Report of the analysis of the Modernising the New Doctor consultation

Annex A Report of the analysis of the Modernising the New Doctor consultation Introduction and method 1. Modernising the New Doctor: A Consultation on PRHO Training was published on 4 February 2004 for a formal consultation period of three months closing on 30 April 2004. 2. An electronic link to the consultation document was sent to over 1300 organisations and individuals. The organisations included all UK NHS Trusts, private healthcare providers, groups representing patients, doctors in general, doctors in training, students, organisations specialising in equality and diversity issues and organisations representing other health care professionals. The link was also sent to all GMC Council members, GMC Associate members and the Education Visitors. 3. Responses could be received by email, fax or by letter or could be submitted directly via an electronic form on our website. 4. We received 93 responses in total from a wide variety of individuals and groups. 1 These included responses from each of our target groups. 5. Some responses consisted solely of drafting points on The New Doctor. Some responses were free text responses and some responses addressed the consultation questions asked. 6. The responses were entered into a database with categories for each of the consultation questions asked and a section for drafting notes on The New Doctor and a General section for issues that did not fit into any of the consultation categories. 7. Each response was then entered into the relevant part of the database. 8. A broad numerical analysis was undertaken. This is limited in that a subjective interpretation of answers was needed to fit them into some categories. In addition all responses were given equal weight despite the fact that some responses were more informed than others. 9. However, the analysis has shown that on most issues the extent of agreement was very high and it is submitted that this agreement, considered along with the broad range of experience of those responding, enables the responses to most questions to be considered a good indication of the general agreement and thus to be relied upon. 10. In addition, we have taken as background material, the results of our four UK multi-stakeholder seminars and our seminar on the issue of disability. 1 It was subsequently discovered that there were 96 responses to the consultation. See QA Report, paragraphs 3 and 10 A1

These multi-stakeholder discussions broadly mirrored the numerical results of our consultation. 11. An electronic copy of the responses received and the analysis is available on request from David Skinner (email: dskinner@gmc-uk.org). Goals and principles Q1. Are our goals and principles appropriate to our review? Q2. What goals and principles have we not included? 12. The goals and principles that we consulted on are set out below. They have been almost unanimously endorsed. There have been some suggested additions. 13. In undertaking the review of PRHO training, our goals have included: a. Ensuring that there is an educational continuum between undergraduate medical education, the Foundation Programme and postgraduate medical training. b. Identifying the added value of PRHO training to a medical graduate. c. Applying modern educational principles to PRHO training. 14. Our principles have been: a. The GMC s main objective, set by the Medical Act, is to protect, promote and maintain the health and safety of the public. b. The GMC should provide a clear set of outcomes to be met by medical graduates before being granted full registration. c. A new legislative framework is necessary to enable the Education Committee to respond quickly and effectively when change is required. d. Those bodies involved in PRHO training must be given the freedom to design effective and innovative training programmes which meet the outcomes set out in The New Doctor. e. The GMC should provide a platform at full registration that the Foundation Programme can build upon. f. A system of quality enhancement is necessary to ensure that PRHO training is effective and to provide a mechanism to allow the aspirations of contemporary society to be met and good practice to be disseminated and fed into improved standards. A2

15. Additional goals and principles that have been proposed include: a. It may be useful to issue national guidance to bodies involved in PRHO training to ensure consistent standards whilst supporting innovations with some local flexibility in delivery (RCP Edinburgh). The need to issue national guidance is a theme which has come through the Modernising Medical Careers UK Strategy Group, Modernising Medical Careers UK Delivery Group and is mentioned in some of the consultation responses. b. Quantity and quality of patient care must be maintained (RCGP). c. Applying modern educational principles implies that previous education was faulty. We should not entirely lose aspects of the apprenticeship training that was previously enjoyed. There was much to be commended about having good role models and feeling a responsibility to a good team that there is a danger of losing if the PRHOs are attached to firms for too short a time (RCA). d. The need to protect and value our young doctors in training should be recognised alongside the need to view this period of change as a transition rather than a radical change (for example, specifying the use of log books throughout undergraduate, Foundation Programme and postgraduate training) (University of Glasgow Medical School). The benefits of PRHO training to the medical graduate should be emphasised to give them competence, confidence and awareness of choice in their developing career in medicine (RCOG). e. Any system of quality enhancement needs to be designed with the needs of patients and carers in mind, and the outcomes developed need to be person-centred and focus on what matters to patients and carers. We need humane as well as technically competent doctors. Training needs to include time management, communication, team working skills, and medical ethics (MacMillan Cancer Relief). f. We need to be constantly striving to improve medical education, especially transition from undergraduate to postgraduate (Rebecca Dobson). g. We need to comply with Caldicott principles (Paul Lawler). h. We need a formal evaluated system of careers advice (West of Scotland Deanery). i. We need an emphasis on the acutely ill (RCP Edinburgh). A3

