Health CommitteeWritten evidence from the Severn Deanery, NHS South of England (ETWP 56)

This submission will focus on Postgraduate Medical Education. Severn Deanery is a medium sized Deanery in the South West, which has approximately 2300 trainees and covers a geographical area from Swindon to Taunton. It encompasses eight cities and 12 Trusts including Dental and Primary Care. We believe ourselves to be educationally-strong and in the recent GMC trainees’ survey 80% of our specialties are in the Top 10 nationally, 43% in the Top 5 and 23% in the Top 3.

1. The right numbers of appropriately qualified and trained healthcare staff at national, regional levels

1.1 There are approximately 50,000 trainees in the UK who are being trained in 65 main specialties and 34 sub-specialties. We support the desire for UK to be self-sufficient. Since 2007, the Medical Programme Board has been able to produce national trainee and speciality specific data which has resulted in the recruitment process being more efficient and closely tiered to the workforce needs.

1.2 90% of workforce planning works well. Unfortunately when this is not the case then the remaining 5–10% attracts a lot of attention. This has particularly happened in recent years in Obstetrics & Gynaecology and Cardiac Surgery where over-production turned to drought very quickly.

1.3 There is a failure to understand how workforce planning is carried out. Some Trusts feel that within a Local Education Training Board (LETB) they will be able to expand their specialty posts. In fact to expand a speciality needs agreement of the Specialty Association, Centre for Workforce Intelligence (CfWI), the Specialist Advisory Committee (SAC), the Lead Dean, and national numbers with WAPPIG.

1.3.1By 2020 we estimate that England will be producing around 5,898 CCT holders, of which 3,132 will be in General Practice and 2,766 in the remaining specialties.

1.4 CfWI is still developing and in the next two to three years will be able to deliver hard data.

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

2.1 All specialties and sub-specialties have a curricula that is approved by the General Medical Council (GMC) and produced by the Specialty Associations and the Royal Colleges. A key role for the Deanery is to ensure that the curriculum is being delivered and assessments take place.

2.2 Service models often tend to be five years behind the curve of technology. Therefore to be innovative and embrace service design, there needs to be a much more creative and slicker approach.

2.3 Although less than 5% trainees struggle and have to have their training extended, there is nevertheless a small cohort of 0.1% or less who may need to be removed from a programme because of failure to progress. To remove such trainees can result in employment tribunals which are expensive

2.4 Medical postgraduate trainees and students attend a generic professional and skills course where medico-legal as well as ethical standards are taught.

2.5 Patient safety is the first domain of the GMC quality management process. Recent cases, such as the Mid-Staffordshire experience, have demonstrated that trainees also have a role in highlighting when patients are put at risk or given inadequate care. Therefore there needs to be a triangulation between the Care Quality Commission (CQC), the Trusts, GMC and Deanery reports from their quality management visits. Severn Deanery led on developing shadowing with a week-long induction for Foundation Year 1 doctors to reduce errors and improve patient safety.

3. The contribution that all providers and commissioners of healthcare (both NHS and non-NHS) play an appropriate part in developing the future workforce

3.1 Medical training programmes tend to be long and complicated. Primary Care is unusual in having a three-year programme; for most specialties it’s around about eight years. Oral Maxillofacial Surgery (OMFS) is at the other extreme where trainees have to have both a medical and dental degree and it can take almost 18 years to get a CCT and a Consultant position.

3.2 The concept of commissioners and providers is an inappropriate tool for education. Education commissioning is facilitated through Deaneries. There is no large scale commissioning as happens with non-medical numbers which are contracted with universities.

3.3 The second area of confusion is about how education is funded. The funding is not controlled by the Deaneries. Currently the funding comes from the Treasury to DH and then to Strategic Health Authorities (SHA) who pass on the funding to Trusts and PCTs through the Learning Development Agreements (LDA). The Deanery does not have any control over the funding and acts in an advisory capacity. This makes it difficult to move funds between specialties and Trusts. The current scenario is far too bureaucratic especially as to develop primary care some funding may need to be removed from secondary care. Given flexibility, the Deanery and the Postgraduate Dean as the senior responsible officer for this budget would be in a good position, to support and develop new innovative programmes which are cost effective and meet the service needs.

3.4 Trainees are under pressure to deliver the service commitment. This is increasingly more so because of the European Working Time Regulation (EWTR) and the David Nicholson challenge to reduce service costs of £20 billion over the next four years.

3.5 Education delivery depends on educational and clinical supervisors being given sufficient time to make sure that the curriculum is being delivered and the assessments are being carried out and trainees are being supported. This activity is usually part of the consultant SPA and job planning contracts. There is a real squeeze on this in the Trusts and use of SPA time needs to be more clearly defined, and where it is utilised for education, this should be strongly supported by the management.

4. 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 multi-disciplinary and multi-professional leadership however, the term multi-professional is misunderstood and for some people this means all professions learning together in a classroom. There are specialised curriculum and assessments which are appropriate for each healthcare workforce and then there is generic learning that is common.

4.2 A good way of developing multi-professional and multi-disciplinary learning is through simulation which includes communication skills, team working, and human factors training with a priority for patient safety.

5. High and consistent standards of education and training

5.1 This is our highest priority. A key way to ensure that high and consistent standards are being delivered is through the GMC trainees and trainer surveys. Severn Deanery has the highest national return in the trainee and trainer surveys.

5.2 Additional kite marks are:

Each postgraduate school’s annual reports.

Exam success rates.

Annual trainee assessment outcomes.

The GMC quality assurance of the Deanery.

Feedback from the generic and professional skills training and the appraisal for trainees and trainers.

Deans also have national roles.

