Tooke MMC Inquiry

The principles underpinning postgraduate medical education and training should be redefined and reasserted, building on those originally articulated in Unfinished Business but in particular emphasising flexibility, ‘broad based beginnings’ and an aspiration to excellence. In devising policy objectives the interdependency of educational, workforce and service policies must be recognised.

All four Departments of Health in the UK and the four Chief Medical Officers must be involved in any moves to change medical career structures. In many instances it seems likely that the Department of Health in England will continue to have a lead role but from time to time, collective agreement may determine that lead responsibility for specific issues passes to another Health Department and/or its Chief Medical Officer. Regardless of which Department leads, accountability should be explicit and every effort made to acknowledge the views of the four countries.

DH should have a coherent model of medical workforce supply within which apparently conflicting policies on self-sufficiency and open- borders/overproduction should be publicly disclosed and reconciled. We recommend that overseas students graduating from UK medical schools should be eligible for postgraduate training as should refugee doctors with the right to remain in the UK.

DH Workforce should urgently review its medical workforce advisory machinery to ensure that it receives integrated and independent advice on medical workforce issues to inform/complement SHA and local deliberations. Both national and devolved workstreams must be adequately resourced. The medical workforce advisory machinery should also take account of national policies impacting on the workforce such as the shift of more care to the community. Revisions to the current arrangements need to reflect the following principles: N Medical workforce planning needs to embrace the consensus view of the role of the doctor and roles of other healthcare professionals referred to in Recommendation 5 N Plans should be based on robust information on available and projected medical specialist skills, requiring relevant databases. N Whilst recognising that doctors are just one part of the workforce, sufficient attention and resource needs to be devoted to medical workforce planning reflecting doctors’ crucial roles and the expense involved in their development. N A national perspective needs to be integrated with regional requirements including the views of service, particularly with regard to the maintenance of sufficient subspecialty expertise to meet the needs of the nation, and the overall health of clinical academia. Consideration should be given to the creation of an arm’s length body, NHS Medical Education England, NHS:MEE, mirroring NIHR to undertake commissioning of higher specialist training that is not required in every locality. The criteria for the award of such training positions should reflect the Trust’s performance in relation to training, innovation and clinical outcomes. N Professional advice to the medical workforce advisory machinery needs to include that from doctors at the cutting edge of their discipline with the foresight to project potential developments in healthcare. The Panel believes that this might best be accomplished through arrangements that mirror those in place for the previous Medical Workforce Standing Advisory Committee (MWSAC). N Regional workforce plans should be subject to a national oversight and scrutiny advisory committee with service, professional and employer representation. Such oversight should encourage local responsiveness and acknowledge issues facing the devolved administrations whilst ensuring national consistency on roles and standards. N Modelling capacity should be enhanced by drawing on the expertise in the University sector, e.g. health economists, epidemiologists, modellers etc. The assumptions underlying projections should be subject to professional scrutiny and regular review.

The Panel recommends that DH should work with the GMC to create robust databases that hold information on the registered/certificated status of all doctors practising in the UK. This will provide an inventory of the contemporary skill base and number of trained specialists/subspecialists in the workforce, as well as those in training for such positions, to inform workforce planning.

The content of higher specialty training and the numbers of positions will be informed by dialogue between the Colleges, Deaneries, employers, and medical workforce advisory machinery to allow finer tuning of the nature of the specialist workforce to reflect rapidly evolving technical advances and the locus of care.

Explicit policies should be urgently developed and implemented to manage the transitional ‘bulge’, caused by the integration of eligible doctors into the new scheme, with appropriate credit for prior competency assessed experience.

DH should recognise the burgeoning supply of medical graduates it has commissioned and make explicit its plans for the optimal use of their skills for the benefit of patients. It is recommended that sufficient numbers of Core Specialty training posts (see Recommendation 33) should be made available to accommodate doctors successfully completing FY1 and the use of commissioning funds for this purpose should be monitored.

