Health CommitteeWritten evidence from the Committee of English Deans (ETWP 49)

1. The Committee of English Deans welcomes the opportunity to provide written evidence to the Health Select Committee. The Committee of English Deans represents all the postgraduate medical deans in England. In formulating this response, the English deans are mindful of the collective responsibility to maintain the function of high level programme management and oversight of all 56,000 medical and dental trainees currently in training programmes across the UK, to ensure a high quality supply of medical and dental workforce; enabling them to enter the next stage of their training smoothly, exit into general practice, consultant or staff grade posts, facilitating their access to a carefully constructed and quality assured range of experiences and supervision to ensure that they complete their training with the competences and capabilities expected of them. In addition to this essential function in ensuring a secure supply of doctors and dentists (and in some cases other health care professions) with the right skills in the right place at the right time, postgraduate deans are also responsible in statute as Responsible Officers (RO) of the General Medical Council (GMC) for all medical trainees with respect to medical revalidation. The deaneries play a vital role in ensuring safe patient care.

Our evidence follows the questions set out by the Health Select Committee.

The right numbers of appropriately qualified and trained healthcare staff (as well as clinical academics and researchers) at national, regional and local levels

2. All the English deans work at a national and regional level taking an active role in medical workforce planning. Each of us has responsibility as a Lead Dean, working with one or more medical royal colleges to manage the cohort of training numbers, leading selection and recruitment and working to manage aspirations in popular specialties and encourage medical students and trainees to consider less popular specialties. We work with NIHR to support and develop academic programmes. We manage the annual progression of all our medical trainees, to ensure that they meet the GMC and college standard to exit from their specialty with a certificate of completion of training.

3. Professor Sir Peter Rubin has most eloquently clarified the essential nature of role of the doctor. We must ensure that our future medical workforce is able to: synthesise conflicting and incomplete information; manage uncertainty; manage a range of competing priorities; identify and manage risk; be decisive deliver and be compassionate and accept ultimate responsibility for their actions.

4. The deaneries ensure that the doctors completing the programmes have clinical as well as research, education and leadership skills. We also work closely with our provider trusts and training practices to ensure that the senior doctors responsible for providing education and training have the necessary skills. We are working with the new shadow Local Education and Training Boards to match training output to future workforce needs and to develop the commissioning and delivery of multiprofessional education and training for the future workforce.

5. We have faced a series of challenges:

Funding to increase the numbers of doctors training for general practice has become increasingly difficult to secure. The funding streams for general practice training are different from those in hospital training and as we have expanded the opportunities to deliver the GP curriculum this has had an impact on service delivery.

Reducing the number of trainees in specialties where reductions are necessary has resulted in service gaps in that specialty.

Allowing trainees time to widen their skills through out of programme opportunities to pursue research or health aid programmes has left gaps in the training programme and a service pressure.

The doctors of tomorrow have difficulty attaining the experiences and skills that they will need to deliver the future health care because they are essential to health care delivery today. We have difficulty for example enabling more learning in the community and outpatients when trainees are needed to deliver service on the wards.

That training curricula reflect the changing nature of healthcare delivery, including the medico-legal context

6. All English deans ensure that the training programmes within their deanery meet the standard set by the medical royal colleges and approved by the GMC. Each dean in their lead dean role reviews any changes to the curricula and ensures that they reflect the changing nature of healthcare delivery.

7. We continue to face challenges:

Although we have increased the training opportunities in primary care, we still have insufficient capacity and funding to allow all foundation trainees an opportunity to include four months in general practice and thereby understand the complete patient journey.

Much of out of hours care is delivered by doctors in training, this combined with the 48 hour week and insufficient consultant presence outside the normal working day reduces the opportunities for trainees to learn the full range of patient care, particularly the care of patients in outpatient setting.

That all providers and commissioners of healthcare (both NHS and non-NHS) play an appropriate part in developing the future workforce

8. All English deans work actively within their SHA boundaries to ensure that, where appropriate, all health care providers take an active role in medical education and training; this includes the independent sector, the third sector and primary care. We also work actively to engage those responsible for commissioning healthcare; we are concerned for example that a change in referral pattern can have a negative impact on the ability of our local health care trusts to deliver the curricula.

9. Postgraduate deaneries are in an unusual position. Most of our activity involves leading, managing and contracting for medical education at a local level. We work closely with commissioners of other healthcare education in Strategic Health Authorities. We hold local education providers to account through a learning and developmental agreement which encompasses the GMC standards for training. We also have a role in specialist activities for which there is a need for both a wide perspective and specific expertise. For example training the trainers and providing support for trainees in difficulty, particularly those of a complex nature as most local education providers have insufficient expertise and experience in managing the more complex cases and the work is time consuming with a high risk of litigation if handled inadequately.

