This statement should be seen as a stimulus to further discussion and development, and is not definitive policy.

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Grant Singleton
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1 POSTGRADUATE MEDICAL CAREERS IN THE UK Cardiff Discussion Document This statement should be seen as a stimulus to further discussion and development, and is not definitive policy. Background: The Modernising Medical Careers (MMC) UK Co-ordinating Group (plus additional representatives of key stakeholder groups) met on 9 10 September 2008 in Cardiff to reflect on the lessons arising from the implementation of the MMC reforms, particularly taking account of the various inquiries that had been held. At the same time, a UK-wide perspective was applied to wider developments such as the work being taken forward by other groups to develop a consensus view on the role of the doctor. Following on from this, the Group undertook work to identify the principles, and approaches to the implementation of such principles, underpinning postgraduate medical education in the UK. (The membership of the MMC UK Co-ordinating Group is shown at Annex A). UK-wide arrangements for postgraduate medical education and training were viewed as being desirable for a number of reasons. Particularly important reasons included the fact that medical training across the UK has to meet common standards set by a single competent authority, and the transferability of the medical workforce is facilitated by commonality of approach. However, as medical training is largely delivered as part of the day to day delivery of health care, potential tensions arise as the four countries develop their respective health systems to reflect fully their local needs and priorities. The following statement sets out the underpinning principles proposed by the Group, makes some initial suggestions on action and then highlights the challenges that would have to be overcome. Key Principles: 1. The overriding principle of any future policy must be to ensure the highest quality of patient care both in terms of outcomes and in terms of the patient experience. 2. The delivery of a high quality service can only be furthered through the encouragement of excellence and development of expertise amongst those pursuing a medical career. This objective is best met through the provision of high quality education and training within structures that are sufficiently flexible to respond swiftly to changing service requirements and technological advance whilst being sensitive to doctors aspirations. 1

2 3. The need to ensure that career opportunities to progress to a recognised and meaningful level of capability, with the need for greater flexibility for both the service in terms of improved workforce planning and for individual doctors in developing their careers, is recognised. 4. The main aim of medical training should remain the production of doctors who achieve specialist registration, including in general practice. Whilst it is not and never has been - possible to fulfil all individual aspirations, doctors employed in the UK at a level commensurate with the successful acquisition of the Foundation Programme competences should be able to access postgraduate medical training to a level that will enable them to practise and be employed as competent practitioners with an accredited set of capabilities in the NHS or other healthcare settings. The opportunities overall to progress to specialist registration, including general practice, should be consistent with meeting the needs of patients and delivering high quality patient care throughout the UK. 5. The principles underpinning recent changes to postgraduate medical training are endorsed. The shift towards a reduced reliance on doctors in training for service delivery remains a key aim. These principles have been detailed and refined in various MMC and related workforce documents starting with the publication of Unfinished Business (2002) and Securing Future Practice (2004) in Scotland. There are currently slight variations with respect to both the principles and practice of postgraduate medical education across the four UK administrations, but these are very much seen as variations on a common UK theme. 6. The principles of policy decision-making based on consensus (where possible), evidence and thorough piloting and evaluation of new initiatives as articulated in the report of the Tooke Inquiry, Aspiring to Excellence, are accepted by each of the four countries. 7. Although there are four diverging health care systems in the UK, medical training has to recognise and be responsive to certain common themes. These include the shift from secondary to primary and community care, the need for greater focus on the management of chronic disease and increasing co-morbidities due to an ageing population, and an increasing focus on promoting health and improving well being within the population as a whole. 8. In all communications, consistent and clear definitions and terminology are needed to avoid ambiguity. 9. Regulation can make a significant contribution to supporting high quality education and assuring its quality. 2

