Health CommitteeWritten evidence from The Patients Association (ETWP 39)

Summary

There needs to be greater patient involvement in the development of curricula for healthcare professionals.

Patients should also be involved in the teaching of courses where their insights can help improve understanding of relevant issues.

Patients want curricula to include training to improve healthcare professionals understanding and communication skills.

Lack of healthcare professionals communication skills is a major issue for the patients contacting the Patients Association.

Research suggests improved communication skills can improve patient care.

We are concerned that the role of the Secretary of State in setting priorities for education could lead to greater instability in the education of healthcare professionals.

Healthcare professionals from overseas, including EU countries, should be proficient in the English language and NHS procedures before they begin practising.

Care must be taken to ensure healthcare professionals trained in one country within the UK but working in another are given extra support where needed to provide effective and safe treatment wherever they are working.

1. Patient Involvement in the development of curricula

1.1 Patients are the reason why the NHS exists and patients must be an integral part of the education process of healthcare professionals and the ongoing professional development of healthcare professionals while they are practising.

1.2 The earlier the process of patient involvement begins in a healthcare professional’s career, the better the impact.1 , 2 As a result, education takes on a crucial role in ensuring new healthcare professionals are as best equipped as possible to engage with the diverse group of patients they will encounter in their careers.

1.3 Ultimately it is patients who will most thoroughly understand their own needs and they should have an important role in setting the priorities of the education and training of healthcare professionals.

1.4 In September 2010, the Patients Association held a focus group alongside University of Birmingham Medical School to investigate what the medical curriculum should include from a patient’s perspective and to identify where patients could become involved in the curriculum and could enhance the training of medical doctors.3 Two clear themes emerged from discussions on what patients wanted to see within the medical school curriculum—better understanding and better communication.

1.5 Patients want to be treated as real people and not seen as just a condition. The focus group suggested simple factors such as acknowledging family members or carers and listening to patients, would improve this. Patients also said there was a greater need for empathy and an ability for doctors to pick up on the behaviour of patients, in particular non-verbal communication skills.

1.6 The recommendations that emerged from that focus group were as follows:

Improve empathy with patients through:

Organising a focus group in student doctors’ first year to discuss issues important to patients.

Exposing students to elderly and disabled patients earlier in the course.

Consider work placements for students in care homes or nursing teams in their first or second years.

Improve understanding of the patient journey by devoting curriculum time to teach post discharge care of patients, including how patients can care for themselves.

Improve communication by involving patients in teaching and assessing communication skills.

1.7 The General Medical Council’s (GMC’s) regulations for the training of medical professionals, does include stipulations on involving patients in the education of doctors but recognises that patient involvement in the development of the medical school curricula is relatively uncommon but says they is great potential for development. They call for greater attention to be given to the variety of perspectives that individuals can bring.4

1.8 We further recognise and welcome the greater emphasis that has been placed on involved patients within the medical school curriculum. For example, a research paper published in 2005 asked a group of patients, “what should undergraduate medical students know about psoriasis?” and used group discussion with those patients to develop a curriculum relevant to them.5 The conclusion of this research was that using the views of patients to build the curriculum had been helpful and beneficial to patient care. The authors recommended that patients should be more closely involved in the development of curricula for other chronic diseases.

1.9 Furthermore, in 2009, the British Medical Association (BMA) recommended that, “Patients should be actively involved in the development, review and implementation of undergraduate and postgraduate medical curricula”.6 They also said that Patients should also be given adequate training and support.

1.10 When patients are being involved in the education and training of healthcare professionals, care must be given to ensure trainees are exposed to diverse groups of patients as they will need to have awareness of the differing needs of people from Black and Minority Ethnic groups and from Lesbian, Gay, Bisexual and Transgender group. In 2006, the BMA’s medical welfare survey found that just under half of medical students felt that they had been prepared for treating and understanding the needs of patients of different sexual orientations.7

1.11 There is also some evidence that involving patients even more actively as teachers as well as contributors to medical education can help improve the acquisition of skills, increases respect for patients and place textbook learning in context.8

1.12 Moving beyond doctors, patients must also have a part to play in the development and delivery of curricula of all healthcare professionals. There are tangible benefits to involvement patients in the education of healthcare professionals, including nurses, which are strongly associated with enhanced quality of care.9

2. Healthcare Professionals’ Communication Skills

2.1 Through our Helpline, the Patients Association (PA) receives numerous complaints about poor communication. These calls tend to be grouped around three crucial areas of communication: diagnosis, treatment and compassion.

