The Scottish Government

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June 2005
ISBN 0 7559 4715 0

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Introduction

In December 2000 our first White Paper on Health "Our National health: a plan for action a plan for change" made a commitment to undertake a fundamental review of the medical workforce. Professor Sir John Temple's two Reports " Future Practice" and subsequently "Securing Future Practice", together with this " Review ofBasic Medical Education in Scotland" by Sir Kenneth Calman, have enabled us to fulfil that commitment.

Sir John's first Report identified the need to explore increased output from Scotland's medical schools, quantify the case for further increase, provide for mature entry and improved social diversity and to enable some or all of University of St Andrews students to complete their undergraduate medical training in Scotland. These together with the commitment in "Our National Health: a plan for action, a plan for change" to consider the possibility of fast track graduate-entry medical degree courses in Scotland, set the terms of reference for Sir Kenneth's review.

It is a challenge to provide a multi-professional health workforce able to meet current and future demands across Scotland. The medical workforce is an integral part of that challenge and is often pivotal in securing effective care. Doctors increasingly work within teams sharing responsibility for care with other health professionals and now need to be trained to work in that environment. Sir Kenneth's Review looks to the future and recognises the need to prepare doctors for new and changing professional roles and new ways of working.

Sir Kenneth begins his Review by stating that "our primary objective in addressing our terms of reference is to improve the health and health care of the people of Scotland." That is a sentiment that we strongly share. We are grateful to him for setting out key areas of basic medical education in which we need to make progress. They link closely to Sir John Temple's recommendations on the medical workforce. But Sir Kenneth has helped us understand better the relationship between our universities and our health service. His Review, although wide-ranging, focussed on four broad areas:

• medical student numbers and the case for increasing them;
• admission to Scottish medical schools;
• collaboration between the Scottish medical schools; and
• particular actions to be taken by NHSScotland and the Scottish Executive.

There are recommendations in each of these areas to which we have given careful consideration and, as will be seen in this Response, we are making progress in all of them. But there is still much to achieve. Our medical schools are important to Scotland. We recognise their contribution and want to ensure that they are able to build on their deserved national and international reputation of excellence. We therefore welcome the proposal to establish a Board of Medical Education in Scotland. It will have a key role in supporting the work of our medical schools and in advancing Sir Kenneth's recommendations.

We have accepted the need to increase medical school output and have set out how we see that being achieved. We have also accepted Sir Kenneth's recommendations for broadening access and for increasing diversity amongst those entering medicine.

We thank Sir Kenneth and his colleague Michael Paulson-Ellis and the many people who contributed through their comments and support to their work. They have provided a helpful, timely and clear analysis of a challenging matter important in improving health care in Scotland.

We would welcome comments on Sir Kenneth's Review and on our Response to it, and invite interested parties to send their views to:

Mr Scott Miller

or by e-mail at scott.miller@scotland.gsi.gov.uk.

Allan Wilson, MSP Deputy Minister for Enterprise and Lifelong Learning June 2005	Andy Kerr, MSP Minister for Health and Community Care June 2005

Specific Responses to the Recommendations contained in Review of Basic Medical Education in Scotland

Additional medical student numbers

Recommendation 1

The Scottish Executive makes it possible for Scottish Higher Education Funding Council ( SHEFC) to fund an additional 100 places per annum in Scottish medical schools at the full rate applied to all such places; but that SHEFC and the universities jointly agree mechanisms by which these places be specifically restricted:

• to schemes and courses that increase the diversity of Scottish medical students, including but not limited to access schemes, foundation year course(s) and accelerated four year course(s) for graduate entrants; and
• to students likely to be committed in the long-term to the Scottish NHS.

(Paragraph 75)

Response

We accept in principle that the current graduating output of around 800 should increase to between 950 and 1,000 by an additional 100 new-funded places per annum and by incorporating St Andrews fully within Scottish medical education. We have set out in our response to Recommendation 3 our view that:

• the increase in funded places should be phased and subject to review within the next 2 - 3 years; and that
• the first phase should provide all St Andrews' students with opportunities to continue training in our four clinical schools.

