Reintroduction of that mechanism is worthy of consideration.

6.0 Development and reskilling of the existing workforce for the future

6.1 Continuous Professional Development for the purposes of both professionalism and revalidation is a work stream at the heart of preservation of standards as well as a mechanism for recurrent training and advancement in the competencies and skill set of existing workforce. This college makes substantial commitment to CPD through course delivery, surgical skills enhancement, e-learning products (ESSQ-the Edinburgh surgical sciences qualification has received recognition as a front-runner in surgical education delivered online).

6.2 Investments in research also require integration into any policy designed to promote advances in competencies and skills. Whilst there are no specific questions in relation to research, research into applied healthcare is fundamental to progress within the United Kingdom and we would support its inclusion in the considerations of the health committee.

6.3 Financial support for CPD and study leave is inconsistent throughout the United Kingdom. They would suggest a policy be developed to remove the element of postcode lottery that is currently a feature of the financial support for professional and study leave.

6.4 Better recognition and accreditation of transferable skills between programs is currently under active consideration by all colleges.

7.0 The future of postgraduate deaneries

7.1 Using NHS Education Scotland as a reference point, we would strongly recommend preservation of postgraduate deaneries along these lines with HEE providing an overview as the umbrella organisation in England. The existing scale structure purpose of functionality has not been subject to any substantial criticisms or demonstrable inadequacies. The uncertainty surrounding future structures is potentially profoundly destabilising.

7.2 Deaneries in Scotland have demonstrated the value of local administration of training whilst at the same time the potential for integration and coordination at national level. We see no merit in revision of the current deanery structure in England recognising that governance responsibilities for training needs to be shared by Royal Colleges, Schools of Surgery and the deaneries.

8.0 The proposed role, structure, governance and status of Health Education England (including how it will take on the roles of Medical Education England and the professional advisory boards), and its relationship to professional regulators and to the other parts of the new NHS system architecture

8.1 As indicated above, Health Education England would be well served by modelling much of its role, structure and governance on those functions as executed by NHS Education Scotland. There would be particular benefit in identifying responsibilities for foundation years (particularly the 2nd year) with greater clarity in relation to the role of the regulator. The lack of clarity around the new NHS system architecture in relation to education makes a more definitive response difficult beyond indicating that the more locally economy exists for delivery of education, the greater the potential for inconsistency and fragmentation of training schemes that need to be provided seamlessly across United Kingdom. The merits of commissioning in this area are unclear to us.

8.2 Also as indicated above quality assurance of training and education would be a task better engaging the colleges to provide externality, expertise and consistency, rather than residing in the duties of the regulator.

9.0 How professional regulators, healthcare providers and commissioners, universities and other education providers, and researchers will all participate in the formulation and development of curricula

9.1 Royal colleges currently have primacy in the duty of formulation and development of curricula. There is merit in extending this to a partnership approach through agencies responsible for service development (eg NHS Institute). The Arm’s-Length Review however has made the future of these agencies less secure and hence investment in partnership with them less predictable. A closer alliance with a standards agency (eg Nice) could provide additionality to the current mechanisms of curricular development.

10.0 The place of overseas educated healthcare staff within the workforce

10.1 Cognisant and supportive of the strategy of the United Kingdom being self-sufficient in its consultant workforce, and that that workforce is the one charged with and is responsible for delivery of healthcare, we would wish to note that the vacancy factor in terms of training numbers that accompany the reshaping of the workforce will open up educational opportunities that could be filled by overseas educated healthcare staff This therefore provides opportunity for supporting healthcare education in other nations particularly developing nations and this country has a rich tradition in such endeavours. Indeed we would see the current exclusion of many doctors from the Third World as being an abrogation of our global responsibilities towards improvement in health care worldwide.

10.2 We would strongly support expansion of a well-managed International Medical Graduates Scheme that allows placement adequate supervision and planned exit in an accountable fashion, and wish you to note that we currently administer such a scheme on behalf of the UK surgical colleges.

11.0 How the workforce requirements of providers of NHS and non-NHS healthcare will be balanced

11.1 There are distinct differences in the case mix between surgical units within and outwith the NHS with the latter units being occupied with minor and intermediate complexity procedures in the main. The depletion of these cases from the NHS precludes access for training purposes and leaves training to be based upon a more complex caseload with the attendant challenges that that poses. Moreover the proportion of cases treated in non-NHS institutions varies from surgical specialty to surgical specialty (there are significant examples eg in cosmetic and aesthetic surgery as well as an orthopaedic surgery), and in these specialties the lack of exposure of trainees to the non-NHS institutions is deemed as prejudicial to training in the full spectrum of case complexity. This requires revision and better regulation.

12.0 The implications of a more diverse provider market within the NHS

12.1 related to our response in paragraph 3.1, we are concerned that diversity may translate into inconsistency in support of the educational process and the potential for lack of consistency in prioritisation and investment in the future of quality and safety of the workforce of the NHS through adequate education and training.

13.0 How the new system will relate to healthcare, education, training and workforce planning in the other countries of the UK

13.1 As indicated above, it is crucial that a pan UK approach is taken to training and education to avoid the potential for postal code training provision in a workforce that moves freely from country to country within the United Kingdom and a workforce where the political and geographic boundaries do not and should not translate into differences in quality of patient care. Whilst implementation of healthcare is devolved, there is no such restriction on the strategic approach to education and training of our workforce (as witnessed by the Academy of Medical Royal colleges being a pan UK body) and the health select committee would be best served by a wider vision in its strategic approach.

December 2011

Prepared 22nd May 2012