Policy responses and statements

Name of organisation:

The Scottish Government

Name of policy document:

Aspiring to Excellence - Scottish Government's Consultation on Professor Sir John Tooke's Recommendations

Deadline for response:

1 April 2008

Background: Professor Sir John Tooke published his report on Modernising Medical Careers (MMC) "Aspiring to Excellence" on 8 January 2008. This report suggests a reworking of many aspects of postgraduate medical education (PGME) and contains detailed recommendations (full details available at www.mmcinquiry.org.uk). In Scotland, the Scottish Government recognises that some of the recommendations made by Sir John will need further discussion on a UK basis.

This paper focuses on the actions the Scottish Government is taking forward in Scotland. The main sections covered outline the Government's views and planned work being taken forward. Each section has a set of questions to which views and comments were invited.

COMMENTS ON
THE SCOTTISH GOVERNMENT
ASPIRING TO EXCELLENCE - SCOTTISH GOVERNMENT'S CONSULTATION ON PROFESSOR SIR JOHN TOOKE'S RECOMMENDATIONS

The Royal College of Physicians of Edinburgh is pleased to respond to the Scottish Government on its consultation on Professor Sir John Tooke’s recommendations.

Governance and Policy Making Structures

1. In your view, are the current governance arrangements sufficiently robust? What further structures and actions, if any, should be taken to improve governance arrangements in Scotland?

It is imperative that the quality of Scottish medical education is protected and the selection and recruitment procedures fair and equitable. To this end, the College is working closely with the Scottish Academy, NES, PMETB and the Joint Royal College of Physicians Training Board (JRCPTB) over the governance and quality assurance aspects of postgraduate medical education in Scotland and, indeed, across the UK. Training policy, curricula and assessment methods as they apply to physicians should continue to be developed on a UK- wide basis, although there is scope for some local variation in delivery.

The CMO in Scotland must retain an active and prominent role on the Specialty Training Programme Board in Scotland and the UK co-ordinating bodies. This will help retain the support of the profession (at junior and consultant level), whose confidence has been severely damaged after the experiences of 2007.

NHS employers must sign up to the governance arrangements and accept their responsibility for ensuring the quality of training delivered through their hospitals. The proposed Directors of Medical Education will be instrumental in this regard.

The College believes that improved workforce planning is critical to the success of MMC and calls for greater professional involvement at speciality level in the modelling of future workforce numbers. The membership of the Selection and Recruitment Delivery Board should reflect this to ensure the numbers of training posts in Scotland is appropriate.

2. What are your views on what can be done by Scotland at UK level to meet the recommendation made by Professor Sir John Tooke to "Redefine and reassert principles underpinning postgraduate medical education" to ensure UK consistency where appropriate?

The main principles of “Unfinished Business” were to provide greater flexibility within defined training pathways to ensure junior trainees made efficient progress through to CCT. The inflexibility engineered into run-through training as proposed by MMC in 2007 must be corrected, but not at the expense of forcing early choices before trainees have had the opportunity to choose or demonstrate aptitude for a particular career.

Tooke has recommended the abandonment of Foundation Year 2, but the College believes this is precipitous given the emerging evidence of the success of the 2 year Foundation curriculum. The educational arguments for a second generic foundation year still hold true. However, it should be feasible to introduce elements of optional training into the Foundation Year 2 in advance of selection into broad modules in early specialty training.

Run-through training, if continued in Scotland and rejected in other parts of the UK, will present a problem if the numbers of speciality training opportunities is not matched to the core training output. Also, unless the number of training posts is increased there will be many specialities in Scotland where there are few or no opportunities in some years, providing a real disincentive for some of the brightest to remain in Scotland. How critical this becomes may depend on the decision of the House of Lords to allow prioritisation of UK medical graduates for training posts. The College is also unclear whether the Fresh Talent scheme in Scotland may provide a loophole for overseas graduates of Scottish medical schools.

The College remains adamant that medical training should be compatible across the UK given PMETB’s UK powers, and welcomes the linkage of the Scottish Specialty Training Programme Board to the MMC UK Coordinating Board to “ensure UK consistency”. Consideration should be given to strengthening the role of the Coordinating Group.

