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Review into the regulation of education and training

By Mike Broad - 8th February 2010 12:29 pm

The GMC is going through an enormous period of change, with the introduction of revalidation, the merger with PMETB and the shift in responsibility for adjudication in fitness to practise cases to the Office of the Health Professions Adjudicator.

In September 2007, as part of the inquiry into Modernising Medical Careers, Sir John Tooke recommended that: “PMETB should be assimilated in a regulatory structure with the GMC that oversees the continuum of undergraduate and postgraduate medical education and training, continuing professional development, quality assurance and enhancement.”

This was accepted by the government and PMETB is due to merge with the GMC in April.

Although the merger will bring regulatory responsibility for the whole of medical education and training under one roof, this consolidation of functions will not, in itself, achieve the full benefits envisaged by Sir John Tooke’s report.

To ensure that those benefits are realised the GMC invited Lord Naren Patel to lead a review of the current arrangements for the regulation of medical education and training and make recommendations that would inform future policy developments by the GMC.

The review’s draft report makes 27 recommendations to the GMC and they are currently out to consultation. Here is a summary:

1. All those involved in developing the skills and commitment of doctors must fulfil their responsibilities if the UK is to provide world class training. The GMC was urged to enhance links with other key interests, such as training providers and regulators.

2. Regulation has to reach across the different stages of doctors’ education and learning and support their transitions. Effective systems need to be developed for the transfer of information across all different stages.

3. Medicine is both a profession and a vocation. One of the goals of undergraduate medical education is to instil a culture of professionalism, and to begin the process of induction into the profession, that will inform doctors’ practice throughout their careers. It has been argued that the current undergraduate experience does not always achieve this and that student registration could be one way of fostering professionalism and a sense of professional identity. However, the review panel was not convinced. Instead it called on the GMC to evaluate the effectiveness of its existing arrangements for engaging with students and how professionalism is fostered by medical schools.

4. Newly qualified doctors need to be able to deliver the same standard of care regardless of where they qualified. Until now the GMC has set high level standards and allowed medical schools considerable flexibility in the way those standards are met. It must evaluate the effectiveness of the new requirements in delivering outcomes that are consistent and reliable to determine whether further measures are needed to achieve these ends.

5. Anomalies with the regulation of the Foundation Programme need to be addressed. Doctors in the first year of their foundation training may be working many miles from the medical school which is formally responsible for their training. This leads to an unsatisfactory lack of clarity over responsibilities. Equally unsatisfactory is the lack of any clear regulatory outcome required from the second year of the Foundation Programme.

6. The GMC should develop a framework for the accreditation of trainers. It should also look at the case for accrediting the environments in which education and training takes place, in addition to approving posts and programmes as currently undertaken by PMETB.

7. Above all, the GMC should develop a regulatory framework for the education and training of doctors in career posts. This is not only in the interests of the doctors concerned (who are often disadvantaged by limited access to training and CPD opportunities), it will also provide reassurance that these doctors are meeting national standards overseen by the regulator.

8. The public and employers must have confidence in the medical registers, and in the fitness to practise of doctors entering those registers. One factor militating against this is the lack of equivalence between the standards required of UK and European doctors entering the specialist and GP registers. The GMC should explore how this might be addressed. It proposes that European specialists and GPs should only be eligible for inclusion on the medical registers ‘at the point of first revalidation following completion of training’. This would require the GMC to uncouple the completion of specialist and GP training from the decision to allow a doctor onto the specialist or GP register. The move, it says, ‘could provide a mechanism for continuing to meet EC requirements in relation to recognition of training while ensuring greater equivalence in standards at the point of entry to the specialist and GP registers’.

9. The GMC should also examine, with the Department of Health, the current legislative anomaly that makes it possible for doctors not on the specialist register to take up locum consultant posts.

10. At the conclusion of specialty or GP training, participation in CPD is key to maintaining and further developing competence and performance. In 2004, the GMC issued guidance on CPD, but its regulatory role to date has been largely passive. Revalidation will provide a new focus for ensuring effective and appropriate CPD for all doctors but it will require the GMC to re-examine its role in this area. At the very least, it should provide clear guidance on what doctors will be required to do to keep up to date for the purposes of revalidation and the role of CPD within that.