j. PRHOs must receive support including pastoral support, mentorship, career support and clarification of supervisory structures. PRHOs should feel valued, fulfilled and committed to medicine k. Competent authorities must collaborate (RCGP). l. We need flexibility allowing transferring during the Foundation Programme (RCOG). m. We need fairness and equity for doctors (BMA JDC). These suggestions on our goals and principles provide a useful framework within which to consider our consultation issues. Q3 Do you endorse a move from an experience based model to an outcomes based model? Total Responses Yes Partly No 76 69 6 1 16. The consultation responses supported a move to an outcomes based approach. Those responses which were unable to answer yes were qualified by the following points: a. There is a need for experience within the outcomes based approach. b. We need to be aware of the practical difficulties including the resources and time which could impact on the success or effectiveness of a move to an outcomes based approach. c. We need to be certain that the outcomes that we set are specific, measurable and achievable. 2 Q4 Are the outcomes required for The New Doctor as revised appropriate and measurable? Total Responses Appropriate Yes Appropriate No Measurable Yes (unqualified) Measurable No or not all Not specified (either appropriateness, measurability or both) 59 45 3 13 33 19 in total 17. Most responses dealt with appropriateness and measurability separately. We were therefore able to count each response twice once for 2 The QA assessors felt that this analysis of this question did not accurately reflect the strength of feeling expresse by the respondents. See QA report, paragraph 15. A4

appropriateness and once for measurability. Some responses only dealt with one aspect of either appropriateness or measurability. 18. The clear majority of those responding to this question found that the outcomes were appropriate. However, there was no such agreement on the whether the outcomes were measurable. We recognise that the main reason for this was that validated assessment methods for many of the outcomes specified have not yet been developed for this level of training. 19. There was some comment about the level of detail required to define the outcomes and competencies specified in The New Doctor. Some of those responding thought that more detail was necessary. Others thought that there should be less detail. There are advantages and disadvantages to both approaches. If more detail is specified for the outcomes, this has the advantage of being able to demonstrate reliable assessment more easily. However, it has the disadvantage of inadvertently making PRHO training too prescriptive meaning that it will be more difficult for those with a disability to demonstrate outcomes appropriately and that the outcomes may become out of date and less relevant to current medical practice. Similar considerations apply to broader outcomes. 20. We recognise that further work about the detail of the outcomes, competencies and their assessment will need to be carried out during the transition period under the auspices of the Transitional Group (See the proposals in the Item 4 covering paper for further detail about this model). We have taken specific drafting comments on board in the transitional edition of The New Doctor. Q5 Should there be a period of PRHO training? Total Responses Yes No 69 67 2 21. Reasons given for a PRHO year included: a. To consolidate knowledge, skills, attitudes and behaviours. b. To learn new knowledge, skills attitudes and behaviours. c. To support PRHOs and give them confidence in the workplace. d. To ensure patient safety as the PRHO takes on professional responsibility for the first time. e. To enable effective assessment of performance whilst carrying responsibility in the workplace as a paid member of the profession. 3 3 The QA assessors discovered that there was a written response to this question which did not address the question posed. The assessors felt that the response was a difficult one for the office to deal with. See QA report, paragraph 12. A5

