GMC response to HEE draft workforce strategy, Facing the facts, Shaping the future

Transcription

1 GMC response to HEE draft workforce strategy, Facing the facts, Shaping the future Summary The challenge 1 We welcome the development of the draft workforce strategy for England and the principles that have been identified. However, we urge HEE to be far more specific in itemising the challenges for medical staffing and how these will be addressed. We must not miss this opportunity. 2 We have reached a crucial moment a crunch point in the development of the UK s medical workforce. We have set out four warning signs: The supply of new doctors into the UK medical workforce has not kept pace with changes in demand Our dependence on non-uk qualified doctors has increased in some specialties The UK is at risk of becoming a less attractive place for overseas doctors to work both to those already in the UK and those outside it The strain on doctors who are in training, and those training them, continues. 3 To attract and retain doctors we must address the environments in which they work, the expectations on them and the quality of their induction, training, supervision and support. Currently there are over 50 training sites subject to Enhanced Monitoring by the GMC. 70% of trainers say their daytime workload is heavy or very heavy. In just four years, the proportion of doctors taking a break from formal training programmes after the Foundation Programme increased from 30% to 54%. 4 These trends predated Brexit and we are very concerned about the implications should the decline in EEA doctors licensed to practise in the UK become precipitous.

2 The GMC s contribution 5 The GMC s role is defined by statute. We do not determine the size of the medical workforce and we do not quality assure employers in the health services. 6 We are however closely involved in supporting the 25% expansion of medical student numbers in England by providing data and regulating the medical schools involved. We have transformed our approach to the regulation of medical education and training and are developing flexibility including transferable competencies and common content in curricula. Our credentialing framework, being developed in conjunction with the four UK governments, will ensure that doctors are trained well in areas of practice that are outside of postgraduate training. 7 However, we need flexible legislation to: reform how we consider the equivalence of overseas specialists and GPs bring more flexibility to training particularly in relation to recognising prior learning, transferability across specialties and credentialing establish agile and appropriate regulation for medical associate professions achieve more effective joint working across the regulators address the opportunities and challenges posed by leaving the EU. Rising to the challenge 8 We have identified ten points that the workforce strategy will need to address: A flexible legislative framework is essential for professional regulation. HEE must address the potential implications of Brexit for medical staffing. HEE should collect evidence and the government should urgently take action on the Tier 2 visa system. The strategy must be aligned with the other three nations of the UK and take consideration of impacts UK-wide There should be a stronger focus on workforce wellbeing. We need undertakings about the training pathways for UK medical graduates. Quality management needs to be well resourced. There should be a UK framework for credentialing. 2

3 We must jointly ensure the environment supports doctors to be reflective practitioners. There needs to be a resource implementation plan with specific milestones around what types of clinical staff will be needed and when they will be needed. The challenge 9 We welcome the development of the workforce strategy, the recognition of the scale of the task and the principles that have been identified. 10 In relation to medical staffing, the need for a strategic approach is urgent. We have set out our perspective and the evidence supporting it in our annual series on The state of medical education and practice in the UK (SOMEP). In 2016 we highlighted the state of unease in the medical profession and in 2017 we referred to a crucial moment a crunch point in the development of the UK s medical workforce. We set out four warning signs: A. The supply of new doctors into the UK medical workforce has not kept pace with changes in demand 11 The ageing of the population and the growth in the prevalence of long-term conditions and multiple morbidities have not been matched by the size of the medical workforce, particularly in some geographical areas and areas of expertise. 12 It is particularly startling that between 2012 and 2017 the number of doctors on the GP register increased by 3%, below the 4% increase in the UK population, and well below the increase in the population aged 65 and over. This is likely to be a key factor in the high vacancies reported for general practice. 13 Despite the emphasis on mental health, over the same period the number of consultant psychiatrists fell by 1% and the number of doctors in training in psychiatry fell by 9%. And despite the emphasis on prevention, the specialty of public health has declined by 19%. 14 The overall 1.7% increase in doctors in training between 2012 and 2017 is nowhere near sufficient. And between 2012 and 2017 the number of licensed doctors who are neither GPs nor specialists and are not in training declined by 8% - this is a group that has historically felt neglected and taken for granted, despite their critical role in service. 3