11. The GMC should re-examine the current focus on assuring the quality of the processes used for training doctors. Instead, it should consider placing greater emphasis on outcomes and the quality of the individual trainees produced by those processes. What matters to patients is the quality of the doctors who treat them, not the processes by which they were trained.

Commenting on the report, Niall Dickson, chief executive of the GMC, said: “We have a great opportunity now to create a system in which every stage of education and training is fit for purpose, successfully prepares the doctor for the next one, where standards are constantly rising and which treats all doctors fairly, wherever they come from and whatever stage they are at in their careers.

“I hope the consultation stimulates debate and encourages as many as possible to comment on the conclusions and recommendations of the draft report. This will help us set the way ahead and ensure a robust approach to the regulation of education and training in the years to come.”

Doctors can consult on the recommendations until 9 March. A final report will be submitted to the GMC at the end of that month. Read the full list of recommendations.

Read more on the GMC’s corporate strategy 2010 to 2013.

Tags: GMC, Training
Posted in Features | 2 Comments »

European doctors could face quality check in UK

By Mike Broad - 19th January 2010 4:24 pm

A major review of the regulation of doctors’ education and training has taken the first steps in controlling the quality of European doctors entering the UK.

The review’s draft report makes 27 recommendations to the GMC a head of it taking over the regulation of the whole of medical education in April, following its merger with the Post Graduate Medical Education and Training Board.

The report challenges the automatic inclusion of senior European doctors, with supposedly equivalent qualifications, on the specialist register.

Member states of the European Economic Area are required by law to recognise the qualifications of each others’ doctors. It means that the GMC cannot carry out additional assessments of knowledge and skill.

‘This clearly limits the effectiveness of the registers and the ability of the GMC to protect patients,’ the report says.

It proposes that European specialists and GPs should only be eligible for inclusion on the medical registers ‘at the point of first revalidation following completion of training’. This would require the GMC to uncouple the completion of specialist and GP training from the decision to allow a doctor onto the specialist or GP register.

The move, it says, ‘could provide a mechanism for continuing to meet EC requirements in relation to recognition of training while ensuring greater equivalence in standards at the point of entry to the specialist and GP registers’.

Last year, consultant anaesthetist John Hutchinson campaigned for greater monitoring of European locums, while last week an inquiry started into the circumstances surrounding the death of a patient at the hands of a tired, German locum GP.

The independent review, commissioned by the GMC and chaired by Lord Naren Patel, covers the entire career of a doctor, from the first day at medical school to the last day in practice.

On revalidation, the report says: ‘At the very least, the GMC should provide clear guidance on what doctors will be required to do to keep up to date for the purposes of revalidation and the role of CPD within that.’

It also calls on the regulator to focus on delivering the outcomes required from training, rather than simply assuring the process. ‘What matters to patients is the quality of the doctors who treat them, not the processes by which they were trained,’ the report says.

This review is taking a long-term look at the future regulation of medical education and training as a whole and considering how this fits in with the GMC’s other responsibilities.

Niall Dickson, chief executive of the GMC, said: “We have a great opportunity now to create a system in which every stage of education and training is fit for purpose, successfully prepares the doctor for the next one, where standards are constantly rising and which treats all doctors fairly, wherever they come from and whatever stage they are at in their careers.

Doctors can consult on the report until 9 March. A final report will be submitted to the GMC at the end of that month.

Tags: GMC, Overseas doctors, Training
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Compulsory training considered for foreign doctors

The Guardian - 11th January 2010 6:08 pm

Compulsory training and induction programmes for doctors who have never worked in England before are among measures being examined in a government safety review following the case of a German doctor who accidentally killed a patient on his first out-of-hours locum shift in this country.

Also under discussion is the creation of a national database that would allow NHS organisations and private providers to check whether applicants for GP work had failed in previous attempts. Employers could also find out more easily whether doctors had formal warnings or disciplinary restrictions on the work they could do when they moved from different parts of the country.

Measures to standardise the ways local NHS trusts check applicants’ standard of English and medical competence are being studied too as part of a broad review of out-of-hours work being led by David Colin-Thomé, the Department of Health’s director of clinical care, and Steve Field, chairman of the Royal College of General Practitioners who has already championed such measures. The General Medical Council, the profession’s regulator, says it is willing to hold the data nationally. Ministers would have to approve the package.