Finally, Tooke is to be applauded for his emphasis on aspiring to excellence. The Scottish government must ensure Scotland continues its proud tradition of developing the best doctors.

3. What other work do you think should be undertaken in Scotland to improve i) the organisational structure of postgraduate medical education; and ii) the career framework, in Scotland?

1. To ensure local provision is treated with appropriate priority there should be a senior Board member given specific responsibility for postgraduate medical education within each provider health board.

2. Career advice has been limited across the UK and improved provision is required urgently from medical school level upwards. This must include realistic competition ratios and reflect improved workforce planning assumptions.

Given the high achievements and capabilities of those gaining entry into Scottish medical schools, the training focus should remain on producing doctors trained to CCT level to provide expert care to the Scottish public.

Role of Doctor

4. Do you agree there is a need to review the role of the doctor before we can move to a healthcare system delivered by trained doctors?

The College has a fundamental problem with the term “trained doctor”. Indeed, our Lay Advisory Committee fails to see the distinction for a profession that supports life-long learning. Patients require reassurance that the doctor treating them is trained for the task, although he/she may not yet have reached CCT level. We urgently need a new nomenclature which may also be helpful in removing the stigma associated with staff grade and associate specialist roles.

However, the College agrees that a review of the role of the doctor will be helpful for workforce planning (for doctors and other healthcare professionals). This review must gather evidence of the value, unique attributes and costs of employing doctors in the NHS in Scotland. Recent emerging evidence suggests that doctor substitutes (where appropriate) may not offer significant cost savings1 or reflect patient preferences and may increase risk.

The College has commenced discussions with Fellows and Members in Scotland over the role of the doctor in the NHS today, and will expect to participate in the work to be led by the Scottish Association of Medical Directors. Annexe A to this document summarises our early work in this regard.

5. Currently doctors in training are an integral part of service delivery. Do you consider that in future doctors in training should be largely 'supernumerary' to service requirement?

The College believes that it would be a major mistake to treat doctors in training as supernumerary. It would be both wasteful for the service and restrict the quality of clinical training. Doctors learn best by practising within their areas of competence. However, they need more clearly delineated supervision and feedback following service episodes. The balance of service to training will inevitably change with experience.

6. In your view do all services need a judgement safe/unsupervised doctor? If not, which services are the exceptions? How should we take discussions on this issue further?

All services need senior doctors to take ultimate responsibility for patients under the care of a multi-disciplinary team. Similarly, all patients have a right to be treated by a doctor who is “judgement safe” to the appropriate level for the investigation or care required. One of the key professional responsibilities of a doctor is to recognise limitations and seek senior support when necessary. Clearly, the need for supervision declines with training and experience. Judgement safe and unsupervised are separate concepts.

There are particular issues for emergency and out-of-hours services where quality of care will depend on rapid access to a professional with an appropriate level of training. The NCEPOD report published in 20072 clearly illustrates the link between rapid access to senior medical support and improved outcomes for acutely ill patients. This will add to the pressure for additional consultants to provide care on a 24/7 basis.

The medical staffing requirements of different services must be reviewed with input from experienced doctors within the different specialties. This is a clear clinical governance issue and a generic formula is inappropriate. The Scottish Academy is in an ideal position to co-ordinate the input of the different specialties.

7. Do you agree with our approach towards defining the role of a trained doctor? In your view, what other work should we be doing to improve definition of the role of the doctor and/or to improve medical workforce planning.

The College cannot emphasise too strongly the need to engage the profession in workforce planning to ensure that generic and speciality-specific issues are accounted for in both the grades and numbers of doctors required in the future. The College also believes that the public should be brought into the debate about the unique role of the doctor in providing care.

Workforce Planning

8. In your view do you consider it appropriate that the Scottish Government determines medical training numbers? If not, which other organisation/body would be more appropriate and why?