4 B. Our dependence on non-uk qualified doctors has increased in some specialties 15 Despite the widespread support for moving towards self-sufficiency in medical staffing, we remain heavily dependent on overseas doctors. Specialties where more than 40% of doctors are non-uk graduates include obstetrics and gynaecology, ophthalmology, paediatrics, psychiatry and pathology. 16 Nine of the ten largest specialties have increased their reliance on non-uk qualified doctors. In emergency medicine, medicine and paediatrics the number of non-uk qualified doctors increased by more than 20% between 2012 and C. The UK is at risk of becoming a less attractive place for overseas doctors to work both to those already in the UK and those outside it 17 We do not yet know the terms on which we will leave the European Union or the long-term impact on doctors wishing to move to or from the UK. But in February 2017 we surveyed EEA doctors practising in the UK. 61% were considering leaving the UK and of those 90% said the UK s decision to leave the EU was a factor. 18 Even before the referendum, 14% to 16% of EEA doctors relinquished their licence to practise each year between 2014 and Between 2012 and 2017 the number of EEA doctors acquiring a licence fell by 32%. The number of EEA doctors licensed to practise in the UK fell by 6% (20% in the case of Northwestern Europe). 19 A substantial decline in EEA doctors working in the UK could have a major impact on the health services. In 2017 there were 21,609 EEA doctors licensed to practise in the UK so a 61% reduction would mean the loss of nearly 13,200 doctors. Even without Brexit, we could expect the numbers of EEA doctors in the UK to continue to fall if the economies of other countries improve and the resourcing of the UK health services remains austere. But this trend is likely to be exacerbated particularly should EEA doctors be required to access the medical register via the equivalence route as currently mandated by legislation for international medical graduates. D. The strain on doctors training and being trained continues 20 Our annual national training surveys now cover nearly 80,000 doctors across the UK and reveal the pressure on doctors. Just over 40% of doctors in training rate the intensity of their work as heavy or very heavy including over 70% of doctors training in emergency medicine. 70% of trainers said their daytime workload was heavy or very heavy. 21 It is becoming far more common for doctors to take a break from formal training programmes after the Foundation Programme. Between 2012 and 2016 the proportion doing so increased from 30% to 54%. 17% of F2 doctors say they aim to take a break from training and reasons they cite include achieving a better work-life balance (86%) and suffering from burnout (51%). Almost a third of trainers feel 4

5 their job plan does not contain enough time for their role as an educator and around a third of doctors in training say poorly designed rotas have an impact on their training opportunities. 22 Poor quality training, impacting on trainers, doctors in training and patients, is a key concern for the GMC. We have over 50 sites in our Enhanced Monitoring process and have taken robust action in the last 12 months to protect trainees at both East Kent and North Middlesex. 23 In the 2017 edition of SOMEP we identified four priorities: Maintain a healthy supply of good doctors into UK practice Help the UK medical profession to evolve to meet the future needs of patients and healthcare Reduce the pressure and burden on doctors wherever possible Improve the culture of the workforce, making employment and training more supportive and flexible. The task 24 The draft workforce strategy is an important initiative and a first step which we welcome. The scale of the task before us is undeniably daunting. We have identified ten key areas that need to be addressed in the final version of the strategy. Flexible legislation on professional regulation 25 We call on HEE to give its explicit support for flexible legislation on professional regulation to support the direction of travel that we share, in line with our response to the DH consultation on Promoting professionalism, reforming regulation. A flexible legislative remit will be critical to: reform the highly bureaucratic procedures for considering the equivalence of overseas specialists and GPs - currently doctors who have not followed traditional training paths but who are qualified and willing to work as GPs or consultants are forced by outdated legislative requirements to submit over 1,000 pages of evidence to the GMC which can take many months. bring more flexibility to training particularly in relation to recognising prior learning, transferability across specialties and credentialing this would avoid doctors wasting years repeating training and demonstrate they have the specific skills needed in the health services 5