Where there are red flags on the trainee and trainer survey, these are looked at by Quality Panels which also have trainee representation.

6. Developing the existing workforce and re-skilled for the future

6.1 Service design and workforce is about five years behind the technological and innovation curve that occurs. In addition, innovation does not happen in a rigid top-down structure. For innovation to succeed there is the need to create learning and working environments that allow freedom of thought, motivation, support, engagement of staff through conversations, working in teams and give departments the ability to develop and innovate.

6.2 A good example is the National Surgical Interface Fellowships which are led on by the Severn Deanery.

6.3 The NHS is good at coming up with ideas but embedding good practice takes far too long. The future with academic health science networks and embedding of ideas which make for efficient and effective patient care, particularly though integrated patient care pathways, would be the preferred way forward.

7. Open and equitable access to all careers in healthcare for all sections of society

7.1 Currently women make up about 60% of intake in medical schools. There is not only just the gender change but also the Y generation who have portfolio careers and will not be working full time in medical practice.

7.2 Therefore workforce planning needs to take this into account.

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

8.1 We have concerns about this. The NHS Commissioning Board and Health Education England (HEE) are still embryological, the Future Forum has not reported yet, the CfWI is also developing and the Health & Social Care Bill is still going through Parliament. In the background is the David Nicholson challenge of producing savings of £20 billion over four years. See hosting in section 9.

9. The future of postgraduate deaneries

9.1 One of the biggest challenges is the failure of the service, as well as DH, to understand Deanery functions with request to host this in a service model. The majority of Deanery staff and virtually all of its functions are carried out in the service. All the clinical supervisors, educational supervisors, heads of schools, training programme directors, directors of medical education are all based in the service. This lack of understanding has created misconceptions about what a Deanery really is.

9.2 The Severn Deanery paper on Deanery Functions is attached with this submission. There has been huge support nationally for Deaneries, in particular, from the trainees, the GMC, the BMA, the Academy and the Future Forum.

10. The future of Health Innovation and Education Clusters (HIEC)

10.1 This has had a limited impact primarily because the scale and funding was reduced to £1 million. With the future being developed more in innovation and academic health science networks, then our expectation would be that the HIEC would be subsumed into that organisation.

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

11.1 We welcome the statement from the Education Outcomes Framework that the Secretary of State should have a responsibility/leadership role to deliver on education and training.

12. The proposed role, structure, governance and status of Health Education England

12.1 We welcome that the HEE will be responsible for the Multi Professional Education and Training (MPET) budget. This should prevent some of the top-slicing that happens due to pressures on service delivery. We also welcome that delivery of education and training would have a educational and finance governance line to HEE. It has already been suggested that one way of Postgraduate Deans having externality with the local delivery arm is to have employment by HEE. This may overcome the issue about hosting of Deaneries. Hosting in this context refers to employment contract, terms and conditions of service and HR support.

12.2 We believe that the Chair of HEE should sit on the NHS Commissioning Board to make sure that education and training has a strong voice.

12.3 Medical Programme Board as an advisory group to HEE should be maintained.

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

13.1 The Royal Colleges have primacy and the duty of formulation and development of curricula. Engagement with the service and also local needs would be important to integrate to ensure that the curricula are fit for purpose. The regulator GMC has a key role in this.

14. The implications of a more diverse provider market within the NHS

14.1 Education and training has suffered due to poor planning within different sectors. For instance, the first generation of Independent Sector Treatment Centres (ISTCs) did not have education and training as part of their development. The next generation did and 30% of their payment was to support education. However, this funding should not have been made available until the ISTCs were able to deliver education and training. Many never achieved this status.

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

15.1 Non-NHS does benefit greatly by the training and education delivered in the NHS sector. One must be cognisant of the fact that many non-NHS sectors do wish to engage with education and training and are willing to provide placements. This has been our experience for instance with aesthetic reconstructive surgery.

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

16.1 We agree with the five domains of the Education and Training Outcomes Framework.

17. The role of the Centre for Workforce Intelligence

17.1 CfWi is still developing and it will probably take another couple of years to bed down and start making a real contribution. Their ability to provide data analysts and start developing sophisticated models for the future is essential.

18. The role of NHS Employers

18.1 They are an important and key stakeholder in the delivery of patient care as well as education and training and this relationship needs to be given a high priority.

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

19.1 The £5 billion education and training budget will be hosted by HEE and then be devolved to local/regional organisations such as LETBs. Exactly how LETBs will engage with the academic health science network is not clear and it is possible that it will be the Academic Health Science Network that drives the LETB. However, there needs to be a very clear finance governance arrangement between HEE and the provider organisations to make sure that the funding for education and training is utilised for that purpose. The role of the Postgraduate Dean is critical in this matter. To be innovative we feel that the Deaneries should be empowered to have more freedom in how the budget is utilised such as developing different training models including simulation which complement service models. (See Section 12)

20. How future healthcare workforce needs are being forecast

20.1 See sections 1–3.

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

21.1 The traditional male doctor who worked full time is being replaced by new generation of both female and male doctors who have portfolio careers and will be contributing part time. Some of the work pressures, particularly bureaucratic pressures, mean that innovation is restricted and productivity goes down. It is estimated that something like 13% of the Consultant/GP workforce plan to retire over the next two years. The other forecast is that possible 26% of the workforce will retire over the next five years.

22. The place of overseas educated healthcare staff within the workforce

22.1 This is an area of high importance. If the UK wishes to be at the leading edge of research, integrated care pathways and innovation then it has to develop good relationships with the rest of the world. In recent years, the UK has lost out to North American and Australian universities.

22.2 The GMC does engage with International Medical Graduates but can do much more particularly over registration.

December 2011

Prepared 22nd May 2012