Q6 How long should the period of PRHO Training be? Total Responses When the competencies are achieved (no fixed period) 12 months 2 years Other 71 6 57 5 8 months 1 18 months 1 A fixed period - 1 22. A fixed minimum period of PRHO training of one year has the following advantages: a. Patient safety demands that posts be filled as far as possible for a fixed period of time to enable replacements to be planned and to ensure continuity in the care of patients. 4 This enables jobs to be filled for a certain period ensuring patient care. It also enables rotas to be planned appropriately. b. One year enables sufficient time to settle into working environment and ensures a stable environment. It allows clinical experience and competence to be developed. c. A minimum period of time, as opposed to a fixed maximum period of time, allows space for remediation. d. A fixed period will ensure that subsequent training posts are filled in an equitable manner as appointment processes would be open to most at the same time. e. Effective and consistent application of competencies requires experience. f. The arrangement allows time for potential problems to be identified. g. For those able PRHOs who clearly achieve competencies earlier than the fixed period of one year, it will enable them to develop and refine their skills of lifelong learning as new goals are identified during the remainder of PRHO training. h. Enables time for robust continuous assessment of outcomes and competencies to take place. 4 Our publication, Good Medical Practice, reflects this principle. At paragraph 41 it states: You must take up any post, including a locum post, you have formally accepted unless the employer has had adequate time to make other arrangements. A6

i. A move to full registration part way through the Foundation Programme would enable a further consolidation period with all the rights and privileges of full registration gained in a well rounded environment which could in due course count towards specialist training. 23. There was strong support from the armed services to have a period of provisional registration lasting for a period of two years mainly because their cadets sign up for six years of service after registration. They do not think, however, that they can use F2 for military purposes - under the new system they are not sure at what stage the cadets would make the move to captain (at present this is on full registration) and they are worried that they will lose a year of military service commission as a result of this. (Section 43 (1)(a) of the Medical Act 1983 provides that full registration is required before a doctor can take up an appointment as a physician, surgeon or other medical officer in the naval, military or air service.) 24. There were also some other reasons put forward against a fixed period of one year. It was suggested that a fixed period may disadvantage the exceptionally able trainee. It was also suggested that there was no evidence base for a period of training of one year. 25. The results of our consultation have also suggested that as the Foundation Programme and robust assessment methods of outcomes develop, it will be necessary to keep this minimum and maximum time period under review. This should be reviewed as the Foundation Programme develops and will be considered again during the evaluation of the transition period. Q7 Should there be a power to impose a maximum period of registration? Total responses Yes No Not sure Notes 61 52 8 1 Of those who said there should be a maximum period of PRHO training, most (11) thought a period of two years was appropriate. However, for a number of reasons including the needs of flexible trainees, those with a disability, those with child care responsibilities or illness, there was no consensus on what the maximum period of training should be. Many respondents wanted flexibility to deal with this on a case by case basis with guidance from the GMC. 26. The consultation has shown three main considerations in relation to a maximum period of PRHO training. A7

a. The need to ensure that those who train flexibly, those who are ill, those who are on maternity or sick leave or those with a disability must not be disadvantaged by a fixed minimum period of training or a maximum period of training. b. The need to ensure that PRHO training is carried out within a reasonable period from graduation to ensure that knowledge, skills, attitudes and behaviours are kept up to date. c. The need to ensure that those who are unable to complete PRHO training following appropriate remediation, support and counselling are guided towards another career and that patients are not put at risk by an endless period of unsuccessful training. 27. This suggests a need for more specific guidance about maximum periods of PRHO training/registration. 28. More specific comments included a recommendation to consider parity with the position of international medical graduates (IMGs). IMGs have time limits that they need to comply with when passing the IELTS and PLAB tests. IELTs must be passed within two years of undertaking the PLAB test (Part 1) or being registered, whichever is the earlier. If not, evidence of postgraduate study in English is required. In addition, Part 2 of the PLAB test must be taken within three years of Part 1 being passed. Registration and work in the UK must be undertaken within three years of passing Part 2 of the PLAB test. 29. However, it is also clear from the responses received that we must ensure that those with child care responsibilities, those who undertake flexible training, those with illness and those with disability are not discriminated against, particularly in light of the rapidly changing equality legislation in this area. 30. For this reason, legislation may not be the appropriate vehicle for imposing a maximum period of registration at this stage, in the absence of robust evidence identifying an appropriate maximum period of provisional registration. But guidance to enable those responsible for training to decide when to refer a case to us may well be appropriate and helpful. Q8 Should we move away from practice based on experience in specified branches of medicine towards practice using specified knowledge, skills, attitudes and behaviours set out in The New Doctor as revised? Total Responses Yes No Not sure 75 47 -absolutely 2 provided that branches were covered in the Foundation Programme 20 6 A8