6 establish agile and appropriate regulation for medical associate professions (whether by the GMC or another body) these healthcare professionals need to be brought within an effective regulatory structure to give employers and patients the confidence to make full use of their potential achieve more effective joint working across the regulators through a general expectation on regulators to pursue joint working address the opportunities and challenges posed by leaving the European Union for example by protecting four year Graduate Entry Programmes if provisional registration is abolished and by tackling the equivalence route. Addressing overseas recruitment and the Brexit impact 26 The final version of the strategy needs robustly to address the challenges to the overseas recruitment of medical staff since we are so far from achieving selfsufficiency. The consultation document has not adequately reflected the potential implications of Brexit for the workforce, particularly should EEA doctors be required to access the medical register via the equivalence route as currently mandated by legislation for international medical graduates. A visa regime to support overseas doctors where they are needed 27 In the short term, we are aware of the concerns about the impact of the current visa arrangements. We urge HEE rapidly to collect and publish evidence about the impact of the Tier 2 visa system and to work with other agencies to ensure that government urgently addresses the issue. Currently while one government department is working hard to recruit doctors into an overstretched health service, another is enforcing eligibility conditions which stifle those efforts. Alignment across the four nations 28 It is critical that workforce planning and development reflect the reality of where doctors work and how they move across the four nations of the UK. There need to be explicit links drawn across the workforce strategies, demonstrable alignment across the UK and consideration of impacts UK-wide. The UK Medical Education Reference Group (UKMERG) can be an effective and agile UK-wide forum dedicated to workforce planning. As the UK medical regulator, the GMC should be fully involved in UKMERG in a supportive role, recognising that workforce planning is a matter for the four governments. Workforce wellbeing 29 There should be a stronger focus on workforce wellbeing and a clearer commitment to collaborative working to drive this. The Pearson review, albeit England-only, is a 6

7 major opportunity and needs to reflect the GMC s leading and active role in relation to mental health and wellbeing in the medical profession across the UK. Clear training pathways for UK medical graduates 30 Early clarification is needed about the arrangements to respond to the 25% increase in students graduating from UK medical schools in England and the expansions planned in the other countries: 1500 additional places per year will be provided in England and another 100 in Scotland while Ulster medical school is aiming for 60 places. Clear commitments must be given on increasing positions in the Foundation Programme and subsequent specialty training and how these will be resourced. Protecting quality management for medical training 31 Quality management systems for medical training need to be well resourced and the regional resources of HEE need to be properly protected. Otherwise, there is risk to the quality of training across England. We are concerned that recent changes to the structures of HEE regional teams are putting pressure on those responsible for providing proper oversight of postgraduate training which ultimately has implications for both trainee and patient safety. Introducing focused credentialing across the UK 32 The approach to credentialing should support the GMC s aim to introduce a UK framework to approve training outside postgraduate programmes that has been endorsed by the four UK countries. Credentials must be proportionate, focus on patient safety and support the development of the medical workforce. Ensuring reflective practitioners 33 The workforce strategy should emphasise the importance of doctors being reflective practitioners and the commitment of the GMC in this respect. We are working with key organisations including the BMA Junior Doctors Committee, the Academy of Medical Royal Colleges, COPMeD and the MSC - to provide clear guidance for doctors and medical students across the UK on how to approach reflective practice. Specifying the shortfalls, the solutions and the timescale 34 We need to work towards a joint understanding on options for the role, shape, standing and morale of the medical profession and allied professions in meeting healthcare needs in coming years. While uncertainties are inevitable, the current crunch point must be recognised and addressed. The final version of the workforce strategy needs to be far more specific in identifying specialties and geographical areas where shortages are particularly acute. There needs to be a resource implementation plan with specific milestones around what types of clinical staff will be needed and when they will be needed covering investment in UK education and 7