Ultimately, the Scottish Government should determine the medical training numbers to ensure the NHS in Scotland retains the required capacity for service, replacement, growth and other responsibilities ie contributing to the training of doctors from under-developed countries. This should not be left to the discretion of local employing health boards. The numbers should be informed by a robust workforce planning system that involves the medical profession. The College is concerned that the workforce planning systems currently in place are insufficiently sensitive to specialty determinants of growth and have little insight into the retirement plans of the existing workforce. The Federation of the Royal Colleges of Physicians conducts an annual census of physicians across the UK and thus the College has ready access to a wealth of qualitative information to support workforce planning.

9. Please outline any suggestions you have to improve the process for determining the level of controlled medical training numbers.

The College believes that training numbers must reflect the future need for doctors and the training obligations that Scotland may accept for some overseas countries. This will depend on a wide range of variables including service configuration, changing technology, demographic changes in the workforce and legislative influences eg European Working Time Directive, or increased devolution. Planning assumptions must become more sophisticated and employment conditions more flexible.

A national database, linking NES data on trainees with payroll and other data, will provide an improved source of quantitative information and Colleges can support with qualitative information drawn from national or more local College surveys.

Forward planning must offer some security to young people considering a career in medicine, and the training numbers and competition ratios must be updated regularly and placed in the public domain.

Scotland must not adopt an isolationist approach to training given the global market for doctors. Also, Scotland has an international reputation for medical education and this in turn supports the adoption overseas of UK-based medical systems, products and services. The numbers of undergraduate places offered in Scotland should remain sensitive to this international profile. The College believes that Scotland should aim to provide sufficient Foundation Year 1 (FY1) places for all Scottish medical students to allow these young doctors to be registered and accepts it will be a challenge to guarantee this for FY2.

The decision of the House of Lords regarding the guidance on overseas doctors will be critical, as will the replacement guidance proposed by the Department of Health. If overseas doctors or overseas graduates of UK medical schools are entitled to apply for training posts on the same basis as UK nationals, then the numbers in medical school will become more of an issue.

10. Do you have any further views or comments on postgraduate training in Scotland?

Fair implementation of MMC requires effective selection mechanisms, particularly for the popular specialties with high competition ratios. Trainees will expect UK-wide selection processes, particularly given the impact of timing and geography on availability in some specialties.

11. Historically Scotland has trained many more doctors than needed by NHSScotland at a senior level (Calman Review). In your view do you think that Scotland should be trying to align the number of training places with the number of trained doctors required by NHSScotland?

The alignment of numbers must start at medical school. It makes no economic sense to train an excessive number of UK medical students with high expectations and then lose them to Australia and other net importers of doctors due to limited training and career opportunities here in the UK. At present, our highest achievers at school enter medical school, creating a cohort of students with the intellectual ability to acquire and sustain the knowledge to function as high quality doctors. If students perceive their chances of a rewarding career are reducing, they will enter other professions or seek work outside Scotland. The numbers should be aligned with some head room, which can only be determined once the position of overseas doctors is clear and the role of the doctor has been reviewed.

Scottish Advisory Committee on the Medical Workforce (SACMW)

12. Do you agree with our view that the remaining roles of the Scottish Advisory Committee on Medical Workforce could be remitted to NHS Boards?

The College considers that the approval of staff grade and associate specialist posts should remain with SACMW, at least until the workforce planning assumptions and medical training strategies are finalised for Scotland.

Commissioning and Management of Postgraduate Medical Education and Training

13. Do you agree that the development of Directors of Medical Education and flexibilities around regional arrangements will add value and clarity to responsibilities for postgraduate medical education at service level?

As stated in Q.3 above, the College believes that Scotland requires a senior medical officer with responsibility for medical education in each health board and welcomes this development. Funding to support space within job plans for interested applicants will be necessary.

14. What are your views on this role for NHS Education for Scotland, which is different from the organisation in the other UK countries?

The College believes that NES has a valuable role to play in co-ordinating and supporting the Deaneries to deliver high quality postgraduate medical education. The College, through the Scottish Academy, has a key part in the proposed governance structure for postgraduate medical training in Scotland and is contributing to quality assurance and other developments with NES.