31. The consultation responses outlined a strong support for exposure to certain contexts, for example, emergency medicine and treating the acutely ill as outlined in our consultation document. There was also support for exposure to chronic disease management which relates to medical and surgical patients, primary care, acute take and surgery. The PMETB response emphasised that achievement of an outcome in one context was not necessarily an indicator that such an outcome would be able to be achieved in a different context. 32. There was also some support for other mandatory branches of medicine such as general practice to be included. 33. It was noted if the legal requirements of medicine and surgery were abolished, this should not be done until after robust assessment methods of outcomes had been developed. 34. It was noted that there should be a minimum period of time spent in each post without specifying what these posts were to ensure that there was sufficient time for adequate educational supervision and assessment and to ensure that underperformance did not go unnoticed. 35. It was stated there is a need to recognise that illness occurs 24 hours a day and that night work needs to be included in experience requirements. 36. There is a need to recognise that Foundation training must prepare doctors to be able to undertake SHO posts and specialist training. Q9 What is the purpose of assessment during training? Total Responses: 63 which detailed the following purposes of assessment: 37. The purpose of assessment as identified by those responding included: a. To ensure patient safety by ascertaining that PRHOs are safe to practise. b. To support and motivate the trainee, identify strengths and weaknesses and direct their learning appropriately (formative) c. To ensure the trainee meets minimum expected outcomes consistently including humanitarian competencies (summative performance assessment) d. To allow the trainee to demonstrate that they will benefit from further training. e. To ensure that the patient is fit to practise and to gain full registration / general licence. A9

f. To enable feedback to those delivering training about the quality of a training placement. g. To ensure that the trainer and trainee know what is expected of them. h. To provide a basis for career advice and guidance. Q10 What is the best model for assessment of PRHOs to demonstrate that they can put into practice the knowledge, skills, attitudes and behaviours learned as an undergraduate and during PRHO training? Total Responses National Examination In training assessment delivered locally Hybrid Model 75 3 50 14 8 Not sure or alternative models 38. Of the responses received, those who supported an in-training assessment also advised that the following factors should be part of such a model: a. Training for assessors to ensure consistency. b. Resources to allow assessment to happen on the job. c. Assessment to take place to clear national standards. d. External moderators or assessors to be built in. e. An appeals process. 39. The responses showed support for the in-training model of assessment. However, it is clear from the responses that such a form of assessment needs to be developed it is not yet in place for this period of training. There are different models for such a development of effective assessment of outcomes. (These are discussed further in the transition section of the Item 4 cover paper.) Q11 Which organisation should be responsible for PRHO training and how should that responsibility be defined? Total Responses Postgraduate Deans Universities / Medical Schools Other 70 30 12 Joint responsibility 15 GMC 6 PMETB 3 No definitive answer - 4 A10

40. The following points were made in the consultation responses: a. Continuity of the programme throughout postgraduate training is required. b. PRHO training is the sixth year of basic medical education. There needs to be a link between the content of undergraduate education and PRHO training. c. Lines of responsibility must be clear. d. Responsibilities should be clearly defined across the UK. e. Trusts should have vetos f. Flexible responsibility could be applied (different strokes for different folks). g. There should be coherence of responsibility across the Foundation Programme recognising that PRHO training is the first stage of Foundation training. h. There need to be explicit arrangements relating to the passing of information between universities and postgraduate deans. i. Functional components of responsibility include: i. Providing information and careers advice to students about the Foundation Programme and recruitment (matching or selection schemes) ii. iii. Quality assurance of clinical placements Supervision of trainees iv. Support and monitoring mechanisms including for example managing sick leave. v. Managing trainees in difficulty vi. vii. viii. Signing off PRHOs as fit for full registration. Understanding who is legally accountable. Feedback to university courses j. There must be clear mechanisms for dialogue between all organisations involved in PRHO training. A11