Career aspirations and choices should be informed by accurate data on likely employment prospects in all branches of the profession and the likely competition ratios based on historical data, supplemented by professionally agreed foresight projections. Such information should be updated annually by the redesigned medical workforce advisory machinery and made publicly available so as to inform would be medical students, students and trainees. Medical schools should play a greater role in careers advice including i) information in prospectuses concerning career destinations and likely competition ratios, ii) offering selective components of the programme to allow experience in discrete specialties, iii) formal personalised advice/mentoring.

The medical profession should have an organisation/mechanism that enables coherent advice to be offered on matters affecting the entire profession. In relation to postgraduate medical education and training we recommend that NHS:MEE assumes the coordinating role.

There should be enhanced opportunities for training in medical management during postgraduate training years to fuel an increase in clinically qualified managers and an awareness of the interdependency of clinicians and managers in the pursuit of optimal healthcare.

Policy development should be evidence led where such evidence exists and evidence must be sought where it does not.

Doctors in training should be better represented in the management structures of Trusts to ensure that they better understand service pressures and priorities and Trusts better appreciate their service role and training needs. The majority opinion of those involved in the delivery of medical education and training is that training budgets remain vulnerable if not ring-fenced for the purpose. With the devolution of training budgets to SHAs in England and cutbacks imposed in 2006/07 to resolve overall NHS financial balance that vulnerability was realised. It is not clear that the SHA is the appropriate level to commission all postgraduate medical education. Furthermore the funding structure in England is flawed and there are insufficient incentives to become involved in postgraduate medical education. In addition to the anxieties about the current commissioning arrangements the management and governance of postgraduate medical education and training is complex involving, in England, SHAs, Postgraduate Deaneries and service providers. At present Deanery arrangements in England do not encourage career flexibility nor the necessary collaboration to optimise equity of access to specialist expertise across the country. Central accountability is unclear. Such complexity is enhanced by the lack of co- terminosity between SHA and Deanery boundaries. Employer and service links with Deaneries are suboptimal. The cohesion of Deanery function across England is also lacking. NHS Trusts’ engagement does not adequately recognise their accountabilities as employers of trainees. Employer and service links with management structures for postgraduate training must be strengthened. There is little relationship to local Universities/Medical Schools other than in the first Foundation year in the majority of Deaneries in England (in contrast to the Devolved Administrations) despite clear demands throughout the history of the NHS for close collaboration. On the other hand, medical schools’ involvement in Foundation training has been largely token, and other than in highly specialist centres, their contribution to postgraduate training limited, with the exception of clinical academic careers. Such arrangements are in marked contrast to the situation in many other developed countries. The value of such linkages is obvious in relationship to access to educational expertise and relevant bespoke courses that reflect local needs. In recent years there have been several expensive, poorly evaluated healthcare training initiatives. Cost efficiencies are likely to flow from adopting evidence based or critically evaluated approaches to education and training that acknowledge the necessary educational foundations for a particular professional role. Such approaches demand close dialogue with Higher Education providers. Notwithstanding the 6 THE COMMISSIONING AND MANAGEMENT OF POSTGRADUATE MEDICAL EDUCATION AND TRAINING 40% 50% 30% 20% 10% Excellent Good AUKUH Fair Weak 0% Acute Non-AUKUH 32% 16% 47% 34% 18% 42% 3% 8% Quality of Service 06/07 (Source: Healthcare Commission data) educational benefits that could derive from a stronger partnership there is also increasing evidence that solid health:education sector partnerships drive up healthcare quality: those Trusts in England which major on education and research achieve higher scores in Healthcare Commission ratings compared to those that do not. CONSULTATION RESPONSE The creation of a DH Director level lead for medical education, review of SHA commissioning of training and contracts for PGMET, as well as review of the English Medical Postgraduate Deanery relationships and accountabilities received strong support. Support for the trialling of ‘Graduate Schools’ was slightly less enthusiastic (69% in agreement/strong agreement compared with 9% in disagreement/strong disagreement). There was very considerable support for introducing mechanisms to incentivise Trusts to engage fully in PGMET and for Medical Directors assuming a key role in this regard. Interim Recommendation 21 A suitably qualified Director level lead for medical education within DH should be identified and act as the reference point for interactions with the medical profession including postgraduate Deans. The relationship and accountability of this lead to the following should be explicit: CMO, DH Head of Workforce, NHS Medical Director, and medical educational leads within devolved administrations. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 48.61% 421 35.91% 311 13.51% 117 1.39% 12 0.58% 5 Interim Recommendation 22 Recognising i) the importance of linking workforce supply and demand, ii) the very recent devolution of workforce commissioning function to SHAs in England, we recommend that this situation prevails for the moment for initial Postgraduate Medical Training subject to the forging of closer links at all levels with the Higher Education sector. A formal review of the compliance with Service Level Agreements between DH and the SHAs relating to commissioning training and the functionality of the arrangements should be undertaken in 2008/9. Any deficiencies should prompt urgent consideration of a National Institute for Health Education (as outlined in Recommendation 12) assuming the commissioning function. Interim Recommendation 23 Funding flows for postgraduate medical education and training should accurately reflect training requirements and the contributions of service and academia. The current MPET Review should lead to a clearer contractual basis reflecting both agreed volumes and standards of activity and should recognise the service contribution of trainees and the resources required for training. Interim Recommendation 24 The Medical Postgraduate Deanery function in England should be formally reviewed to address whether i) the relationships and accountabilities are currently optimal ii) the present arrangements meet redefined policy objectives of optimal flexibility in postgraduate training and aspiration to excellence, and the NHS imperative of equity of access. Any new arrangements should conform to redefined principles, referred to in Recommendation 1, co-developed to govern postgraduate training. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 34.07% 291 41.22% 352 22.01% 188 1.52% 13 1.17% 10 Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 57.71% 494 34.81% 298 7.13% 61 0.12% 1 0.23% 2 Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 46.61% 399 37.85% 324 13.55% 116 1.52% 13 0.47% 4 Interim Recommendation 25 Postgraduate Medical Deans should have strong accountability links to medical schools as well as SHAs in line with Follett appraisal guidelines for clinicians with major academic responsibilities. Such arrangements will improve links with medical pedagogical expertise and will facilitate the educational continuum from student to continuing professional development. Interim Recommendation 26 Reflecting the fact that Postgraduate Medical Education and Training involves service, academic and workforce dimensions, it is proposed that the Foundation School concept be developed further as Graduate Schools, on a trial basis initially, where supported locally. The characteristics of such Schools, the precise nature of which would depend upon local circumstances and relationships, need to reflect the crucial interface function played by the medical Postgraduate Deanery between the service, the profession, academia and workforce planning/commissioning. Graduate Schools would involve Postgraduate Deans, Medical Schools, Clinical Tutors, Royal College and Specialist Society representatives and would have strong links to employers/service and SHAs. The Graduate Schools could also oversee the integrated career development of the trainee clinical academic/manager (see Recommendation 41), as well as NIHR faculty. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 44.06% 378 37.06% 318 13.52% 116 3.96% 34 1.40% 12 Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 33.18% 283 35.52% 303 22.27% 190 6.92% 59 2.11% 18 Interim Recommendation 28 Responsibility for the local delivery of postgraduate medical education and training should form part of the explicit remit of Medical Directors of Trusts. Part of that responsibility should include regular reporting to Trust Boards on the issue. Interim Recommendation 29 Training implications relating to revisions in postgraduate medical education and training need to be reflected in appropriate staff development as well as job plans and related resources. Compliance with these requirements should form part of the Core Standards. Interim Recommendation 27 To incentivise Trusts to give education and training sufficient priority they should be integrated into the Healthcare Commission’s performance reporting regime. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 60.82% 520 27.60% 236 9.24% 79 1.75% 15 0.58% 5 Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 57.68% 492 31.30% 267 7.27% 62 3.28% 28 0.47% 4 Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 57.53% 493 35.47% 304 6.18% 53 0.58% 5 0.23% 2

The CMOs as leads for Medical Education will interact with NHS:MEE and equivalent structures in the Devolved Administrations as the reference point for interactions with the medical profession over matters relating to PGMET.