2.2 In our recent report, “We have been Listening, Have you been Learning?”, the Patients Association documented 16 cases of poor care that we have heard through our Helpline. In one of these cases in particular, that of Sally Abbott-Sienkiewicz, poor communication skills played a major part in severely hindering Mrs Abbott-Sienkiewicz’s care and wellbeing. In Mrs Abbott-Sienkiewicz’s case, lack of communication between healthcare professionals including nurses and doctors meant that she was left in a great deal of pain despite clearly needing help. Staff were also not able to communicate effectively with her relatives when they tried the highlight the severity of her situation to the healthcare professionals looking after her.10

2.3 Other research undertaken by the Patients Association has revealed that while healthcare professionals were amongst the most commonly used sources of information, they were not considered to be particularly useful. GPs, for example, were the most regularly used source of information about health with 58.6% of patients saying that they had used them, but only 37.1% felt that they were useful sources of information. Similarly, 32.3% of patients we surveyed had used hospitals as a source of information, but only 19% had found them a useful source.

2.4 More emphasis should be put on communication skills during clinical training so healthcare professionals have the ability to communicate effectively with their patients. While efforts have been made to improve training in communication skills amongst doctors, our survey suggests that other healthcare professionals in particular may require further training in these skills. Nurses, pharmacists and other healthcare professionals were rated poorly as sources of information. This may be due to poor communication skills, gap in knowledge of the healthcare professional, not engaging effectively with patients or time constraints. It is essential that this needs to be addressed.11

2.5 In the Patients Association report, Public Attitudes to Pain, figures revealed that only 66% of patients felt that they had a good understanding of the side effects they may experience and only 33% felt they understood how to manage the side effects of medication prescribed for them. When asked whether they had always taken the prescribed dosage of their pain medication, 17% said that they had taken more than the prescribed dosage and 15% had taken less than the prescribed dosage.

2.6 NICE guidelines on Medicines Adherence state that there must be frank and open approach which recognises that over and under-medication is very common.12 However, it is clear that many patients do not feel comfortable or able to have such discussions with their healthcare professional. We believe that extra focus on communication skills during training would help make patients more comfortable about talking to their healthcare professional not only about side effects but also non-adherence to medicines. Those patients who took less than the prescribed dosage said they were very concerned about the side effects of their medication and with the possibility of addiction. Those who took more than the prescribed dosage said they did so because their medication was not effectively relieving their pain. Patients were generally afraid of being reprimanded for not taking their healthcare professional’s advice.

2.7 The importance of good communication cannot be overestimated: it is essential in allowing patients to understand their condition and the treatment course to follow. Further, effective communication is a way of retaining patient commitment to their treatment path and good communication has been shown to lead to improved emotional and physiological outcomes.13

3. The role of the Secretary of State for Health in the new system

3.1 The Secretary of State for Health retains ultimate responsibility for providing and ensuring comprehensive NHS healthcare in England. This will naturally include the education of healthcare professionals as in order to ensure equal access to healthcare, their will need to be enough staff to provide the care patients need.

3.2 However, we would have concerns about any in depth role in deciding the priorities of healthcare professional education. When the Organisation for Economic Co-operation and Development (OECD) published its latest report comparing healthcare systems across the world, Mark Pearson, Head of Policy at the OECD said, “The UK is one of the best performers in the world. But outcomes are not what you expect because there is a big reform every five years. We calculate that each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK”.14

3.3 Similarly, if the Secretary of State for Health set education priorities for healthcare professionals, would these change every time there was a new Government? Furthermore, we are also concerns would priorities may be set for political reasons rather than necessarily in the best clinical interests of patients.

4. Balancing workforce requirements of NHS and non-NHS providers

4.1 It is clear that there will be the need for strong guidance on this point. We are concerned that private providers might drain resources and staff away from NHS providers leaving a very unbalanced system. The system of education of healthcare professionals needs to ensure that all providers, whether they are NHS providers or non-NHS providers, have adequate levels of skilled staff to provide the care that patients need.

4.2 The clearest example is in dentistry where there has been an ongoing problem with ensuring high quality NHS dentistry as dentists move to the private sector. This has been attributed to falling income from the NHS compared to private dentistry.15

4.3 The NHS does provide the funding for courses including nursing, medical training and training of other healthcare professionals.16 Private providers should also be asked to help support the education of healthcare professionals directly as the NHS does to ensure that all providers who benefit from having well trained staff contribute to their education and training. This could be done by giving some responsibility for the training of healthcare workers to private providers as well as the NHS.