We agree that Scottish medical schools in general and Scottish domiciled students within them are important to NHSScotland. We believe that there is a case to increase the proportion of applicants and entrants who are domiciled in Scotland since, in the long term, they are more likely to be committed to work in NHSScotland. Scottish medical schools should individually and collectively seek to do so (see also Recommendation 7). We see this being supported by increasing the diversity of entrants to our medical schools. We therefore welcome Sir Kenneth's proposals for widening access: an intensification of existing initiatives; new initiatives working with schools in disadvantaged areas; the development of foundation courses to bring able students to an appropriate standard; and building collaborative links with FE colleges. The Executive will work with HEIs to explore these further.

We recognise that some 10% of our entrants to our standard courses are graduates. We agree that they too contribute to diversity and that there should, within the funded places, be provision for an accelerated four year course(s) for graduate entrants.

We recognise that some 10% of our entrants to our standard courses are graduates and agree that there should, within the funded places, be provision of an accelerated four years course(s) for graduate entrants.

Recommendation 2

The Scottish Executive makes it possible for SHEFC to fund one or more Scottish medical school(s) to enable them to provide clinical education for St Andrews' students under the arrangements for amalgamation or partnership agreed by the universities in question and by SHEFC.

(Paragraph 75)

Response

Accept. We agree that St Andrews' students should be incorporated fully within Scottish medical education. We set out our view on how that should be achieved in the response to Recommendation 3.

Recommendation 3

Implementation of the additional funded student places be phased, with a first phase providing 50 new places per annum, and up to 50 places for the clinical education of St Andrews' students, and kept under review over the next 2 - 3 years in the light of the development of workforce planning information; and that student numbers in the Scottish medical schools (as increased by our recommendations) be further addressed thereafter in the light of that work.
(Paragraph 77)

Response

Accept in part. We agree that implementation of additional funded places should be phased and revisited over the next 2 - 3 years. This review should be informed by improved workforce planning provisions (including better recruitment and retention), by any increase in the proportion of Scottish-domiciled students, by new ways of working and of service delivery and by the extent of the continuing pressure for more doctors. We believe however that, during this first phase, this increase should be secured by providing all St Andrews' students with funded opportunities to complete their undergraduate medical training in Scotland's four clinical schools. This should be phased in from August 2006 under arrangements agreed by the universities and SHEFC, taking account of the views of the students, the six universities concerned, the Board of Medical Education in Scotland, the Department of Health and the Scottish Executive. Accordingly provision for additional funded places on five year courses should be deferred.

We also accept that, in integrating St Andrews fully within Scottish medical education, it does not follow that St Andrews' students need necessarily follow a six-year curriculum. In light of the new arrangements proposed above, SHEFC should review funding to ensure the provision represents good value for money for students, the universities involved and for the interests of Scottish health care.

Recommendation 4

The Scottish Executive and SHEFC take special account of the position of medical education in their review of the effects on Scottish higher education of changes in the funding regime in England.

(Paragraph 81)

Response

Accept. We announced in June 2004 that we would examine the case for setting a separate flat-rate tuition fee for medicine, as part of a package of measures to protect the interests of Scottish domiciled students from the changes to tuition fees being introduced in England from 2006-07. In line with the fee legislation in the Further and Higher Education (Scotland) Bill, we are holding a public consultation exercise about this proposal.

Recommendation 5

Additional funding be provided to universities to cover the additional costs of establishing and maintaining schemes and courses that increase the numbers and diversity of Scottish medical students and the Enterprise, Transport and Lifelong Learning Department and the Health Department jointly consider whether these funds are a proper charge on the higher education or the health workforce budgets.

(Paragraph 82)

Response

In responding to this recommendation, both Departments and SHEFC will also consider the scope of existing initiatives to widen access to medical study which have been identified elsewhere in Sir Kenneth's Report or from other sources.