Recognising i) the importance of linking workforce supply and demand, ii) the very recent devolution of workforce commissioning function to SHAs in England, we recommend that this situation prevails for the moment for initial Postgraduate Medical Training subject to the forging of closer links at all levels with the Higher Education sector. A formal review of the compliance with Service Level Agreements between DH and the SHAs relating to commissioning training and the functionality of the arrangements should be undertaken in 2008/9.

Funding flows for postgraduate medical education and training should accurately reflect training requirements and the contributions of service and academia. The current MPET Review should lead to a clearer contractual basis reflecting both agreed volumes and standards of activity and should recognise the service contribution of trainees and the resources required for training.

The Medical Postgraduate Deanery function in England should be formally reviewed with respect to whether i) the relationships and accountabilities are currently optimal ii) the present arrangements meet redefined policy objectives of optimal flexibility in postgraduate training and aspiration to excellence, and the NHS imperative of equity of access. Any new arrangements should conform to redefined principles, referred to in Recommendation 1, co-developed to govern postgraduate training.

Postgraduate Medical Deans should have strong accountability links to medical schools as well as SHAs in line with Follett appraisal guidelines for clinicians with major academic responsibilities. Such arrangements will improve links with medical academic expertise and will facilitate the educational continuum from student to continuing professional development.

Reflecting the fact that Postgraduate Medical Education and Training involves service, academic and workforce dimensions, it is proposed that the Foundation/Specialty School concept be developed further as Graduate Schools, on a trial basis initially, where supported locally. The characteristics of such Schools, the precise nature of which would depend upon local circumstances and relationships, need to reflect the crucial interface function played by the medical Postgraduate Deanery between the service, the profession, academia and workforce planning/commissioning. Graduate Schools would involve Postgraduate Deans, Medical Schools, Clinical Tutors, Royal College and Specialist Society representatives and would have strong links to employers/service and SHAs. The Graduate Schools could also oversee the integrated career development of the trainee clinical academic/ manager (see Recommendation 41), as well as NIHR faculty.

To incentivise Trusts to give education and training sufficient priority they should be integrated into the Healthcare Commission’s performance reporting regime.

Responsibility for the local delivery of postgraduate medical education and training should form part of the explicit remit of Medical Directors of Trusts. Part of that responsibility should include regular reporting to Trust Boards on the issue.

Training implications relating to revisions in postgraduate medical education and training need to be reflected in appropriate staff development as well as job plans and related resources. Compliance with these requirements should form part of the Core Standards.

DH should formally consult with the medical profession and the NHS on all significant shifts in government policy which affect postgraduate medical education and training, workforce considerations, and service delivery and ensure that concerns are properly considered by those responsible for policy and its implementation.

PMETB should be assimilated in a regulatory structure within GMC that oversees the continuum of undergraduate and postgraduate medical education and training, continuing professional development, quality assurance and enhancement. The greater resources of the GMC would ensure that the improvements that are needed in postgraduate medical education will be achieved more swiftly and efficiently. To this end the assimilation should occur as quickly as possible.

Under the Medical Act, Universities already have responsibility with regard to FY1. By breaking the employment linkage with FY2, it will be possible to guarantee an FY1 position in the new graduate’s local Foundation School subject to prevailing local selection processes. The employment linkage between FY1 and FY2 should cease for 2009 graduates.

