The Scottish Government

Recommendation 1

The public must be fully informed about the sustainability of 24/7/52 emergency services and know what to expect in these situations.

Response

The public and patients must have confidence in the arrangements for providing health care, including emergency care, whether in hospital or in the community and wherever they are in Scotland. We have recently begun work to develop a national framework for service change in the NHS in Scotland which should raise public awareness about the drivers for change, including those relating to sustainability. The public must also have opportunities to participate in the process for reform of service delivery both at the local and at the national level.

Recommendation 2

The service must recognise that current means of delivering service will in many cases not be sustainable. Redesign is necessary if the service is to survive, and this can only be achieved by organising Scotland around much larger health economies than are provided by the current health boards.

Response

It is true that the current means of delivering a number of services are not likely to be sustainable in the future . Service re-design to provide safe, accessible, affordable and quality services is a high priority across all health sectors. It will be important in considering service re-configuration and re-design that NHS Boards work collaboratively and play a full role in regional planning of health services. But it is equally important that service redesign takes place at the Board level and at the community level. Community Health partnerships can play an important role in promoting sustainable change at a local level. This programme of work is currently being taken forward on many fronts: e.g.

• (at a national level):the work on the national framework will provide a strategic context for service change and a shared understanding of the future shape of the health care map in Scotland. An integrated programme of workforce planning linked to service delivery is also being introduced.

• (at a regional level): we have introduced legislation requiring NHS Boards to collaborate on service planning and new arrangements are in place to facilitate Health Boards to work together to plan service across Board boundaries. Managed Clinical Networks will continue to play an important role by integrating primary and secondary care.

• (at a local level): The Centre for Change and Innovation will continue to provide a focus for service redesign, working with NHS Boards to develop patient-centred approaches to care.

Recommendation 3

The service must set out service goals (outcomes for planning the service) - nationally, regionally and locally. These must:

• be as local as practicable, safe and based around the patient journey;

• ensure that elective work is carried out where possible at a local level;

• provide for emergency and acute care in all locations. This will involve, where required, effective partnership with larger more extensively resourced centres and the support of effective and reliable transport geared to sustain patients during transfer; and

• be integrated linking primary and secondary care.

Response

Clearly, services should be delivered locally wherever possible and safe and accessible emergency care is of paramount importance. These issues will all be covered in some detail in the development of a national framework for service change.

Recommendation 4

The service must re-evaluate ambulance services, including air transfer, to ensure that they continue to provide the support needed as NHS services are redesigned.

Response

The Scottish Ambulance Service (SAS) keeps services under regular review, including monitoring of emergency and non-emergency performance, and is consulted by NHS Boards about proposals for material changes in the location of hospital-based services. This ensures that SAS is able to consider and advise on the impact of service changes at an early stage in planning. The air ambulance service contract is currently under re-procurement; NHS Boards and SEHD are closely involved. The development of a national framework for service change will also consider overall implications for ambulance services.

Recommendation 5

Politicians, the profession, the public and the service must pursue consensus on what services can be delivered safely and to a high quality in a local setting.

Response

Safe and sustainable local services are important throughout Scotland and ought to be a shared objective.

Recommendation 6

The public should be treated by competent and trained doctors.

Response

The Executive supports a shift in emphasis to the delivery of medical services by trained doctors working in teams. Modernising Medical Careers(MMC) will deliver trained doctors who are judged clinically competent and who go on to make provision through revalidation of their registration to maintain that competence and so demonstrate their continuing fitness to practise.

The reforms set out in MMC, taken with the progressive application of the Working Time Regulations to doctors in training will mean the introduction of different patterns of work across medical services and particularly within the hospital-based training grades. Increasingly, service that was once undertaken by trainee doctors will be provided in other ways, for example: by increasing the ratio of trained doctors to doctors in training; by developing new roles, often within teams, for all health professionals; and by rationalising service provision often informed by service re-design.

Training programmes for doctors will be more focussed and better managed to ensure that doctors in training can reach the required competence without the delays that are a feature of current training arrangements.

Recommendation 7

For any discipline there should be three broad kinds of doctor:

• a doctor in training;

• a trained doctor who is both judgement-safe and competent in his or her field of specialist practice; and

• a trained doctor who is judgement-safe but who has also acquired the additional competences for more advanced or in-depth specialist care in his or her field of practice.

Response

This recommendation is compatible with and will be taken forward though the Modernising Medical Careers programme.

Recommendation 8

The judgement-safe categories of doctor must be 'set' at a level synonymous with acquiring Specialist or General Practitioner Registration.