k. There should be consistency and maintenance of a common standard best achieved by one body. l. There is a need to clarify who is responsible for making reasonable adjustments for the needs of trainees with disabilities. m. There is a need to ensure that any arrangement protects education delivered in the service environment. Q16 Should responsibility for PRHO training be set out in Primary Legislation? 5 Total Responses Primary Legislation Regulations under control of Education Committee 49 18 24 (although many specified a legal duty to consult should be included) Not sure 7 41. It is of note, however, that key respondents including CHMS, COGPED, BMA- JDC and the Department of Health thought that the issue should remain in primary legislation. We also note that there is no clear agreement on this issue. Q12 If the organisation you recommend was given responsibility for PRHO training what would the resource implications be? Responses: 56. Very few contained precise figures and these were stated to be estimates. There was a wide variety of responses ranging from minor resource implications to significant resource implications. 42. Generic resource implications as a result of the change from experience to outcomes were stated to include: a. Hours taken away from service to enable training of assessors, training of PRHOs, supervision of PRHOs, assessment of PRHOs by educational supervisors and assessors and evaluation costs. b. Cost of external assessors / moderators c. Administration and management of Foundation Programmes. d. The increase in output from medical schools as a result of expansion. e. Additional funding for remediation. 5 Please note that Question 16 has been included in this section to marry up the policy and legislative implications. A12

Health and Conduct Q13 Do you support the principle that provided PRHOs can meet the outcomes set out in The New Doctor, there is no requirement for the General Medical Council to approve training programmes for PRHOs with disabilities? Why? Total Responses Yes No No clear answer 65 45 13 8 43. Although numerically, it would appear that there was majority support for the abolition of Section 10(4) of the Medical Act 1983 which requires approval from the GMC if the experience requirements for PRHO training cannot be met, further examination of responses showed that this was not the case. 44. Virtually all those responding indicated that it was important for PRHOs with a disability not to be discriminated against. However, some of those responding thought that this was best achieved with a special provision and some thought that this was best achieved without such a special provision. 45. Those responding said: a. There needed to be flexible interpretation of how the outcomes could be achieved. b. The Deaneries were very keen to deal with these issues locally, but would like to be able to seek advice from the GMC where necessary. c. The GMC must provide a safety net or an appeals process for those with disabilities who are unable to meet the outcomes set out in The New Doctor. d. We must ensure equal opportunities for all doctors. e. There was a need for national guidance in this area. f. We must not make it more difficult for a disabled person to achieve outcomes. g. Restricted licences or registration might be an appropriate way to ensure that doctors with a disability were still able to qualify if the core outcomes could not be met. 6 6 The current review of Registration and Licensure under the remit of our Registration Committee, considered this point expressly. They concluded that the introduction of a limited licence restricting doctors to particular areas of practice would introduce undesirable rigidity into medical practice which would make efficient utilisation of the workforce more difficult without providing better protection for the public. Instead the key lay in the duty imposed on all A13

46. On 18 July 2004, the Education Committee held a seminar specifically on issues of disability. The majority of those present thought that a special provision should remain in the Medical Act 1983, to ensure fairness for those with disabilities and to provide a safety net for doctors with a disability to ensure that they were not discriminated against. Q14 Is the section on PRHO health and conduct helpful and appropriate? Total Responses Yes No No clear answer 51 44 0 7 47. Those responding mainly indicated the need for clarity in some of the drafting of this section. There was overwhelming support for the principles. The drafting comments and suggestions have been taken into account in the revised edition of The New Doctor. Legislative instructions for the Section 60 order Q15 Support for the Principles underpinning our proposed legislative changes. Responses: 52 responses were received to this question. 44 supported the legislative principles without qualification. Six supported the principles but with some additions or reservations. Two were not sure. 48. In view of the fact that there were few significant comments about our proposals for legislative change it is submitted that little further work needs to be done until the draft order is published later on this year. Transition Q17 If a change to an outcomes based approach is confirmed, how long would the transition period need to be? Total Responses 2 years or less 3 years No specific time period 60 11 30 11 a need for a robust assessment system to be in place before the change is made. Other 8 between 2 and 5 years doctors by Good Medical Practice to recognise and work within the limits of their competence. GMC Council Paper, Item 6, Council, 20 January 2004. A14