8 training and steps to support the immigration of healthcare professionals where they needed. The questions Question 1. Do you support the six principles proposed to support better workforce planning; and in particular will the principles lead to better alignment of financial, policy, and service planning and represent best practice in the future? 35 We support the six principles to support better workforce planning in England. 36 We have set out our perception of a crunch point in medical staffing. This calls for immediate action on recruitment and retention, including measures on training, support and environments. We need to consider the interests and motivations of both UK graduates and non-uk graduates; medical students, doctors in training, consultants and GPs, and doctors who are neither in training nor consultants or GPs. 37 Effective use of data and collaboration between healthcare stakeholders will be an integral part of workforce planning. We are in a unique position to provide data and intelligence on the healthcare landscape. Question 2. What measures are needed to secure the staff the system needs for the future; and how can actions already under way be made more effective? 38 It is important that the workforce strategy for England is developed with an eye on parallel developments across the UK including the new roles of Health Education and Improvement Wales (HEIW) and NHS Education for Scotland (NES) in workforce planning. There need to be explicit links drawn across the workforce strategies of the four nations and demonstrable alignment across the UK. 39 The draft strategy rightly emphasises the importance of doctors and other staff being encouraged to return to practice. Clearly, effective induction is important alongside realistic expectations of recent returners and appropriate support and supervision this is critical for both professional morale and patient safety and effective arrangements should be routine across the health sevices. 40 As set out in our response to the DH consultation on Promoting professionalism, reforming regulation, our legislative powers must be flexible enough to ensure that we can be fully responsive to the changing role of the doctor and emerging professions that work within the medical model. Legislative changes should also allow us to introduce less burdensome controls over the international workflow. 41 In particular, the Medical Act (1983) and various other statutory instruments currently set very specific requirements in a range of areas including prescribing 8

9 how overseas GPs and specialists can join our register. Currently 850 doctors a year, who have not followed traditional training paths but who are qualified and willing to work as GPs or consultants in NHS systems, are forced by outdated legislative requirements to submit over 1,000 pages of evidence to the GMC to get on to our specialist and GP registers. These burdensome requirements currently apply to doctors from outside the EEA but could apply also to EEA doctors post EU exit. 42 Leaving the European Union could create opportunities for flexible and proportionate regulatory approaches if the appropriate statutory reforms are put in place, for example to preserve four-year Graduate Entry Programmes should provisional registration be abolished. And without a modern statutory framework, there is substantial risk to the flow of medical staff into the UK post EU exit. 43 Also see our response to the DH consultation on The regulation of medical associate professions in the UK, and our recognition that new roles are emerging. In order to protect patients, some of these roles may need to be regulated. 44 The most appropriate mechanism for legislative reform would be the introduction of a high level framework of duties. We would then regulate in accordance with these duties and be afforded rule-making powers to revise processes in consultation with all affected stakeholders, without the current need for revisions to be approved by Parliament. 45 It is notable that we already have rule-making powers in some areas, such as the specific nature of the language requirements for overseas doctors who wish to join our register. We recently used these powers to widen the range of approaches that doctors can use, demonstrating the advantage of a flexible legal framework. Question 3. How can we ensure the system more effectively trains, educates and invests in the new and current workforce? 46 We are currently reviewing the Outcomes for graduates, following our extensive consultation and taking on board the comments from HEE and other respondents. The revised Outcomes will help to ensure that undergraduate curricula are focused on the needs of patients. The blueprint for the Medical Licensing Assessment will draw heavily on the revised outcomes. 47 Postgraduate curricula are currently being revised in light of the Generic professional capabilities framework. The curricula will be considered by the GMC s Curriculum Oversight Group (COG). The COG is made up of representatives from the four departments of health and four statutory education bodies. 48 We aim to secure an effective continuum in education and training. The revised Outcomes for graduates will draw the Generic professional capabilities into undergraduate education. The GPCs are already reflected in the Foundation Programme Curriculum. Over the next two years, professional outcomes will be 9

