Health CommitteeWritten evidence from the Royal College of Pathologists (ETWP 48)

Summary

Transition to the new system must recognise the current stresses in the system, acknowledge developments in training and education that are already on-going and maintain current funding levels for medical training.

Feasibility testing of the new structures and mechanisms should be considered before full implementation.

Postgraduate deaneries should be wholly retained, preferably governed by and regionally representative of HEE.

HEE should be embedded within a statutory framework that defines its role and responsibilities, and which ensures the engagement and participation within the new system of all bodies interacting with and taking advantage of health education and training.

Commissioning and quality assurance and management of health education and training should rest outside of the responsibilities of LETBs.

Formulation of medical and scientific curricula should remain the responsibility of the royal colleges, regulated as currently by the GMC/HPC.

Provider diversity brings with it risks to the provision of training which should be addressed in contracts and statutory frameworks.

The National Education and Training Outcomes Framework should include more comprehensive performance indicators to be of significant value, especially during this time of change risk to training provision.

Funding for education and training should be controlled by HEE and allocated to LEPs through LETBs on a real time basis (see below).

This system will struggle to stand alone in England without the cooperation and buy-in from the devolved nations.

Public Health should be reconfigured as a specialist health authority directly accountable to HEE or DH.

Submission

1. Plans for transition to the new system, up to April 2013

(a) In transition, there are several issues that concern the College. The quality and commitment of trainers within the current system is fragile and must be supported and maintained. Medical training numbers have been reduced, and financial pressures within the service delivery context are high. With the added difficulty of training within the European Working Time Directive (EWTD), delivery of high quality education is becoming increasingly difficult.

(b) Pathology specialties (along with others) are developing curricula and assessment systems for scientists wishing to progress via the Modernising Scientific Careers/Higher Specialist Scientific Training programme. Implementation of these systems and training posts will occur over a similar timescale to the changes to education and training. Transition should ensure that workforce planning and commissioning of education and training takes into account these on-going developments.

(c) The College is also still concerned that, in the transition to a multi-professional Healthcare Education England (HEE), the level of funding for Medical education and training is maintained (allowing for the current climate of savings), and not reduced in real terms.

(d) Feasibility testing of these new structures should be considered; one simple example would be testing the mobility of the workforce to access distributed training opportunities, responsibility for which has not been described. Excess haste in introducing the new system may disadvantage trainees in all professions.

(e) This College has serious concerns about the lack of continuity between heterogeneous undergraduate curricula in the teaching of basic disease mechanisms and Foundation programmes which fail to fill those knowledge gaps. The GMC shares our concern and has agreed we should study this problem in depth and make recommendations to them. Any suggestions will need careful integration, or these gaps will likely be exacerbated.

2. The future of postgraduate deaneries

(a) We were extremely concerned at the possible abolition of the Postgraduate Deaneries within the original consultation, even allowing for the recognition that “Deanery Functions” should be maintained within the Local Skills Networks (LSNs).

(b) Deanery functions are not solely related to quality assurance of postgraduate education and training. Deanery postgraduate schools are largely responsible for the improvements in postgraduate training over the last five years, and these structures must not be lost in any new system.

(c) Deaneries also manage trainees in difficulty, Annual Reviews of Competence Progression, remedial training, recruitment to training programmes (local and national), training for educators and supervisors and liaise with medical royal colleges to ensure our standards and curricula are translated into practice. Colleges and Deaneries work closely together and our work would be severely disrupted if these essential functions were diluted or lost.

(d) All of these functions must be maintained within the new structures. In our original feedback, we recommended that Deaneries were wholly retained, and could for example become regional offices of HEE. This would be a logical context in which to situate the quality assurance of training programmes. We also recommended that the commissioning function for education and training be returned to the Deaneries on behalf of HEE. These recommendations remain our preferred position; wherever the Deaneries are hosted however, it is their retained ability to function that is essential.

3. The future of Health Innovation and Education Clusters

(a) HIECs are potentially useful if they integrate local training initiatives and posts in Trusts with each other and with their local educational institutes. There is no clear evidence that this is working uniformly or well across the country and there is some doubt about the capabilities of the staff running them. This is a high level function requiring organisational and negotiating skills which could be operated jointly between HEE, LETBs, Deaneries, Universities and Trusts, not to mention the powerful potential of alliances with AHSCs.

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

How can the Secretary of State be responsible for postgraduate education in the context of Foundation Trusts who are allowed to decide how they deliver healthcare?