The Executive will provide pump-priming funding to support the establishment of an accelerated four year course(s) for graduate entrants.

Admission to the Scottish medical schools

Recommendation 6

The Scottish medical schools establish a single body to ensure and enable greater diversity of students, to review the relationships between secondary and further education in Scotland and entry to medical school, to lead the development of new selection instruments, and to integrate the processing of applications while leaving the final decision to individual schools.

(Paragraph 96)

Response

Accept. The Executive supports the universities as they seek to widen access to medicine but we agree with Sir Kenneth that there is scope to develop further strategies for widening access that he has identified in his Review. We accept his analysis that, in order to increase the proportion of Scottish domiciled students in our medical schools and thus the number of doctors likely to live and work in Scotland, Scottish medical schools need to give more attention to the "realities of secondary education in Scotland" as these apply across all our schools and impact on numbers entering medicine. We agree, for example, that universities should consider removing the restriction that, as a condition of entry, five Highers must be obtained in a single sitting. The Board for Medical Education in Scotland ( see Recommendation 8) would have an important role in considering these issues.

Recommendation 7

The Scottish medical schools individually and collectively seek to increase the proportion of applicants and entrants domiciled in Scotland.

(Paragraph 75)

Response

Accept. The Executive supports all efforts by the medical schools that will increase the proportion of applicants and entrants domiciled in Scotland.

The Executive recognises that the percentage of Scots-domiciled entrants to our medical schools has fallen over the past decade or so to around 50%, that the recent growth in applicants to medicine elsewhere in the UK has not been paralleled by similar growth in Scottish-domiciled applicants, and that the proportion of Scottish domiciled entrants of all UK entrants to medicine is projected to fall below the population proportion of Scotland within the UK. At the same time NHSScotland finds it difficult to retain sufficient medical graduates to meet its needs. We also recognise that Scottish-domiciled entrants to medicine are much more likely to pursue a career in Scotland.

Collaboration between the Scottish medical schools

Recommendation 8

The universities establish a Board for Medical Education in Scotland, responsible to them for:

• strategic overview of collaboration between the medical schools;
• setting and monitoring the objectives of subsidiary bodies responsible for collaboration in individual areas, including inter alia admissions, medical education, clinical skills training, and research;
• collaboration and interaction with other organisations with a stake in medical education, including the Scottish Executive Health and Enterprise and Lifelong Learning Departments and NHS Scotland (including NHS Education for Scotland); and
• promoting Scottish basic medical education as an entity.

(Paragraph 115)

Response

Accept. We welcome the establishment of such a Board. It will enhance and support the work of the universities and medicine without compromising their independence. There is a significant agenda which includes:

• providing a strategic overview of academic medicine between schools in support of their role in meeting Scotland's needs for newly qualified doctors;
• fostering a range of collaborative work across education and research including curriculum development and clinical skills training;
• reviewing the arrangements for admission and for broadening access and for ensuring that Scots applicants are not disadvantaged;
• informing arrangements to assimilate St Andrews' students and the introduction of new courses and funded places;
• development of clinical education networks;
• promoting basic medical education in Scotland; and
• working collaboratively with the Scottish Executive and NHS Education for Scotland on workforce planning and development.

The membership of the Board should include the medical school deans together with representatives of other stakeholders including the public, NHS Education for Scotland and NHSScotland. There should be observers from SHEFC, The Scottish Executive Health Department ( SEHD) and The Scottish Executive Enterprise Transport and Lifelong Learning Department ( SEETLLD). We agree that this body would benefit from being chaired by a distinguished figure appointed independently of the Board. A small, dedicated staff should support the work of the Board. We would welcome reports of the work of this Board being placed in the pubic domain.

Recommendation 9

The universities create a single Scottish Centre for Basic Medical Education, to lead development and facilitate and encourage collaboration in curriculum and assessment matters and new uses of technology, and to form a base for enhanced research in medical education, including research into and development of the admission process.