The GMC is also stepping up its campaign to change rules for recognising medical qualifications across the EU. It wants doctors from Europe to face tests on their knowledge and skills before being added to the professional register in this country, just like doctors from other parts of the world, but a European commission review of the rules is not planned until 2012.

Will the WTD review get to the truth?

By Mike Broad - 6th January 2010 5:23 pm

As far as the government is concerned, the implementation of the 48-hour for juniors has had no impact on either clinical care or the training of juniors. When the Working Time Directive (WTD) is criticised, the stock response is that there’s no evidence to suggest they’ve been compromised.

They have, however, acknowledged juniors’ concerns about their training and, back in July, at the eleventh hour, asked Medical Education England (MEE) to conduct a review.

It’s been a long time coming but, just before Christmas, MEE announced the review was underway. MEE has appointed Professor Sir John Temple, former president of the Royal College of Surgeons of Edinburgh and chair of the Specialist Training Authority, as review chair.

Sir John and his expert group will soon be listening to oral evidence, and this will include focus groups and face-to-face meetings. A final report is due to be presented to the health secretary by April.

Evidence is now the big issue. The government believes the PMETB Survey of Trainees for 2009 supports its current position. There is, however, a growing body of evidence which contradicts this just not from ‘official’ sources.

A survey by Remedy showed a high level of rota non compliance among juniors. Then a large survey among surgical trainees showed that two thirds felt training was being compromised. And then there’s the small matter of record numbers of junior doctor vacancies as more people are required to fill rotas. Are you telling me this isn’t compromising care?

Sir John needs to cast far and wide in his search for evidence. Often ignored, frontline doctors have important stories to tell. Mr Peter Mahaffey, consultant surgeon in Bedford, recently dropped me a line. He said: “There can barely be a senior consultant surgeon anywhere who hasn’t witnessed the extraordinary reduction in practical skills amongst trainees and more frighteningly the relative helplessness of new consultant colleagues fresh from this neutered training.”

He was responding to an article by Mr Munchi Choksey, consultant neurosurgeon at University Hospitals Coventry and Warwickshire NHS Trust, which criticised the Royal College of Surgeons for not having done more to resist the implementation of the WTD.

Sir John has to get beyond the usual suspects and canvass frontline opinion. The acquiescence of many of the profession’s representatives, including many of the royal colleges and the BMA, has brought the profession to this crisis point.

He also needs to park the knighthood, retain his independence and be prepared to tell the health secretary some hard truths about the impact of the 48-hour week, as I’m sure a rigorous evidence search will reveal.

Will this review simply re-arrange the deck-chairs on the Titanic? I hope not. Tomorrow’s patients also deserve confident, highly trained and experienced hospital doctors.

Tags: MEE, Training, WTD
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Call to postpone review of training funding

By Mike Broad - 15th December 2009 11:27 am

The Department of Health should halt their review of training funding as it threatens to cut millions of pounds from junior doctor training, the BMA claims.

The review of the Multi Professional Education and Training Levy (MPET) which will decide the future of how NHS training funding is distributed is currently underway and changes could start rolling out as early as April 2010.

The review deals with the funding of both undergraduate education and postgraduate training for all healthcare workers, and is seeking to better reward excellence in medical education. MPET is likely to be replaced with a tariff-based system where the funding follows the student or the trainee.

But, the BMA’s junior doctor committee passed a motion at its recent meeting expressing serious and urgent concerns in the principles and assumptions underpinning the review.

It is calling on the Department of Health to postpone implementation until all the information in the MPET budget is made available for external independent review; all the research relating to the review is made public; and, the underlying funding principles for external review and stakeholder agreement are explicitly stated.

It is also calling for full and meaningful engagement with all stakeholders in all stages of review and decision-making and for the use of quality metrics.

Fears concern proposals to cut the money paid to trusts for the provision of undergraduate medical education. Current funding of between £10,000 and £100,000 a year for each student is to be replaced with a flat rate of £40,000.

Funding that trusts receive for the salaries of junior doctors is also likely to be re-allocated to fund only the education and training element of posts and not the service contribution.