FY1 should be reviewed to ensure that i) harmonisation with year 5 is optimised; ii) the curriculum more clearly embraces the principles of chronic disease management as well as acute care; iii) competency assessments are standardised and robust. In future doctors in this role should be called ‘Provisionally Registered Doctors’. 8.2 Core Training The concept of Core Training replacing current FY2/ST1/ST3 is entirely consistent with the ‘broad based beginning’ principle expressed by Unfinished Business. CONSULTATION RESPONSE The relevant Interim Recommendations received strong support, albeit with a significant minority (18%) disagreeing with the ‘abolition’ of FY2. Interim Recommendation 33 Foundation Year 2 should be abolished as it stands but incorporated as the first year of Core Specialty Training. The current commitment to FY2 GP placements should continue as part of Core Specialty Training and developed further as resources permit. Doctors in Core Specialty Training should be called Registered Doctors. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 51.02% 400 22.19% 174 9.06% 71 7.40% 58 10.33% 81 Interim Recommendation 34 At the end of FY1 doctors will be selected into one of a small number of broad based specialty stems: e.g. medical disciplines, surgical disciplines, family medicine, etc. During transition, ‘run-through’ training could be made available after the first year of Core, for certain specialties and/or geographies that are less popular than others. Core Specialty Training will typically take three years and will evolve with time to encompass six six- month positions. Care will be taken during transition to ensure the curricula already agreed with PMETB are delivered and the appropriate knowledge, skills, attitudes and behaviours are acquired in an appropriately supervised environment. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 50.13% 392 28.01% 219 9.21% 72 7.03% 55 5.63% 44 Interim Recommendation 35 For those doctors who do not know to which Core Specialty to commit at the end of FY1 there will be the capacity to take up to 2 years in hybrid rotations allowing experience in four main Core areas. Experience in the subsequently selected Core area will count towards the completion of Core Specialty training subject to successful competency assessment. Interim Recommendation 36 Colleges should work together with the Regulator and service to devise modularised curricula for Specialist Training to aid flexibility/transferability. They should also devise common short-listing and selection processes that have been standardised across the country to allow sharing of assessments between Deaneries. This work should be completed within two years.

Foundation Year 2 should be incorporated as the first year of Core Specialty Training. This will require broad based ‘theming’ of the current FY2 provision. The acquisition of competences of the current Foundation Programme should continue across FY1 and first year of Core pending formal review of this curriculum and development of detailed Core curriculum objectives. The current commitment to FY2 GP placements should continue as part of Core Specialty Training and be developed further as resources permit. Doctors in Core Specialty Training should be called Registered Doctors.

At the end of FY1 doctors will be selected into one of a small (e.g. 4) number of broad based specialty stems: e.g. medical disciplines, surgical disciplines, family medicine, etc. During transition, ‘run-through’ training could be made available after the first year of Core, for certain specialties and/or geographies that are less popular than others. Core Specialty Training will typically take three years and will evolve with time typically to encompass six six-month positions. Care will be taken during transition to ensure that the curricula already agreed with PMETB are delivered and the appropriate knowledge, skills, attitudes and behaviours are acquired in an appropriately supervised environment.

For those who remain uncertain regarding career destination there will be opportunities for competitive transfer between the Core stems during years one and two. For a minority, therefore, Core training might thus extend to 3.5 to 4 years.