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

10. The postgraduate deans have already established a range of opportunities for doctors in training, and those who have completed their training to develop skills in leadership. Many of our programmes offer opportunities to learn alongside other professions. For example the Emerging Clinical Leaders Programme which has activity in most parts of the country specifically brings together a range of healthcare professionals. Other activity includes work between the deans and the Royal College of Physicians in their “Learning to Make a Difference Programme”.

High and consistent standards of education and training

11. All the English postgraduate deans are actively involved in ensuring high and consistent standards of education and training. We use a variety of methods, including questionnaires to trainees and trainers, site visits, focus groups and soft intelligence to identify the strengths and weaknesses of our training sites and through the Learning and Development Agreement set specific goals so that every medical training placement meets or exceeds the GMC standards. We work with the Academy of Medical Educators and the medical royal colleges to ensure that our trainers are striving to meet the agreed standards and in particular are leading through example in patient involvement. Many doctors associated with the postgraduate deaneries are GMC partners and associates, contributing to the quality assurance process. Although they will all receive training for their specific GMC role, much of their intrinsic knowledge has been developed through their work in the deaneries.

12. Postgraduate deans are responsible for ensuring the delivery of in training assessments and approval of completion of training for all doctors in training. Deans are the final point of appeal against assessment outcomes for trainees and the experience and expertise of the deans in this regard ensures that doctors entering the workplace are both capable and competent.

That the existing workforce can be developed and reskilled for the future (through means including post-registration training and continuing professional development)

13. Almost all the activity of the deaneries relates to post-registration doctors and dentists. Some deaneries have responsibility for other professions for example Kent Surrey Sussex is responsible for the pharmacy trainee workforce. Deaneries also work with provider trusts and practices in reskilling doctors who have been identified by the GMC or through appraisal as not meeting the expected standard.

Open and equitable access to all careers in healthcare for all sections of society (by means including flexible career paths)

14. Postgraduate deans and deaneries are committed to equality of opportunity and many of our teams work actively in schools to widen participation.

With these key themes in mind, the Committee will look at:

Our response focuses on the areas where the deaneries have major responsibility:

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

15. The postgraduate deans are most concerned to ensure that our key functions continue seamlessly through transition. We have been particularly concerned that our workforce who have a wealth of specialised knowledge to manage our functions are potentially depleting with the long period of uncertainty and the limitations on recruitment to permanent positions. Although this is being actively monitored through Medical Education England we are concerned that we are taking on new areas such as revalidation of doctors in training without additional resource.

The future of postgraduate deaneries

16. Medical training is very different from most other healthcare professions; doctors spend as long, sometimes twice as long in postgraduate/post registration training as in undergraduate training (some, those in less than full time training, may spend 20 years or more in postgraduate training). The regulation of postgraduate certification of doctors is heavily dependent on assessment of performance in the workplace which in turn is dependent on trainees having the opportunity to work with and learn alongside skilled clinicians who are also skilled in education and assessment. The work of deaneries is complex, ensuring that each of the 65+ specialty and 30+ subspecialty curricula are delivered to the agreed standard and managing a small cohort of individuals who, for whatever reason, are unable to progress through training.

17. Postgraduate deans have increasingly taken a national role, contributing to the strategic thinking on the medical workforce and with their detailed knowledge of medical education to the development of the profession.

18. The majority of our work relates to the NHS but each of us has close working relationships with our local universities and each deanery has delegated responsibility for the pre-registration year. We firmly believe that deaneries should be aligned with the NHS.

19. We are concerned that the dean in particular, as leader of the deanery, should be on the board of any provider led organisations within his or her geographical area. However, we remain concerned that the dean should be employed by or at least have clear accountability to Health Education England and should retain independence from the provider led organisations in order to effect change when standards are not being met.

20. Any future system design needs to resolve some of these issues and address where the following functions reside:

Holding to account—increasing value through driving up quality and reducing cost. This includes an accountable point of contact for regulators.

Ensuring capability and capacity—developing training and education providers where necessary.

Developing and preparing for the future—through proactive workforce planning that works with, but looks beyond the workforce horizons of, clinical commissioners.

Leading for and with the system—looking after smaller providers and professions and occupying the negotiating space between regulators, professional bodies, unions, the service and DH/Public Health England/HEE.