10 layered into the learning and development of all medical students and doctors in training. This will bring a new emphasis on key skills and attributes such as working in multi-disciplinary teams and sensitivity to local context. 49 The consultation document suggests actions involving the GMC and other bodies to: Investigate areas such as population health that should be taught across curricula Ensure curricula across all professional groups contain mental health content Explore greater use of gamification in training. 50 We will be interested to pursue these areas further with other regulators and bodies involved in education and training. Population health and mental health are important elements in the Outcomes for graduates review and the General professional capabilities framework. Our set of standards for medical education and training, Promoting excellence, says that medical school programmes must give students the opportunity to work and learn with other health and social care professionals and students to support interprofessional multidisciplinary working. 51 As stated in our response to the DH consultation on Regulation of medical associate professionals, we believe that MAPs should be considered as a single umbrella profession made up of four areas of practice. In considering MAPs in this way, we can coordinate core regulatory functions, offer confidence in the profession and support identifiable career paths with multiple points of entry. 52 The GMC welcomes the HEE review on technology. There is a strong case for the GMC to be part of the governance arrangements for the review. We need an oversight of the implications for medical practice and patient safety across the UK. Question 4. What more can be done to ensure all staff, starting from the lowest paid, see a valid and attractive career in the NHS, with identifiable paths and multiple points of entry and choice? 53 We are keen to build on our activities as an active partner in helping each nation of the UK to have the right number of doctors with appropriate skills and valued careers. We are determined to have a more integrated form of regulation with a shared approach to identification and resolution of concerns throughout the healthcare systems. Undergraduate medical education, registration and the Foundation Programme 54 The consultation document notes our role in supporting the expansion of undergraduate medical places in England by 25%. We are carrying out quality checks on the universities wanting to offer medical degrees. We have liaised closely with HEE and the Higher Education Funding Council for England including providing them with data to support decisions on the allocation of new medical school places. 10

11 55 We look forward to the proposed conversation about further expansion of undergraduate training and clarification of the proposed tendering of medical school places. It will be important to make sure that the quality of undergraduate medical education in all four UK countries is not compromised by over-extension and that clear, well-resourced training pathways are established for additional graduates. 56 Considering the point of registration is identified in the consultation document as an action for the GMC and other bodies, with HEE leading. Our role will be key given our UK-wide status and our regulatory functions and we look forward to playing a full part. The issue may be best addressed once we understand the UK s future relationship with the European Union and whether the Recognition of Professional Qualifications Directive will continue to apply. 57 Reviewing the Foundation Programme is a further action identified as for the GMC and other bodies, again with HEE leading. The Foundation Programme Curriculum is UK-wide and is approved by the GMC. The GMC regulates the training of provisionally registered doctors by statute and is responsible for coordinating all stages of medical education. We should therefore be providing high level input on strategic issues, recognising that the review is largely concerned with strengthening arrangements that already work well. The previous review of the Foundation Programme by Professor John Collins was commissioned by the then Medical Education England but as the report said: Every effort has been made to ensure that this report has the broad support of the other administrations. The new review must involve a similar assurance so we welcome the indications to this effect. Postgraduate training after completing the Foundation Programme 58 By statute, the GMC approves curricula for specialty and GP training and we have been driving a reform agenda to make sure that curricula meet patients needs. 59 Our new regulatory structure places the Generic professional capabilities framework at its centre. The requirements in Excellence by design ensure that specialty curricula take account of future workforce requirements across the UK. The Curriculum Oversight Group advises the GMC on whether curricular submissions meet service and patient need. We will evaluate all the current 103 specialty curricula against Excellence by design by Flexibility in postgraduate training is a key goal for the GMC. It is becoming increasingly common for doctors to take a break from formal training after they complete the Foundation Programme. Some do this because they want better worklife balance while others report feeling burnt out. 61 We were commissioned by the Secretary of State for Health to undertake a review of flexibility. In March 2017, we published our action plan on flexible training, Adapting for the future. 11