Colleges, Specialist Societies and Service should work together to provide modularised curricula for Specialist Training, overseen by NHS:MEE working in conjunction with the relevant authorities in the Devolved Administrations. In this way it will be ensured that the curricula forwarded to the Regulator for approval will embrace the necessary transferability/flexibility as well as the needs of service. 8.3 Selection into Higher Specialist Training We deal with this Issue here and so consider Interim Recommendation 40 out of sequence. In the Interim Report it was stated that the selection system for Specialty Training needs to take greater account of clinical experience, CV and academic achievement. It was insufficiently tailored to take account of the particular aptitudes required for particular specialisms and the specialist professional viewpoint. Inclusion of both would enhance face validity of such a high stakes exercise. It was also asserted that in general terms the selection system overweighted competence, a concept with limited discriminatory function, over excellence. Such considerations are particularly relevant for highly competitive specialties. The single annual application date and the very large size of some Units of Application created problems both for organisations and for candidates. CONSULTATION RESPONSE 81% of consultees agreed/strongly agreed with the proposals for the development of selection into higher specialty training. Interim Recommendation 40 Selection into Higher Specialist Training to the role of Specialist Registrar will be informed by the Royal Colleges working in partnership with the Regulator. The Panel proposes that in due course this will involve assessment of relevant knowledge, skills and aptitudes administered several times a year via National Assessment Centres introduced on a trial basis for highly competitive specialties in the first instance. A limited number of opportunities to repeat the National Assessment Centre tests following further experience will be determined. Candidates will apply via Postgraduate Deaneries or Graduate Schools. Application will take place three times a year on agreed dates. Save in the most exceptional of circumstances, candidates will be restricted in the number of local programmes to which they may apply (and to the number of occasions on which they may apply).They will use a common national form with specialty specific questions and will provide their standardised assessment Core/ranking along with a structured CV. This will avoid the once a year appointment system with its inherent risks to service delivery. Graduate Schools linked to the 30 UK Medical Schools would reduce the size of Units of Application and address the family-unfriendly situations that arose therefrom. Shortlisted candidates will be subject to a structured interview for final selection.

Satisfactory completion of assessments of knowledge, skills, attitudes and behaviours will allow eligibility for i selection into Staff Grade positions in the relevant broad area or ii selection into Higher Specialist Training. Doctors in Higher Specialist Training, in all specialities including general practice, will be known as Specialist Registrars.

Staff grade positions must be destigmatised and contract negotiations rapidly concluded. A new nomenclature should be agreed with those in such positions. The advantages of the grade (accrual of experience in chosen area of practice, consistent team environment) need to be made clear. Doctors in these posts should have access to training overseen by Postgraduate Deaneries and CPD opportunities. They should be able to make a reasonable limited number of applications to Higher Specialist Training positions according to the normal mechanisms. The capacity to achieve CESR through the Article 14 route and CEGP through Article II should be retained.

Doctors should be allowed to interrupt their training for one year or longer by agreement to seek alternative experience that enhances their career and contribution to the NHS, having regard to service need. The Regulator in conjunction with the Royal Colleges will determine whether experiences should contribute to completion of training subject to appropriate competency assessment. Postgraduate Deaneries and the Regulator should positively facilitate such experiences.

Changes to the structure of postgraduate medical education and training should be consistent with the policy objectives and conform to agreed guiding principles.