Response

Changes to the ways that doctors are registered are being introduced. New arrangements for specialist and general practitioner registration will provide a practical, valid and readily understandable indicator of what is a "trained doctor". However, for such registration to maintain value it must be linked to the doctor demonstrating continuing fitness to practise though regular revalidation of his or her registration.

Other than doctors in training we recognise that there are some doctors who may not be on the Specialist or General Practitioner Register when these are fully commissioned. They are likely to be non consultant career grade doctors who are often competent in specific areas of clinical practice. Further work will be needed to identify mechanisms to enable their particular competence to be recognised.

Recommendation 9

There is a move towards a trained doctor-based service.

Response

See Recommendation 6.

Recommendation 10

More work is undertaken to identify new professional roles, new ways of working and how these may be developed within multi-professional teams.

Response

The National Workforce Committee has started a national programme on workforce design, new roles and new ways of working - this will embrace all professional groups.

Recommendation 11

As soon as is practicable and subject to the constraints of service delivery, all locum consultants must be required to be on the Specialist Register.

Response

As new ways of working are introduced which build on teamwork and on different ways of delivering service, further work will be needed to determine the changing requirement for locum consultants. It is acknowledged that many locum consultants already hold Specialist Registration and that demand for locum services will vary across Scotland depending on locality and specialty.

Recommendation 12

A simple career structure more in tune with needs of the service and professional development is introduced.

Response

When completed the Modernising Medical Careers(MMC) programme will rationalise the current medical training and career grade structure across the service. The public will find it more understandable and the service more flexible and relevant to its needs. It will more easily support new pathways for training.

Recommendation 13

Arrangements for the career development of non-consultant career grade doctors need to be made explicit.

Response

Doctors in the non-consultant career grades (NCCGs) provide invaluable service. Their professional development is important both to them and to the service. In line with all other doctors, there will be opportunities for them to progress their careers:

• firstly through the introduction of new legislation governing entry to the Specialist and General Practitioner Registers (for the first time this will enable experience as well the existing provisions for training and qualifications to be taken into account); and

• secondly as the MMC programme is implemented, providing increased opportunities for these doctors to re-enter and complete training.

When a doctor takes time out from formal training or finds him/herself in a non consultant career grade, this should not be a barrier to further career development.

The Scottish Executive will also be participating in a UK review of terms and conditions for NCCGs which will examine, amongst other things, career structures for NCCGs.

Recommendation 14

The public have a right to expect that they are treated by doctors who are trained.

Response

We have already stated what we understand to be a trained and competent doctor (recommendations 6 and 7)

Recommendation 15

The service must ensure that service delivery allows for educational changes and that training must have a high priority and be resourced appropriately.

Response

It is clear that training arrangements, however modified, will remain an important factor contributing to and influencing service delivery. It will also be important to maintain a reasonable balance between training requirements and the delivery of services to patients.

Shorter and more intensive training pathways delivered to high standards and quality assured by external agencies will require an invigorated response to training provision.

The way we train doctors is changing. We will invest in our training arrangements. This is essential if we are to retain programmes approved by the responsible authorities. As important, however, is our commitment to provide optimum training arrangements that will encourage doctors to train in Scotland and to remain to work here.

We are equally committed to ensure that for all staff there are opportunities for their continuing education and professional development in place.

We also believe that providing opportunities for different professions to learn together will help support their work in multi-professional teams.

Recommendation 16

The service must invest in, support and develop the training skills required of educational managers, trainers, consultants and supervisors.

Response

New arrangements will demand a training infrastructure able to support trainees and their clinical supervisors. NHS Education for Scotland will take forward work to strengthen the postgraduate deaneries to ensure that they are equipped for this expanded role. In most learning environments, where trainees undertake less but more targeted service relevant to their training needs, this will mean that how training is supported, managed, supervised and delivered will need careful evaluation. We need to be sure that as these new arrangements are introduced service delivery is sustained.

Recommendation 17

The service must continue to work in partnership with universities to provide incentives and support for doctors who wish to pursue academic careers.

Response

The Scottish Executive is committed to ensuring strong links between universities and the service. A recent HDL on Education Training and Research ³ asks universities and NHS systems to underpin such a partnership relationship though memoranda of understanding.

Doctors in training pursuing an academic career should be supported to do so, particularly when they are also pursuing specialist or general practice training to achieve the same recognised standards as other doctors. Further work is needed to identify practical arrangements to secure the academic workforce that Scotland requires.

Recommendation 18

The profession and the service must work with partners in Scotland and in concert with the other home countries to take forward the programme of work to deliver Modernising Medical Careers through a Scottish Executive led implementation group.