Dr Shree Datta, chair of the BMA’s Junior Doctor Committee, is concerned the review will make it more expensive for hospitals to employ juniors.

She said: “We are seriously alarmed that the impact of this review has not been thought through. The idea that the NHS could press ahead with this as early as next year is simply dangerous.

“Fully trained doctors don’t grow on trees and the Department of Health needs to be very careful that they don’t end up making the training of doctors so unattractive or the funding system so unstable that hospitals no longer want to do it.

“The time has come for this review to stop and for the Department of Health to listen to the serious concerns of the medical profession.”

I’m one year wiser, while the NHS is none the wiser

By Stephen Campion - 25th November 2009 1:55 pm

I woke up on Tuesday morning with the realisation that a further year had been added to my age. The next form I fill in will no doubt make me say “no surely that can’t be right” as I begrudgingly supply the required details.

But as I drove to a meeting outside Northampton I had time to reflect on the ageing process and suddenly realised how lucky I am. Compared to the NHS whose age is marginally older than my own, I counted myself fortunate that I have not needed cosmetic surgery to keep going, whilst the NHS has endured countless operations under the guise of service reconfigurations, organisational restructuring, strategic re-alignment or indeed performance management.

But if human beings get wiser with age, I wondered whether that also applied to the NHS? By the time I arrived at my destination I had worked out that we, mere mortals, do get wiser because we learn from experience. I wish the same could be said of the NHS. The NHS is a modern marvel when it comes to technology and its ability to promote scientific advance. But has it matured with experience?

If anything, the NHS is becoming less experienced as it gets older. Medical training is a case in point. Trainees’ hours in the log book are considerably less than a few years ago - that is not because there is less to learn, far from it.

Consultants are spending less time working in the wider interest of the NHS because trusts are fixed on short-term targets, blind to the longer term benefits consultants can bring to the NHS by active participation with their royal colleges.

There are few chief executives who can claim to have been in post for more than five years; and when it comes to NHS monitoring and quality standards the goal posts seem to move every season.

Getting older is no bad thing if we learn from our experiences, use them to shape the future and share them with those following on behind. But, as the NHS gets older, I worry that those following on will have no-one to learn from.

Tags: Targets, Training
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College seeks to extend juniors’ training

By Mike Broad - 23rd November 2009 10:42 am

The College of Emergency Medicine wants to extend the duration of training for the specialty because there is now insufficient time to develop experienced consultants.

It is due to submit an application by 23 December to the Postgraduate Medical Education and Training Board to extend higher training by a year.

Currently, emergency medicine trainees do two years of Acute Care Common Stem (ACCS) followed by four years in specialist training (ST3 to ST6). The intention is to add an additional ACCS year.

Dr Wayne Hamer, consultant in emergency medicine and chair of the training committee at the college, explained that the request is because the ACCS curriculum and assessment system is large and complex and the trainees need this additional time.

Dr Don MacKechnie, vice president of the College of Emergency Medicine, said the gradual reduction of hours over recent years - with the reform of training and WTD - had compromised the volume of cases doctors working in emergency medicine handled.

“Emergency medicine is a broad church and you can never get too many cases to improve your understanding,” he said. “We’ve just lost too many hours out of the system for the trainees to acquire those competencies they require to become consultants in the specialty.”

Medical Education England were asked by the government earlier this year to review the WTD and its impact on training and appointed Professor Sir John Temple as their review chair. He’s due to report early next year.

A number of other colleges are believed to be considering applications to extend training but are awaiting the outcome of the review.

Dr Richard Marks, head of policy at pressure group Remedy, commented: “The calibre of British consultants in the past was based on their breadth of clinical experience, and appointment to the grade signified that a level of expertise had been reached.

“Modernising Medical Careers set out deliberately to shorten the length of training and narrow the breadth, and it is surprising that it was so widely supported. The shortening of hours has exacerbated the situation. We welcome the planned move by the college to extend training, and hope other colleges will consider doing the same.”

Remedy called on PMETB to be proactive and review all the training programmes they approved a few years ago in the light of the new working and training patterns.

PMETB said the request would receive consideration when it was received. Hamer said if PMETB decline the request the college will still look to expand ACCS to three years and cut higher training by a year to accommodate it.