Selection into Higher Specialist Training to the role of Specialist Registrar will be informed by the Royal Colleges working in partnership with the Regulator. The Panel proposes that in due course this will involve assessment of relevant knowledge, skills and aptitudes administered several times a year via National Assessment Centres introduced on a trial basis for highly competitive specialties in the first instance. A limited number of opportunities to repeat the National Assessment Centre tests following further experience will be determined. Candidates will apply via Postgraduate Deaneries or Graduate Schools. Application will take place three times a year on agreed dates. Save in the most exceptional of circumstances, candidates will be restricted in the number of local programmes to which they may apply (and to the number of occasions on which they may apply).They will use a common national form with specialty specific questions and will provide their standardised assessment score/ranking along with a structured CV. This will avoid the once a year appointment system with its inherent risks to service delivery. Graduate Schools linked to the 30 UK Medical Schools would reduce the size of Units of Application and address the family-unfriendly situations that arose therefrom. Shortlisted candidates will be subject to a structured interview for final selection. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 44.23% 341 37.35% 288 10.12% 78 5.58% 43 2.72% 21 8.4 ‘Post Core’ Careers The Panel believes that subject to the fulfilment of relevant competency assessments all UK medical graduates should have the opportunity to complete Core postgraduate medical training. Satisfactory completion of Core will allow eligibility for selection into Higher Specialist Training or redefined Staff Grade positions that we termed ‘Trust Registrar’. The Interim Report identified the risk that those appointed to FTSTA posts in August 2007 could become the new ‘lost tribe’ as they may not all have accrued the same postgraduate experience as those completing Core training in the future, nor necessarily spent sufficient time in postgraduate positions to be eligible for staff grade positions. The potential attraction of Staff Grade positions was revealed at the trainee workshops that informed the Interim Report. To realise that potential there must be clear opportunities to compete for Specialist Training positions for those so inclined and the maintenance of the CESR route to the Specialist Register. All doctors should be in receipt of some training. Training and development opportunities will be a crucial part of the new contract which still remains to be agreed. To build on career enhancing opportunities during Core training, and in the interests of flexibility, ‘out of programme’ activity should be facilitated for those in ‘post Core’ careers. CONSULTATION RESPONSE There was strong support for the relevant recommendations (37–39) Interim Recommendation 37 Satisfactory completion of assessments of knowledge, skills, attitudes and behaviours will allow eligibility for i selection into Trust Registrar positions in the relevant area or ii selection into Higher Specialist Training. Doctors in Higher Specialist Training will be known as Specialist Registrars, those selected into General Practice specialty training will be known as GP Registrars (equivalent to ST3 and beyond). Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 52.32% 406 36.98% 287 6.83% 53 2.19% 17 1.68% 13 Interim Recommendation 39 Doctors should be allowed to interrupt their training for up to one year (or by agreement longer) to seek alternative experience. The Regulator in conjunction with the Royal Colleges will determine whether experiences should contribute to completion of training subject to appropriate competency assessment.

Integrated clinical academic training pathways in all specialties including General Practice should be flexibly interpreted and transfer to and from conventional clinical training pathways facilitated. The current Academic Clinical Fellowships in England allowing c25% of programme time for research methodology training and development of research proposals will map onto Core Specialty Training in the majority of cases but opportunities should also be available for those seeking to pursue a research career on entry to Higher Specialist Training. Strong, valued FY2 academic programmes should be integrated within Core training where desirable. Other interpretations of the Integrated Academic Training Pathway (e.g. as in Scotland) are welcomed and outcomes of the various interpretations of the pathway should be kept under review to inform future development. Opportunities during Core equivalent to ACFs should be competitively available for those wishing to develop educational, management, and public and global health skills, subject to available resource through, for example, modular Masters programmes.

Clinical lecturer posts in England will normally be coincident with higher specialist training (ST3 and beyond).

Successful completion of Higher Specialty Training as confirmed by assessments of knowledge, skills and behaviours will lead to a CCT, confirming readiness for independent practice in that specialty at consultant level. Higher specialist exams, where appropriate, administered by the Royal Colleges, may be used to test experience and broader knowledge of the specialty and allow for credentialing of subspecialty expertise. Recruitment to consultant positions may be informed by the extent of experience, by skills suited to enhanced roles, and by subspecialty expertise. 8.7 General Practice In the Interim Report it was concluded that the integration of workforce policy and postgraduate training and the length of training in General Practice are currently inadequate to meet the demands of shifts in care to the primary sector, a demand that will grow further as the age profile of the population rises. The location and nature of such extended specialist training in General Practice is an issue for resolution between the relevant Royal Colleges. The related ideal that all doctors practising in the UK should have experience of the nature of general practice during their Foundation Years has not been met. CONSULTATION RESPONSE 75% of respondents agreed or strongly agreed with Interim Recommendation 45. Interim Recommendation 45 The length of training in General Practice should be extended to five years, bringing it in line with specialty training and the other developed European countries. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 44.37% 343 29.50% 228 21.35% 165 3.49% 27 1.29% 10

To be eligible for a Consultant Senior Lecturer appointment, the applicant should possess a CCT in the relevant specialty area. Higher specialist College exams could be tailored to limited subspecialty expertise, recognising the narrower scope of practice that some clinical academics may need to embrace.