Response

A Scottish Modernising Medical Careers Delivery Group has been established reporting to the National Workforce Committee. It links to the UK MMC Strategy Group to ensure that as the MMC programme is taken forward in Scotland, the arrangements remain compatible across the UK.

Recommendation 19

The profession and the service must provide more focused and better-managed training programmes delivering competent clinicians to national standards thus producing the doctors that NHSScotland needs.

Response

We would agree. (See Recommendation 6)

Recommendation 20

The profession and the service should introduce extended GP training programmes to meet UK standards.

Response

We recognise that a number of GP registrars do not, on completion of their training, feel confident enough to assume the growing responsibilities for independent practice as a GP. As the Modernising Medical Careers programme is taken forward, further work is required to evaluate what should be fit-for-purpose GP training programmes relevant to the needs of NHSScotland.

Recommendation 21

The profession and the service should move to seamless and shorter training for hospital-based specialties - removing marking time elements and supporting the "doctor journey".

Response

Hospital training is for many specialties too long with often too much time spent "marking time". The average age for first appointment as a consultant in Scotland at over 37 years remains high. As part of the MMC programme, which we have now commissioned, our medical students will on graduation enter a two-year Foundation Programme. Thereafter they will enter one of a range of progressive or seamless training programmes which lead to a Certificate of Completion of Training (CCT) in specialist or general practice. Many will then have the opportunity to progress to more advanced training where that is relevant. Further work is required to clarify the arrangements for each of the many programmes that will be on offer.

Recommendation 22

The public need to be involved in the staffing arrangements for the service.

Response

The Scottish Executive is fully committed to public involvement in service and workforce change and improvement. The new National Health Service Reform (Scotland) Act places a duty directly upon NHS Boards to secure public involvement in planning and development, and decisions affecting the operation of health services. Guidance on 'Consultation and Public Involvement in Service Change' has been issued to the health service and is currently being revised.

Recommendation 23

The service requires robust, coherent workforce planning building on central leadership.

Response

Our plans to invest in a step-change in our capacity for workforce planning and development at local, regional and national levels were set out in August 2002 in 'Working for Health' - considerable progress has been made since then.

A National Workforce Committee has been established to provide leadership (Professor Temple is a member) and a National Workforce Unit has been established in SEHD to promote and co-ordinate workforce planning activity. Over 3m has been invested in building new capacity for workforce development at local and regional level and two regional workforce officers have been appointed (with the process to appoint the third underway).

In April 2004 the baseline National Workforce Plan was published detailing the annual cycle of workforce planning; and a Workforce Numbers Group has been established to support the National Workforce Committee in this area.

Recommendation 24

The service increase the consultant workforce as a priority. There is also an urgent need to revisit the consultant numbers planned for 2006.

Response

The Scottish Executive aims to increase consultant numbers by 600 by 2006, with further increases thereafter. Further work on assessing Scotland's clinical workforce needs will be undertaken as part of the workforce planning processes outlined above.

Recommendation 25

The service increase the number of general practitioners. There is also an urgent need to plan general practitioner numbers across Scotland.

Response

The Scottish Executive accepts that general practitioner numbers will have to increase. Planning for general practitioner numbers will be taken forward as part of the wider primary care workforce planning process, since the new GMS contract envisages the delivery of primary medical services by the whole practice team. The results of this will feed into the Workforce Numbers Group.

Recommendation 26

The service and the profession do more to retain those that we train.

Response

The Scottish Executive supports this recommendation and is committed to working with employers to ensure that Scotland retains sufficient numbers of professional staff.

Recommendation 27

The service and the profession examine how service redesign can improve retention and recruitment, particularly in posts that are difficult to fill. Delivering an effective strategy for retention and recruitment is urgent.

Response

We are moving towards better co-ordination of service and workforce planning across health boards and regions. This will underpin our ability to recruit, retain and develop the staff to meet Scotland's needs.

Recommendation 28

The service and the profession promote medical careers across Scotland, taking into account the needs of specialties and geographical areas under particular pressure.

Response

These arrangements will be supported by the new career website for NHSScotland which will include easy access to information on careers as well as opportunities for jobs and training development.

Recommendation 29

The service and the profession ensure improved career advice and counselling for all doctors. This must be available throughout training and include linking individual needs and plans for career development to service demands.

Response

We agree. Much support is already provided through NHS Education for Scotland by the deaneries. We are examining how this may be further strengthened to ensure that those completing training or who seek a change in career direction may be able to plan their career appropriately.