Tags: Training, WTD
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Funding review threatens training posts

By Francesca Robinson - 18th November 2009 9:25 pm

A shake up in the way clinical training is funded by the NHS could result in trusts axing junior doctor and medical academic posts, the BMA fears.

The proposed changes could destabilise the NHS, claims junior doctors’ committee (JDC) vice chair Dr Tom Dolphin.

The Department of Health has been reviewing education funding in England because it is no longer considered to be fairly distributed between different organisations or professions. It believes the current system also fails to reward quality in education.

The current Multi-Professional Education and Training levy (MPET) is likely to be replaced with a tariff-based system where the funding follows the student or the trainee.

There are proposals to cut the money paid to trusts for the provision of undergraduate medical education. Current funding of between £10,000 and £100,000 a year for each student is to be replaced with a flat rate of £40,000.

Funding that trusts receive for the salaries of junior doctors is also likely to be re-allocated to fund only the education and training element of posts and not the service contribution.

Trusts currently receive 100% funding from the DH for the salaries of foundation doctors but this is to be cut to 80%. Funding for ST1, ST2 and ST3 doctors is to be cut to 40% and for ST4 doctors to 25%.

Savings from these changes are intended to free up money for training nurses, midwives and other healthcare professionals. Trusts will receive a placement allocation of £90 per student week for this group.

A decision by the DH on the proposed changes is imminent and the new system is likely to be run as a ‘shadow’ programme from April so that trusts can prepare for the shift in funding over a transition period of up to four years.

Dolphin said they were concerned about the speed of the review. He said: “We are deeply concerned that the massive shifts in funding that will occur could result in the loss of many medical academic posts. This means that there will be insufficient staff to train the next generation of doctors let alone carry out research.

“We’re talking about changing the flow of several billion pounds through the NHS, and we can’t be sure that at the end of it employers are still going to find it worth their while to have junior doctors.”

He said the JDC was not satisfied that the impact of the review has been thought through properly and they did not feel the DH had any clear idea how they will measure quality of training even though the changes are designed to shift money in order to incentivise and reward high quality training.

“Consultants and GPs don’t grow on trees and the Department of Health needs to be very careful that they don’t end up making the training of doctors so unattractive, or the funding system so unstable, that hospitals will no longer want to do it.”

NHS Employers head of programmes David Grantham admitted there would be “pain” for some trusts which had been receiving thousands of pounds more for training doctors than others.

But he said: “I don’t think there is anything here for junior doctors to worry about. This is about a redistribution of funding rather than an attempt to cut junior doctor training posts. Some trusts will lose money but others will gain. It might mean that some hospitals will be willing to lose a few training posts but others might be able to expand their training.”

A spokesman for Medical Education England, which has been providing independent expert advice on the review, said: “We are supportive of moves to tackle historical difficulties in this area and of work to ensure greater transparency about funding for clinical training.

“However, we have expressed concern during this ongoing debate about any potential impact, whether intended or unintended. We believe that any proposed changes should be piloted and introduced slowly, with the full engagement and support of appropriate stakeholders and backed by evidence where it exists.”

Tags: Academic posts, Funding, MPET, Training
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“The next generation will not be up to it”

By Mike Broad - 11th November 2009 1:12 pm

It’s a truism that every generation of consultants thinks their trainees will not be as good as them. The view is often that they do fewer hours, see less cases, seemingly show less understanding and appear less committed.

This week two research papers support this prejudice.

The first, in the BMJ, suggests that it takes about 20,000 hours of practice for a surgeon to master the specialty: 10,000 hours for the cognitive skills and 10,000 hours for the manual.

This equates to 4,000 hours a year over a five-year training programme.

The authors suggest that under a 48-hour week juniors are clocking up about 2,300 hours a year making it 11,500 over a five-year period.

They quote the classic sociological analysis of surgery Forgive and Remember, which states: “Surgery is a body contact sport, there is no question about it. You can’t be a good armchair surgeon.”

I think you can probably guess their conclusions.

Can you train a physician effectively in 11,500 hours of practice? I’ll leave that one for you to decide, but the quiet acceptance of the 48-hour week by the non-surgical royal colleges speaks volumes.