5. Place of overseas educated healthcare staff

5.1 Healthcare staff from overseas play a major role in the NHS. However, healthcare professionals from abroad must have a thorough understanding of the procedures and process of the NHS before they can begin to practice. We recognise the difficulties this presents with regard to the UK’s obligations through the European Union (EU) but we would urge the Government to ensure that changes are made urgently to protect patients.

5.2 The General Medical Council (GMC) published a report which has called for induction training for doctors new to the NHS.17 This was as a result of research which has shown that some doctors do not have a sufficient understanding of UK medical procedures. In 2008, the case of Dr Daniel Ubani shocked the UK when he caused the accidental death of David Gray due to his inadequate understanding of UK procedures. Dr Ubani was from Germany and was performing locum duties for the first time in the UK. It was ruled by a coroner’s inquiry that he was “incompetent” because he did not have a full enough understanding of NHS procedures yet he was still able to register as a doctor in the UK. This case has left some patients concerned about the training their doctors have received in UK procedures and shaken confidence in the qualifications and expertise of doctors from abroad.

5.3 Patient safety must be paramount and we are concerned that poor communication as a result of poor language skills could put patients at risk.

5.4 There should be a duty of care on the Government and the regulators to ensure that healthcare professionals are proficient enough in the English language to safely and effectively provide care before their first contact with patients.

5.5 We also note comments from the Nursing and Midwifery Council (NMC) about the registration of nurses from EU member states. They told a committee of inquiry in the House of Lords that they had to operate a two tier system to accommodate European Union rules on free movement of persons.18 This included having to allow the registration of nurses and midwives who had no professional experience for 20 years despite concerns about their understanding of modern nursing practices. This is patently unreasonable and we believe it has to potential to put patients’ lives and wellbeing at serious risk. Patients deserve to be treated by competent nurses who understand medical and administrative procedures as they currently stand, not what they were 20 years ago. We believe there should be provisions to bar the recognition of healthcare professionals who have been out of professional practice long periods of time without undertaking additional training.

6. Relationship with the other countries within the UK

6.1 The movement of healthcare workers across the UK is by no means an unusual phenomenon. It would not be uncommon for doctors or nurses to qualify in Northern Ireland or Scotland but work in England. However, as the four countries within the UK become more separate with greater devolved powers, efforts must be made to ensure that education standards remain at similarly high levels across the whole country.

6.2 If there are changes in practice in one country, doctors and other healthcare professionals moving to that country from within the UK to practise should receive extra training and support to ensure they understand changing practices across the UK.

December 2011

1 Patient-centred medicine through students-centred teaching—a student perspective on the key impacts of community-based learning in undergraduate medical education, Howe A, Medical Education 35: 666-72, (2001).

2 Patient contact in the first year of basic medical training—Feasible, educational, acceptable? Howe A, Dagley V, Hopayian K et al, Medical teacher 29: 237-45, (2007).

3 Patient involvement in medical education, Patients Association, (2010).

4 Tomorrow’s Doctors, General Medical Council, paras 58-67, (2009).

5 What should undergraduate medical students know about psoriasis? Involving patients in curriculum development: modified Delphi technique, Alahlafi A & Burge S, BMJ 330: 633-6, (2005).

6 Role of the patient in medical education, Medical Education Subcommittee, British Medical Association, (2009).

7 Medical students welfare survey report, British Medical Association, (2006).

8 Developing the role of patients as teachers: literature review, Wykurz G & Kelly D, British Medical Journal 325: 818-821 (2002).

9 Patient involvement in education for enhanced quality of care, Le Var RM, International Nursing Review, 49(4):219-25, (2002).

10 “We have been Listening, Have you been Learning”, Patients Association, (2011).

11 Information, What Information? Information Challenges of Shared Decision Making, Patients Association, (2011).

12 Medicines adherence: Involving patients in decisions about prescribed medicines and supported adherence. NICE Clinical Guidance 76, National Institute for Health and Clinical Excellence, (January 2009).

13 Effective physician-patient communication and outcomes: a review”, Stewart, M.A. Canadian Medical Association Journal 152(9): 1423–1433, (1995).

14 Coalition health bill will undermine NHS, says OECD thinktank, Guardian Newspaper, (Wednesday 23 November 2011).

15 NHS dentistry in crisis as record number of practitioners defect to private sector, The Independent, (Friday 11 January 2008).

16 For examples, please visit
http://www.nottingham.ac.uk/studentservices/financialsupport/studentfunding/nursingnhsfundedcourses.aspx

17 The state of medical education and practice, General Medical Council, (2011).

18 HL Deb, 8 September 2011, c455.

Prepared 22nd May 2012