(Paragraph 102)

Response

Accept. We agree there is merit in the universities developing such a resource. Although it may have a major interest in basic medical education it should also contribute to the professional development of other health professions. It would be for the universities in collaboration with the new Board of Medical Education in Scotland to consider how such a centre might best be configured to meet needs across Scotland.

Recommendation 10

The universities seek to create more specialist medical education posts.

(Paragraph 102)

Response

We welcome this approach and recognise the work of universities in increasing the profile of Scottish medical education.

Recommendation 11

The universities and NHS Scotland work collaboratively to ensure the most efficient and effective use of Clinical Skills Centres.

(Paragraph 105)

Response

We warmly welcome this work. Skill centres are invaluable in supporting and assuring the professional development of health professionals throughout their working life. They draw on the advances of changing technology but can be costly to commission and operate, requiring particular expertise to sustain. We would encourage collaboration with NHSScotland.

Recommendation 12

The universities collaboratively develop structured relationships for the provision of clinical education in networks centred on each medical school and including the principal 'teaching hospital(s)', DGHs, primary care settings and if possible other community medicine settings.

(Paragraph 107)

Response

Accept. We welcome and encourage this work. Universities make an essential and invaluable contribution to service delivery across Scotland. We recognise that as patterns of service delivery change there will be opportunities to explore how universities can be better integrated with service provision, for example with: regional arrangements recently established by NHS Education for Scotland; and with regional service planning groups.

Recommendation 13

The universities establish structured relationships to support collaboration between medical schools and those responsible for education of other groups of health professionals.

(Paragraph 120)

Response

Accept. We would expect the new Board for Medical Education in Scotland and the Scottish Centre for Basic Medical Education to support this work.

Other action by NHS Scotland and the Health Department

Recommendation 14

Health Department/ NHS Scotland workforce planning arrangements develop their work on the demand for and supply of doctors and on doctors career patterns.

(Paragraph 89)

Response

Accept. Arrangements have been put in place to support and take forward workforce planning at national, regional and local levels. The National Workforce Plan 2005 - A Framework for NHSScotland will be published this summer. Regional and local workforce plans will be produced shortly after.

Recommendation 15

These workforce planning arrangements work in conjunction with the universities, SHEFC, SEETLLD, and the Universities and Colleges Admissions Service ( UCAS) to secure systematic information on application and entry to and graduation from medical schools.

(Paragraph 89)

Response

Accept. This could be a matter for the new Board of Medical Education in Scotland to facilitate.

Recommendation 16

NHS Scotland radically changes Additional Cost of Teaching ( ACT) funding so that it is transparent and follows students.

(Paragraph 111)

Response

Accept. A reform of ACT funding has already been agreed following acceptance of a recommendation from the Scottish Committee of Resource Allocation in 2004 to overhaul the way in which Medical ACT funding is distributed in Scotland. Revised arrangements are now being implemented.

Recommendation 17

NHS Scotland ensure that full weight is given to medical education issues in consultant and GP contracts and in staff management arrangements for university and NHS staff working in those areas.

(Paragraph 121)

Response

Accept. HDL (2004)25 ¹ issued on 10 ^th May 2004 confirmed the need to address education issues through the new consultant contract, and outlined the strategic approach to be taken by NHS Boards in partnership with the universities. This aspect of the contract is being overseen by the National Partnership Steering Group for the new consultant contract. The General Medical Services contract provides an enhanced infrastructure in GP practices to help support GPs in providing medical education.

Recommendation 18

The Health Department establish a review of the links between undergraduate medical education and the undergraduate education of other health professionals.

(Paragraph 120)

Response

Accept. The Scottish Executive has asked NHS Education for Scotland to prepare a Commissioning Plan for the education of the health workforce in Scotland. The Plan will cover the links referred to in the above recommendation. Work is already underway substantially to address this.

Footnotes

1 NHSHDL(2004)25, Treatment of Teaching, Training and Research Under the New Consultant Contract and Development of Memoranda of Understanding Between Universities and NHS Boards, Scottish Executive Health Department, 10 ^th May 2004.