Developing innovative solutions to workforce challenges.

The future of Health Innovation and Education Clusters

21. The Health Innovation and Education Clusters are still relatively new and many have not yet had an opportunity to complete their initial projects. We consider that their functions could be subsumed by the provider led organisations.

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

22. As service and training are inextricably linked there must be firm connections between commissioning of service and commissioning of training at all levels.

23. Health Education England needs a structure which will ensure that high quality education and training continues and is developed. Any regulatory standards must be met. The paragraphs above have described some of the local issues that postgraduate deaneries have encountered and they will continue despite architectural change. Doctors in training do not necessarily choose to work where there is the best training; many other factors need to be taken into consideration. Equally trainees do not always choose to train and then practice where there is greatest workforce demand.

24. The current process of quality assurance as set out by the General Medical Council is predicated on quality control of local education providers through their own internal processes, quality management by the postgraduate deanery and quality assurance by the GMC. If the deanery functions in relation to quality assurance are housed in the healthcare provider skills networks, which is made up of and is commissioned by the local education providers there is a significant risk of conflict of interest. This will not be the case for other professions where the main provider of education is a higher education institution. We therefore believe that the quality management function currently undertaken by deaneries must continue as it forms an essential component of the GMC Quality Improvement Framework.

25. The Medical Programme Board has established considerable harmony across the varied stakeholders involved in medical education and training, we hope it will continue. We also believe that there would be considerable merit in a modified form of the current Committee of English Deans becoming a subcommittee of HEE or Medical Programme Board.

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

26. As described above the relationship between the Local Education and Training Boards and the postgraduate deaneries is key. There may be merit is considering the deanery separately from the Postgraduate Dean. The deanery will need to be housed in a legal entity. For most of our activity this could be one of a number of organisations.

27. However, the level of litigation from doctors in training continues to rise; the postgraduate deans and their deaneries are seen as the key to entry to the specialist register or achievement of full registration. The consequences of losing a case are significant, not only because of the significant (often multi million pound claims) financial penalty but also the reputational damage. This responsibility may influence the willingness of NHS organisations to take on the hosting arrangements for the deanery. The whole will be made more complex if the dean and deanery is accountable to the organisations which were responsible for training provision for the litigant.

28. There are times when postgraduate deans have to stand firm over standards and times when we need to alert the General Medical Council to unacceptable practice/behaviour. We could find a conflict of accountability if we are employed by and report to a provider organisation.

29. Finally the Postgraduate Dean is the Responsible Officer for revalidation and must be licensed to practise to undertake this role. He or she will therefore need a Responsible Officer. It clearly could not be a medical director of one of the local provider organisations. One solution could be that the postgraduate deans report to and are revalidated by the Director of Education of HEE but this is only possible if that person is medically qualified and licensed.

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

30. For the medical profession all the curricula are approved by the GMC.

The implications of a more diverse provider market within the NHS

31. As explained medical training is long and much is based in a clinical setting. If the diverse provider market limits the opportunities for training because the clinicians delivering the service do not meet the GMC standards for trainers or the environment is unsuitable the supply of the future workforce will be put at risk. The postgraduate dean is well placed to advise the provider networks what is and is not possible to ensure safe training and secure supply.

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

32. The Education and Training Outcomes Framework is still at a high level and is insufficiently detailed to determine whether or not it will marry with the expectations of medical regulation. The MEE Task and Finish Group on Medical Quality Metrics struggled to identify meaningful outcome measures for medical education where no single organisation is responsible for the duration of a doctor’s training.

The role of the Centre for Workforce Intelligence

33. The Centre for Workforce Intelligence is still relatively new. It is essential that HEE has an overview of workforce plans and ensures that small specialties and those with a national perspective including most of the medical specialties are managed through national coordination.

How funding will be protected and distributed in the new system

34. The English Deans consider that there must be protection of funding for education and training to include the direct costs as allocated through the MPET budgets and also the indirect costs. The latter includes all the consultant time invested in developing curricula and assessment methodologies, time invested in quality management and quality assurance and time invested in the annual review of progression, all of which are essential to securing the supply of the future medical workforce and most of which are achieved through good will. There is continual pressure to achieve greater clinical output at the expense of education and training.

The impact of people retiring from, or otherwise leaving, healthcare professions

35. The impact of potential loss of the Clinical Excellence Awards and changes to pensions could be an increase rate of retirement of senior doctors many of whom hold key positions in the deaneries and colleges. Replacing the expertise and the corporate memory will be extremely difficult.

December 2011

Prepared 22nd May 2012