12 62 We recently published a position on less-than-full-time training (LTFT) that sets a regulatory backstop on the amount of training necessary. Our approach is proportionate and, following stakeholder input from all four UK countries, allows organisations to apply the policy flexibly. 63 Our current strands of work relating to flexibility cover: Credentialing (see below) Recognising prior learning Common content in curricula and transferable competencies (which we are taking forward with the Academy of Medical Royal Colleges) Addressing the limitations of prospective approval Considering the opportunities that could arise from the UK leaving the European Union, while paying careful attention to the risks. 64 The consultation document states that the GMC will pilot part-time working for higher specialty trainees in emergency medicine. This is not strictly accurate. We have sent a note of support for the pilot but are not involved in running it. 65 The final workforce strategy should stress the importance of resourcing education and training appropriately including making sure that trainers have dedicated time in their job plans and that financial support for education is not diverted into service to the longer-term detriment of patient care. Credentialing 66 Credentialing is identified as an action for the GMC and other bodies in the consultation document. We are keen to work with bodies taking forward credentialing for other professions. 67 Our credentialing framework will assure patients and employers that doctors are trained safely and competently in areas of practice that are outside of postgraduate training. We are proposing that GMC-regulated credentials will apply to areas of practice with significant patient safety concerns. Credentials may be developed to support strategic workforce requirements. 68 By July 2018, we will propose a consensus-based model that will inform the credentialing framework we will introduce in early However, we will be restricted in taking regulatory action on entries on the register related to credentials by the Medical Act Legislative change will be need for a more robust credentialing framework to introduce: a mandatory scheme for the approval of and assurance of credentials 12

13 enforcement and updating of credential entries on medical register an appeals process for decisions about recognising doctors credentials. Reflective practitioners 69 We are working with key organisations including the BMA Junior Doctors Committee, the Academy of Medical Royal Colleges, COPMeD and the MSC - to provide clear guidance for doctors and medical students across the UK on how to approach reflective practice. 70 The case of Dr Bawa-Garba has raised genuine concerns in the medical profession about practising reflectively and being open and honest. It s vital that doctors are reflective practitioners and we are committed to encouraging this culture. International recruitment 71 We welcome the consultation document's recognition of the role that the non-uk qualified workforce plays in the provision of healthcare. We are collecting and reviewing evidence on the factors behind doctors entering and leaving the UK. 72 We are concerned that the consultation document has not adequately reflected the potential implications of Brexit on the future workforce. The full scale will depend on arrangements for the recognition of professional qualifications and potentially other factors such as the immigration regime in place. It remains too early to be certain what impact any changes to the UK s relationship with the EU might have in the medium term. We are planning for any changes that Brexit may bring. In the meantime, we will continue to publish data about EEA doctors practising in the UK to provide up-to-date information and assurance for employers. 73 We are currently reviewing the various types of evidence that can be provided when overseas doctors apply for registration with a licence to practise. In introducing the MLA, we have no wish to erect unnecessary barriers to good doctors coming to practise in the UK. 74 We recognise that the transition into UK practice is especially hard for doctors who have qualified outside the UK and may be unfamiliar with our culture of healthcare. Our Welcome to UK Practice programme helps these doctors by providing a free, half-day workshop that guides them through the ethical issues they will face in their practice. We are currently evaluating the impact of the programme and have a goal to increase the number of doctors who take part to reach 80% of IMG/EEA doctors new to practice by We are supporting the drive to recruit GPs from overseas. We have been working with the Royal College of General Practitioners to map its curricula against the Australian approach. We have contributed to the RCGP project to provide an 13