The length of training in General Practice should be extended to five years, (three years in Core plus two years as a GP Specialist Registrar supervised by a Director of Postgraduate GP Education). Extension to five years would bring GP training in line with the other developed European countries. Opportunities should exist to accommodate late entrants to GP training with other specialist skills.

The Panel recommends that urgent attention should be given both to ways in which a more flexible approach to EWTD could be legitimately embraced (e.g. separation of service and educational contracts), and compensatory mechanisms (which have been the subject of valuable but as yet unpublished scoping studies) can offset any further reduction in clinical experience. DH should explore contractual solutions. The profession, service, Medical Schools and Deaneries should come together to define compensatory approaches.

The Panel recommends the formation of a new body, NHS Medical Education England (NHS:MEE). This body would fulfil the following functions: Hold the ring-fenced budget for medical education and training for England; Define the principles underpinning PGMET; Act as the professional interface between policy development and implementation on matters relating to PGMET; Develop a national perspective on training numbers for medicine working within the revised medical workforce advisory machinery; Ensure that policy and professional and service perspectives are integrated in the construct of PGMET curricula and advise the Regulator on the resultant synthesis; Coordinate coherent advice to Government on matters relating to medical education; Promote the national cohesion of Postgraduate Deanery activities; Scrutinise SHA medical education and training commissioning functions, facilitating demand led solutions whilst ensuring maintenance of a national perspective is maintained; Commission certain subspecialty medical training; Act as the governance body for MMC and future changes in PGMET; Work with equivalent bodies in the Devolved Administrations thereby promoting UK wide cohesion of PGMET whilst facilitating local interpretation consistent with the underpinning principles. NHS:MEE would be accountable to the SRO for medical education and be advised by an Advisory Board with professional, service, academic, employer, BMA and trainee representation.

There needs to be a common shared understanding of the roles of all doctors in the contemporary healthcare team that takes due account of public expectations. Given the interdependency of professional constituents of the contemporary multiprofessional healthcare team we suggest a similar analysis extends to other healthcare professional groupings. Clarity of the doctor’s role must extend to the service contribution of the doctor in training, doctors currently contributing as locums, staff grades and associated specialists, the CCT holder, the GP and the consultant. Such issues need to be urgently considered by key stakeholders. Notwithstanding the need to keep such a key issue under constant review, stakeholders should seek to reach public consensus before the end of 2008, so important is the issue for current NHS reform. Education and training need to support the development of the redefined roles for each professional grouping and provide the necessary educational foundations to enable them to practise safely and effectively, and to aspire to enhanced roles.

DH should strengthen policy development, implementation, and governance for medical education, training, and workforce issues and their interface with service, embracing strong project management principles and addressing specifically a) clearer roles and responsibilities for a single Senior Responsible Officer, b) clear roles and accountability for senior DH members, c) better documentation of key decisions on policy objectives and key policy choices, d) faster escalation and resolution of ‘red risks’. The CMOs should be the SROs for medical education. Percentage Respondents 800 600 400 200 Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 0 54.81% 547 32.97% 329 8.22% 82 2.40% 24 1.60% 16

The introduction of necessary changes stemming from this report should i) involve all relevant stakeholders especially professional representatives, ii) abide by best principles of project and change management and include trialling where appropriate and feasible, iii) be subject to rigorous monitoring and evaluation.

Recognising the interdependency of education, clinical service and research DH should strengthen its links not only within the Department and with NHS providers but also with other Government Departments, particularly the Department for Innovation, Universities and Skills and the Department of Business, Enterprise and Regulatory Reform. Ministers should receive annual progress reports on the development and functioning of such links.

At a local level Trusts, Universities and the SHA (or equivalent) should forge functional links to optimise the health:education sector partnership. As key budget holders SHA Chief Executives should have the creation of collaborative links between local Health and Education providers as one of their key annual appraisal targets. Success should be measured against tangible outcomes.