3 Recommended Actions: 1 The term MMC refers to specific training reforms that have now been largely implemented and it is consequently misleading as a label for future work. Given the need to develop policy that covers all doctors between Foundation Programme training and completion of training, this work should be redesignated to clearly indicate a departure from the former policy. 2 In order to balance single-country decision-making with broader UK-wide strategy, the MMC UK Co-ordinating Group should be re-constituted as a UK Scrutiny group to provide a UK impact assessment of systems for medical education and training being developed in each administration. Ministerial consideration should be given to the views of the UK Scrutiny Group for major policies produced by bodies within the medical education and training system in the UK where they have UK-wide implications. It would be appropriate in this instance for those UK bodies to consult the UK Scrutiny Group prior to advising Ministers. 3 The concept of introducing one or more new steps in the continuum of medical careers should be explored. Currently, the training and career continuum is defined by three certificated points: graduation from medical school; completion of Foundation Programme training; and completion of specialty/sub-specialty training (including general practice training). It is suggested that further analysis is undertaken to include considering; a. a new intermediate step between Foundation and specialist registration. The curricula would be designed to ensure training to a level commensurate with a doctor providing a meaningful service contribution in the NHS or with other healthcare providers. Each specialty grouping would determine the appropriate level for this new aligned step. Whether training is run-through or uncoupled, once an intermediate step has been determined, further work will be required to define the training within each specialty grouping; b. the emphasis in reaching this step would be on generalism, flexibility and transferable competences to provide more choice and opportunity for doctors in training to change direction in both run-through and uncoupled specialties; c. all doctors employed in the UK at a level commensurate with the successful acquisition of the Foundation Programme competences should have the opportunity to progress through this intermediate step - consequently making them demonstrably qualified to practise with a limited level of direct supervision; d. the new intermediate step would provide a basis for revalidation against standards set by the regulator; 3

4 e. recognising potentially varying specialty requirements, all specialties should explore how their curricula, assessment frameworks and training programmes could be mapped to a potential new step. 4. Currently the specific nature of the end of the Foundation Programme as a certificated point is blurred by the arrangements for full registration with the GMC at the end of F1. Consideration should be given to the case for change, taking into account the need to retain a single standard for progression to full registration that applies to international medical graduates as well as UK graduates. 5. Appropriate resources should be made available in each country to support initiatives to improve patient care through the development of postgraduate medical careers in the UK programme. Challenges: To deliver the recommended actions the following challenges will need to be addressed: 1. Ensure we gain consensus (where possible) and work with stakeholders: engagement of the profession, trade unions and employers, together with patients and the public is vital with early identification and resolution of concerns and obstacles. 2. Clarity of motives a robust UK-wide communication strategy is required to explain the changes being considered and to emphasise that their purpose is to improve the quality of care by ensuring all doctors are trained to standards, providing a workforce more responsive to changing service needs and enhancing choice and opportunity for doctors in their careers. 3. Clarity of concepts and principles: terminology that is unambiguous must be agreed and shared by all stakeholders. 4. Allay concerns about further structural change and potential upheaval the communication strategy must stress there should not be (and this would not be) change for change sake, but rather a process of evolution building upon the successes and learning from the failures and problems of the recent past, responsive to service needs, the interests of patients and the political context. 5. Co-ordinate the strategy across the UK recognising the diverging political and healthcare dimensions in the four UK administrations, medical career structures must be mapped across each administration to balance UK-wide strategy and single-country needs. 4

5 6. Address the associated technical, administrative and legal issues the recommendations to introduce a new step and to consider the case for a change to the point of full registration would require considerable modification of existing systems and procedures. as well as debating the principles and case for such changes, it is acknowledged that there would need to be significant work by stakeholders and regulators to address the issues that would arise. 5

6 ANNEX A MMC UK CO-ORDINATING GROUP MEMBERSHIP Four UK CMOs (acting as chair, on a rotation basis) Four UK Health Department officials MMC England Programme Board co-chairs Postgraduate dean from each country Representatives from: Academy of Medical Royal Colleges GMC PMETB 6

4 Outcome of Consultation on the Review of the Future Regulation of Medical Education and Training Annex B

4 Outcome of Consultation on the Review of the Future Regulation of Medical Education and Training Annex B Final Report of the Education and Training Regulation Policy Review: Recommendations and Options