5. The proposed role, structure, governance and status of Health Education England (including how it will take on the roles of MEE and the Professional Advisory Boards), and its relationship to regulators and to the other parts of the new NHS architecture

(a) The functions assigned to HEE are broadly appropriate, although curriculum review should remain in the hands of the GMC/Health Professions Council (HPC) as independent regulators. Accountability of the bodies within the new structures to HEE should be embedded within a statutory framework to ensure full cooperation and engagement.

(b) As previously suggested, HEE could regulate some functions of the LSNs through Deaneries (which would need to become multi-professional entities where this is not already the case) as local offices. HEE should remain independent of government, and should ensure cooperation through closer integration and interaction with the GMC, GDC, HPC and other regulators. Lay representation is essential. HEE should have responsibility for enforcing the duties of providers for consultation, provision of workforce information, cooperation in workforce planning and the planning and provision of education and training.

6. The proposed role, structure, status, size and composition of local Provider Skills Networks/Local Education and Training Boards, including how plans for their authorisation by Health Education England will address issues relating to governance, accountability and potential or perceived conflicts of interest, and how the Boards will relate to Clinical Commissioning Groups and the Commissioning Board

(a) We welcomed the explicit recognition in the original consultation that workforce planning and commissioning of training could not be left to market forces, and that healthcare professionals and the Royal Colleges would be engaged in these processes.

(b) However, we are still concerned that the new LSNs/Local Education and Training Boards (LETBs) are not appropriate forums in which to manage these two essential functions. An organization that is responsible for workforce planning, commissioning of training, local education providers and quality assurance mechanisms would be rife with conflicts of interest that could only be separated at best by “Chinese walls”. Commissioning of Education and Training and Quality Assurance functions would be better placed outside of the proposed LSNs/LETBs.

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

(a) The formulation of postgraduate medical and scientific curricula (and their associated assessment systems) should remain with the Royal Colleges who are attempting to integrate scientists into their ranks. The provision of input by all relevant bodies and individuals is already ensured by in the consultation mechanisms employed by all Colleges within the curriculum development process, and overseen and regulated by the GMC/HPC.

8. The implications of a more diverse provider market within the NHS, and how the workforce requirements of providers of NHS and non-NHS healthcare will be balanced

(a) Changes to the provider market have removed some training opportunities from trainees who are currently limited to opportunities provided within NHS institutions. An example is ophthalmic surgery training in London, the South West and East Anglia where the introduction of independent contractor centres without educational contracts, the drive for economy and efficiency in NHS operating and variable visual acuity thresholds for cataract surgery imposed locally by PCT managers have all reduced training opportunities in these areas.

(b) Pathology service reconfigurations currently being undertaken bring with them opportunities for private providers to bid for these services. Even though most of these negotiations are at an early stage, there is already anecdotal evidence in several areas, eg South Central, of tenders being provided without any commitment to continue the current provision of training for medical and laboratory scientist trainees.

(c) The College has met CEOs of the main private pathology providers recently. All agree that training and education must be protected and they are mostly happy to protect trainers’ time but they all want funding to come from outside the service contract and NHS CEOs agree.

9. The role and content of the proposed National Education and Training Outcomes Framework

(a) The Framework should form the basis of the accountability mechanism between DH & HEE and will help to shape contracts between HEE & LETBs and LETBs and Local Education Providers (LEPs).

(b) The Framework contains appropriate outcomes and domains, however only two indicators are proposed for 2012–13, which makes it of very limited value for measuring the outcomes of both the Framework and the changes being introduced over the next two years, unless further indicators are developed for 2013–14.

(c) Future indicators of the quality of training might include: curriculum mapping exercises, quality assessment reports from Deaneries, examination results, ARCP outcomes, trainee progression rates, trainee and trainer surveys and patient and staff feedback.

10. The role of the Centre for Workforce Intelligence.

(a) The College previously had great concerns over the viability and fitness for purpose of the Centre for Workforce Intelligence (CfWI). The data that CfWI originally used was flawed and outdated. We were pleased to hear that it would engage with the private sector and major pharma companies in future, however we are unsure whether this has yet happened. We would applaud the fact that CfWI has engaged more comprehensively with the Royal Colleges since the release of the original consultation, and their recognition of our own comprehensive workforce data.

(b) The Department of Health (DH) has agreed to take its advice for short-term workforce planning and annual recruitment into pathology training posts directly from the College. CfWI has also interacted directly with the College to obtain accurate data for its medium to long-term project looking at the future shape of training. We would encourage this system to continue.