Streamlining Regulation

15. What are your views on the recommendation to merge the General Medical Council and the Postgraduate Medical Education Training Board?

The College supports the recommendation to merge the functions of PMETB within the GMC, bringing together the regulatory elements for doctors from medical school through postgraduate training and on to revalidation. The College believes these regulatory mechanisms should continue to be UK-wide.

The College is developing revalidation procedures for physicians jointly with the other 2 Colleges of Physicians and in close co-operation with the GMC. This work is being facilitated through the UK Academy. It is important that revalidation mechanisms are effective and affordable and have the confidence of the profession. The College also believes it is critical that revalidation standards are consistent across the UK, albeit that delivery mechanisms could cope with some local variation.

The College welcomes the proposal to await the results of the English pilots on GMC affiliates before determining the best approach in Scotland.

Structure of Postgraduate Medical Training

16. Do you agree with our view that changes to the structure of postgraduate medical training should await further discussion on the future shape of the medical workforce and that we should minimise that change until that is clearer? If not, why not and what are your suggestions?

The College believes that the structure of postgraduate training to CCT level should be reviewed in the light of evidence as it emerges. The College does not support the recommendation of Professor Sir John Tooke to abandon the 2 year Foundation programme immediately. The results of trainee surveys have mixed results. Tooke spoke with many who were dissatisfied with their FY2 year. However, the recent PMETB trainee survey gave the opposite view. The College feels it will take at least a further 18 months to gather evidence of the efficacy of Foundation and would caution about a rapid non-evidence based decision on Foundation.

The core medical training system for physicians already offers a period of general (core) medical training before selection into speciality. This provides the trainees with time to determine their own preferences and to demonstrate aptitude to aid selection. The development of innovative cross speciality cores eg acute care common stem (ACCS) increases this flexibility and should be continued. The College is working with other Royal Colleges to develop a number of core streams to allow all trainees to enter a more flexible first period of specialist training following their Foundation programme.

The College agrees that the balance of specialist training posts should reflect the (changing) needs of the service in Scotland, but the Government should be aware that for many specialties, numbers should be determined on a UK basis.

There is a need for an early decision regarding the nature of run-through training. The desire for stability in the workforce (both by employers and some trainees) is in direct conflict with concerns about inflexibility. Scotland should remain alert to the dangers of losing trainees to England if run-through training remains and England adopts a more flexible, uncoupled approach. Scotland should consider an uncoupled system with matched numbers of core and specialist posts which would allow fairer competition for the best candidates and deliver high quality trainees in Scotland.

GP Training

17. What are your views on the length of General Practice training and why?

The College supports the changes in the training of GPs to provide a medical workforce in the community that is capable of responding to the service demands of locally based care and extended roles. This must not denude the hospital service of support provided currently by trainees who may seek GP training.

General Questions

18. Do you think that any of the proposals set in this consultation document will raise any specific issues for any of the equality groups (including race, disability, age sexual orientation, gender or religion and belief)?

None anticipated, providing there is adequate provision within workforce plans for those seeking less than full-time training opportunities and that selection procedures do not discriminate against applicants from other parts of the UK or create barriers for those seeking to move outside Scotland.

19. Do you have any other comments you would like to make?

References

1. Impact of nurse practitioners on workload of general practitioners:randomised controlled trial. Laurent MB, Hermens RP, Braspenning JC, Sibbald B, Grol RP. BMJ, 2004 Apr 17; 328

2. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Emergency Admissions: A journey in the right direction? (2007)

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[28 March 2008]

ANNEXE A
THE ROLE OF THE DOCTOR

This working document begins to distil key aspects of the role of a doctor, identifying the essential blend of qualities and the key respects in which the role of the doctor may have changed over recent times. It has been informed by the views of Fellows and Members and our Lay Advisory Committee.

Definitions of Medical Professionalism

Medical professionalism is at the core of the role of the doctor:

“The first duty of a doctor must be to ensure the well being of patients and protect them from harm – this responsibility lies at the heart of medical professionalism”.Defining Medical professionalism for better patient care. Roser and Dewar for the Kings Fund, November 2004.