The second research paper this week highlighting the frailties of the next generation was to be found in the pages of the journal Health Policy. It examined senior doctors’ perceptions of whether their medical graduates were ready to become doctors.

The answer was a resounding “no”. Consultants and SpRs in two teaching hospitals gave less than flattering feed back on a wide range of practical and clinical skills, from the ability to perform basic respiratory function tests to prescribing and advanced communication.

The authors in part blame the GMC guidance - Tomorrow’s Doctors - for not being more prescriptive about the skills newly qualified doctors require.

Should we smile at this time honoured tradition of underestimating the younger generation, or should we be genuinely worried?

After all, the good old bad days weren’t that good. The hours might have been longer, the commitment necessarily high, but who knows what the standards were like at times.

Of course, the other big difference was that medicine itself was simpler 20 or 30 years ago. Modern medicine is infinitely more complex and interventional, which creates another problem.

At the same time as working hours are being reduced and training re-modelled, practice is advancing and becoming more technical and specialist. And that’s without even considering the impact of the downturn on the NHS and how that will affect training and staffing budgets in the future. Or, more consumerist and demanding patients.

This level of change is the problem and we should indeed be worried about our future standards of care.

Few organisations are fronting up to the problem in public. In an increasingly consultant-led and delivered healthcare system, we are in real danger of having under-cooked trainees. Improved training techniques and use of technology are only going to go so far. There isn’t going to be a significant extension to work hours once more regardless of what government is in power.

So the answers lie in either an extension to training or the creation of some half-arsed sub-consultant grade. I know which I think is better for both the profession and patients.

Tags: Sub-consultant grade, Training, WTD
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Surgical trainees between a rock and hard place

By Ed Fitzgerald, president of the Association of Surgeons in Training - 4th November 2009 11:06 am

Surgical training has come a long way in a short time. I type this as I take the fast train up to London this morning, where I’m joining a meeting to review the new curriculum for general surgery with PMETB.

The curriculum, the ISCP website, and the Schools of Surgery supporting training in England, have all done much to revolutionise surgical training in recent years. Arguments remain about trainees shouldering the costs of this, and considerable frustration surrounds the hoop-jumping, user-unfriendly ISCP training website. However, there can be no doubt that surgical training has now been pushed to its rightful place at the top of the agenda.

The elephant in the room remains the working hours in which this training package is delivered, and the deleterious impact of the Working Time Directive. The arguments surrounding WTD have been recited many times - that frequent handovers and the lack of continuity of care harms training and patient safety, and that the skeleton (increasingly non-resident) cover does likewise. The rise of the shift system takes trainees away from both their firms and also core day-time training opportunities, amplified by the unnecessary forced ‘zero hours’ following on-calls.

Surgery finds itself in a particularly vulnerable position. As a post-graduate craft speciality, the apprenticeship model falls short when restricted working hours prevent trainees from learning their craft. Despite what some non-surgeons argue, no amount of high-technology simulation can replace this (and in any case, no-one is proposing to fund this).

So trainees now find themselves stuck between a rock and a hard place. Although the framework that supports surgical training has seen major development in the past decade, at the coal-face there has been little change in how hospitals facilitate training on a day-to-day level within the NHS. A reduction in working hours against this backdrop is disastrous.

The volume of survey responses received by ASiT and BOTA is testament to the strength of feeling generated amongst surgical trainees by this issue. They value their training, and they see it deteriorating in front of them day-by-day. Worse still, they find themselves in the unenviable position of skating around the rules and coming in to work on days off in order to progress their training. This unregulated ‘grey rota’ is not safe, not sustainable, and no way to train a modern surgeon in the 21^st century.

A compromise on working hours is not the complete solution for surgical training, and no-one is suggesting it is. Professor Eraut’s recent report flagged up many problem areas. Other initiatives will be required, such as concentrating training in the hands of dedicated trainers, and concentrating trainers in units accredited and funded for this. However, the pace of change in the NHS is painfully slow and any such modernisation will take many years to approve, fund and implement.

We must take a pragmatic view of the NHS we are currently faced with. An increase in hours is vital to enable adequate training within these current constraints. Only in this way can we prevent creating another lost tribe of surgical trainees without the skill, confidence and experience to give our future patients the care they deserve.

Tags: Surgeons, Training, WTD
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