11. The roles of Skills for Health, Skills for Care and NHS Employers

(a) These organisations can provide consultation on the scope for reshaping the workforce, developing expertise in workforce and recruitment planning, improving the quality of training within new frameworks and changes to working time and conditions.

12. How funding will be protected and distributed in the new system

(a) Funding for education and training has never been satisfactorily organised. These reforms present an ideal opportunity to simplify funding streams and provide transparency. The lack of operational detail in the Bill however represents an unacceptable degree of risk to the current level of funding, imperfectly organised though it may be.

(b) There is a clear risk, often stated by CEOs that Trusts under competitive commercial pressure will simply rid themselves of training posts which bring insufficient income. The Secretary of State could not stop them as the Bill currently stands, not even through Clause 17.

(c) Funding should be distributed to LETBs by HEE, and then to LEPs by LETBs on a “real time” basis, ie funding should only be provided where posts are filled. This will protect funding for education and training, prevent Trusts from filling holes in their service budget with unspent training salaries, and allow for more efficient use of training funding. It will encourage Trusts to fill training vacancies and will also ensure equity of provision of study leave monies, levels of which are currently subject to local service financial pressures.

(d) LEPs through LETBs should be audited and accountable to HEE for education and training expenditure.

13. How future healthcare workforce needs are being forecast, and the impact of people retiring from, or otherwise leaving, healthcare professions

(a) Healthcare workforce forecasting is difficult in a stable system, due to the human nature of its constituent parts. However, in the context of a system that is undergoing dramatic change on an almost constant basis, it becomes virtually impossible. Logically, one should decide the structure of the healthcare system required, and by implication the balance of healthcare workers necessary to deliver such a system, before revising the structure of training and commissioning.

(b) In the transitional period of the next few years, it is essential that there is regular consultation between Colleges, CfWI and DH, that allows expertise and data developed within the Colleges’ workforce planning departments, and which is often multi-professional in nature, to be devolved to local recruitment programmes.

(c) The impact of retirements is grossly underestimated. The College’s current workforce database can be manipulated to show the impact of different retirement ages and rates on the numbers of new trainees needed to maintain an adequate pool of trained CCT-holders for vacancies arising across the country.

(d) Pathology service reconfigurations are already being manipulated by Trusts to encourage consultants to retire early, and are likely to increase and accelerate the use of Mutually Agreed Resignation Schemes (MARS), resulting in significant loss of clinical capacity, trainers and training opportunities. Workforce planning is further complicated by these schemes that were not previously foreseen.

14. The place of overseas-educated healthcare staff within the workforce

(a) Many medical specialties, including pathology have relied heavily on overseas-educated staff, in consultant, trainee- and non-consultant career-grade posts. Recent changes to immigration regulations have limited the ability of overseas-educated staff to take up posts, compounding service pressures in many departments.

(b) The focus on providing preferential access for UK-trained doctors to training-grade posts and reduced overall medical training numbers due to funding reductions have resulted in large numbers of vacant training posts in some specialties and Deaneries. This has led to training opportunities that could have been taken up by overseas-trained doctors being wasted.

(c) This College, like many others, is committed to increase overseas trainees’ opportunities through relaxation of the Tier 5 two-year restriction in line with the wishes of its 2,000 overseas Fellows and their governments. This has been the subject of discussions with DfID and UKBA. These trainees offer experience and skills not readily available to UK trainees who must deal with the changing profile of disease intrinsic to an increasingly diverse immigrant population. Such relaxation would also increase opportunities for UK trainees and trainers to work overseas to gain further invaluable experience. This reciprocity is fully compatible with UK government’s overseas aid commitments and an essential part of UK postgraduate medical education.

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

(a) The College has expressed concern from the beginning that these proposals are aimed solely at England. A system that does not acknowledge the movement of trainees within and between the home countries is destined to be limited in its scope and ability to accommodate real-life workforce issues. The devolved nations’ Departments of Health already bypass many of the edicts issued by the English DH that relate to education and training; national person specifications are one prominent example.

16. How the public health workforce will be affected by the proposals

(a) This College and the Academy of Medical Royal Colleges supports the position of the Faculty of Public Health that current proposals for reorganizing Public Health in England would discourage further medical entry into the profession at a time when its involvement in the reorganization of the NHS and the prioritisation of the use of healthcare funding is more important than ever before.

(b) Public Health should be reformed as a specialist health authority reporting directly to HEE and/or DH.

December 2011

Prepared 22nd May 2012