49. There is significant support for recognising the need for a robust new system to be in place before the end of the transition period. Our suggested transition period of 3 years seems about right. 7 Equality and diversity issues Q18 Do the proposals described in this paper meet our commitment to equality and diversity? Total Responses Yes Other 58 57 1 group wanted clearer proposals before answering this question. 50. Most respondents thought that our proposals met our commitment to equality and diversity. However, there were some caveats to some responses. These related to: a. Opposition to closed matching schemes for appointment to some PRHO posts. b. A need for regular review of our guidance to ensure a continuing commitment. c. A need to ensure the final proposal on the maximum period of PRHO training did not disadvantage those who trained flexibly, or needed to take a career break through illness or disability or through family commitments. d. Mental health needed to be suitably emphasised in the Health and Conduct section of The New Doctor. e. A need to ensure that the proposals were put into practice. Q19 Do the proposals in the revised The New Doctor meet our commitment to equality and diversity? Total Responses Yes 49 49 51. All respondents thought that the revised edition of The New Doctor met our commitment to equality and diversity with the following caveats. a. There was a need to ensure that the proposals were put into practice. 7 The QA assessors felt that the one of the written responses to this question was misrepresented in the database. See QA report, paragraph 12. A15

b. Mental health needed to be suitably emphasises in the Health and Conduct Section of The New Doctor. c. There was a possible query over the level of detail in the competencies. d. We needed to ensure the final proposal on the maximum period of PRHO training did not disadvantage those who trained flexibly, or needed to take a career break through illness or disability or through family commitments. e. There was opposition to closed matching schemes. 52. We discussed the proposals with specific reference to the issue of disability at a dedicated seminar. Focus groups were asked to consider the competencies from the perspective of compliance with the Disability Discrimination Act 1995. All competencies had to be proportionate and non discriminatory. Our focus groups at the seminar helped us to refine some of the competencies to avoid possibility of discrimination. Q20 If not, what other steps may be taken to achieve this? Total Responses: 3 53. Given that the majority of respondents considered that our proposals and the revised edition of The New Doctor met our commitment to equality and diversity, we received very few responses to this question. However, there were some suggestions as follows: a. Proper research needs to be conducted to ensure that students and doctors are meeting the needs of the diverse communities. Research of this nature is in progress under the Research Board of the Education Committee. b. We should put a review date on our guidance and set in place a procedure for review. (This is one of the proposals in the cover paper for Item 4.) c. Consult current PRHOs. We have sought to do this in our publicity for Modernising the New Doctor which included the web link to the consultation in GMC News, a publication sent to all registered doctors, through our UK seminars, each of which included PRHOs, and through our links to other stakeholder organisations including the Postgraduate Deans, universities and the BMA. 8 8 The QA assessors discovered two discrepancies regarding question 20. Firstly the assessors found that there was a written response that was not recorded on the data base. Secondly the assessors found that the third paragraph of the analysis cannot be linked to the database. See QA report, paragraphs 12 and 15. A16

Q21 Are there groups for whom these proposals would have an adverse effect? Total Responses: 24 54. There were some suggestions for groups that should be considered in response to this question. These included: a. Recruitment for international medical graduates. Although we have no direct influence on recruitment to PRHO training, we do set out our principles for recruitment into PRHO training which must use valid, reliable, open, objective and fair selection procedures to make sure that they recruit candidates without prejudice or unfair discrimination. We have also been involved in discussions with all four UK Health departments with a view to drawing their attention to these issues. b. Possibly those with temporary mental illness or chronic infection. We have redrafted the Health and Conduct Section to emphasise that it applies to those with physical and mental impairments. c. Consultant supervisors / assessors /those delivering training These comments related to the additional workload to be shouldered by these groups. We have been involved in discussions with the four UK Health Departments with a view to drawing their attention to the resource implications. During the transition period we will need to implement the practical effect of the implementation if a lack of resources threatens implementation of our proposals. d. The increase in student tuition fees may have a prohibitive effect for certain sectors of society entering medical training and thereafter PRHO training. We have no direct influence over the implementation of tuition fees. However, it is a relevant consideration. e. Poor doctors who do not meet our standards. f. Possibly flexible trainees or those taking career breaks. We have not proposed a legislative maximum at this stage and we have considered this point expressly when redrafting the guidance on maximum periods of training in The New Doctor. A17