14 electronic one-stop guide for overseas doctors who wish to move to the UK. We are working with the Scottish Government, NHS Education for Scotland and the RCGP to ensure that our process for considering the equivalence of overseas GPs (CEGPR) is as responsive as possible within the current legal framework. Despite our best efforts, the programme to recruit overseas GPs has had limited success and we urge the governments to consider additional steps. 76 Other steps we are taking, or have taken, to support overseas recruitment under the current legal structure for medical regulation include: Supporting the expansion of the Medical Training Initiative for which doctors are issued with a type of visa that enables exchanges and educational initiatives Introducing more flexible arrangements for testing English language proficiency Doubling the dates available for the clinical part of the PLAB test. 77 However, a flexible statutory framework for medical regulation would enable us to reduce the burden and delay associated with the equivalence route and to respond appropriately to changes in the UK s relationship with the European Union. 78 It is also important that the future immigration system supports the need for the non-uk doctors to come to the UK to live and to practise, bearing in mind the different needs of the four UK countries. Question 5. How can we better ensure the health system meets the needs and aspirations of all communities in England? 79 Our professional guidance and the outcomes we set for currricula have long emphasised the need for doctors to be responsive to and respectful of varied cultures across the UK. 80 Important developments in making sure that people from a range of ethnicities and backgrounds enter and progress in medical education include: The expansion of medical school places, explicitly linked to widening participation in the medical profession The work of the Medical Schools Council Selection Alliance Data collection and analysis on differential attainment through the UKMED database and with the GMC playing a leading role. 14

15 Question 6. What does being a modern, model employer mean to you and how can we ensure the NHS meets those ambitions? 81 The GMC does not regulate employers but the working culture, the environment and evidence of compassion, support, flexibility and career development will be critical for the recruitment and retention of medical staff. We contribute through: Our standards in Promoting Excellence on the importance of supportive environments for education and training Our roles in the quality assurance and approval of education and training, including Enhanced Monitoring of sites where improvement is critically necessary Our survey on doctors perceptions and experiences about flexibility in training with over 6,000 responses Our health and disability review Our work on mental health and wellbeing in the profession. 82 The consultation document refers to our role in relation to the Pearson review on the health and wellbeing of NHS staff, trainees and students in England. This major opportunity needs to reflect the GMC s leading and active role in relation to mental health and wellbeing in the medical profession across the whole of the UK. Question 7. Do you have any comments on how we can ensure that our NHS staff make the greatest possible difference to delivering excellent care for people in England? 83 We are determined to meet the changing needs of the health services and note the learning opportunities that can be gained from all four countries of the UK. 84 Our contributions include: Our work on professional standards and ethics covering key topics such as communication, consent, making decisions in full partnership with patients, effective working across professional boundaries, end of life care, leadership, management and quality improvement Our revised guidance for medical students on professionalism The strong links that exist between our four-country liaison services and doctors and students on the ground which enable us to identify and act on concerns The annual National Training Survey and in particular the findings that doctors in training often feel short of sleep and that trainers feel increased pressures 15

16 Our support for modern curricula: the Outcomes for graduates, the MLA and the Generic professional capabilities framework Our work with partner organisations on reflective practice. Question 8. What policy options could most effectively address the current and future challenges for the adult social care workforce? 85 We are encouraged by the decision to bring social care and health care together within the remit of the Secretary of State in England and hope that this is a portent of closer collaboration between the sectors. Lessons can be learned from other UK countries integration of health and social care. 86 It is important to ensure that medical education and training is provided in a range of settings where health and social care is delivered. The interface between health and social care has been an important consideration in reviewing the Outcomes for graduates and developing the Generic professional capabilities framework. 87 We are keen to work with HEE and other partners to explore how to give the workforce generally a better understanding of how and when to engage across professional boundaries, including on issues like safeguarding, mental health and addiction issues, and supporting people with learning disabilities. We could help to ensure that experience in the other countries in the UK is brought to the table. 88 Finally, we acknowledge the proposed regulatory approach for Social Work England, which is currently subject to consultation. We endorse the proposal for a more flexible framework which grants the regulator greater autonomy and discretion to adapt and amend individual rules. We believe that this will enable the regulator to respond appropriately to the changing needs of (adult) social care services. 89 This ambition needs to apply to the statutory framework for the GMC and other healthcare professional regulators if we are to play our full part in addressing the workforce issues in the health services across the UK. 16