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ASPIRING TO EXCELLENCE - SCOTTISH GOVERNMENT CONSULTATION ON PROFESSOR SIR JOHN TOOKE'S RECOMMENDATIONS

Background

Professor Sir John Tooke published his report on Modernising Medical Careers ( MMC) "Aspiring to Excellence" on 8 January 2008. This report suggests a reworking of many aspects of postgraduate medical education ( PGME) and contains detailed recommendations (full details available at www.mmcinquiry.org.uk). In Scotland, the Scottish Government recognise that some of the recommendations made by Sir John will need further discussion on a UK basis.

This paper focuses on the actions we are taking forward in Scotland. The main sections covered below outline our views and planned work being taken forward. Each section has a set of questions to which your views and comments are invited.

For further information on any elements outlined in this document, please contact Kerry Chalmers at tookeconsultationresponse@scotland.gsi.gov.uk

Context in Scotland

Modernising Medical Careers ( MMC) is the UK wide long-term programme of action to transform the medical workforce through redesign of postgraduate medical education ( PGME). The main objective ultimately is to improve the patient experience by improving PGME and thus the product of postgraduate programmes who should be better prepared for trained doctor practice in the modern NHS. The MMC approach is competency based and programmatic. The current UKMMC career framework is shown in the figure below.

UKMMC Career Framework Proposal

Last year, we embarked on a robust process of education and awareness about the new processes that were being introduced in relation to the appointment of individuals into specialty training posts. This started in November 2006, for posts to be filled by August 2008. A number of lessons were learned along the way, which can be summarised as those in relation to the IT system ( MTAS), communication (including the application process) and governance.

In relation to the IT system being used, the use of MTAS was suspended mid-year because of concerns raised by junior doctors and others. As some of the functionality which was needed in Scotland was not available on the system, it was agreed that we would not use MTAS for the 2008 recruitment process. NHS Education for Scotland ( NES) is continuing to use and develop our own application management system. It is recognised that there is an on-going need for an overarching single UK portal for entry to cope with the anticipated volume of applications and discussions are ongoing in relation to future years.

It was agreed that some doctors in 2007 were unprepared for the introduction of a competency based application form and some did not fill it in correctly, leading to the concern that some good candidates had been shortlisted out prior to interview. It was therefore agreed that in Scotland we would interview all applicants who applied for a post in Scotland. In 2008, we are continuing to use a competency based approach.

Some important changes to the governance arrangements have also been made in light of this year's experience. These are detailed in the section below.

Work is continuing to try to further refine the costs and benefits of MMC. NES is in the process of estimating the cost of recruitment to specialty training pre- and post- MMC. This consists of collaborating with a number of NHS Boards who have agreed to provide information for this project and we have commissioned work to assess benefits of the new recruitment process. There is some evidence in the economics literature to suggest that the benefits of a centralised and synchronised recruitment procedure may be measured by comparing the mobility of successful applicants before and after the introduction of MMC.

Main Tooke report sections:

The following sections are covered under the headings in Sir John Tooke's report, as follows:

Clarification of Policy Objectives
Policy Development and Guidance
Medical Professional Engagement

MMC Organisational Structure

The new UK governance arrangements are set out below.

The Chief Medical Officer ( CMO) for Scotland represents Scotland at the UK Co-ordinating Group, supported by input from two new Scottish Boards, the Specialty Training Programme Board ( STPB) and the Selection and Recruitment Delivery Board ( SRDB). These governance arrangements are responsible for the strategic development and implementation of MMC in Scotland, including accountability for all policy, and key operational decisions in relation to selection and recruitment in 2008 and for any residual MMC matters from 2007. Governance arrangements include the Specialty Training Programme Board (the "Scotland Programme Board" within the UK governance structure and linking with the UK Co-ordinating Group to ensure UK consistency), which is co-chaired by the Scottish Government HR Director and Chief Medical Officer for Scotland. This Board gives direction to, and takes recommendations from the Specialty Training Delivery Board which the Chief Executive of NHS Education for Scotland ( NES) and the Chair of the Scottish Association of Medical Directors co-chair . The latter Board is responsible for delivering the system of selection and recruitment to specialty training in Scotland in 2008.

The remit of the Specialty Training Programme Board is to determine overall policy and objectives for the selection and recruitment to postgraduate medical Specialty Training in 2008, taking into account wider Scottish policy drivers and the relationship between the implementation of selection and recruitment in Scotland and the UK; to agree Scotland's input to UK governance arrangements and policy development; to approve the project definition, and project plan for 2008, and any deviations from or modifications to them; to agree any necessary central financial provision; to give direction to, and make timely decisions in response to recommendations from, the Selection and Recruitment Delivery Board; to resolve any conflicts arising from the implementation of the project that cannot be resolved by the Selection and Recruitment Delivery Board; and to advise, inform and, where necessary, seek steers from the Cabinet Secretary for Health and Wellbeing. It is also required to determine policy on any residual matters from selection and recruitment to postgraduate medical specialty Training in 2007.

Members
Chief Medical Officer for Scotland, co-chair
Scottish Government HR Director, co-chair
Co-chairs of the Selection and Recruitment Delivery Board
NHS Education for Scotland ( NES) BMA
Academy of Royal Medical Colleges
Representatives of the Scottish Government Health Directorates
Representatives of NHSScotland

The Selection and Recruitment Delivery Board ( SRDB) reports to the Specialty Training Programme Board ( STPB) to produce a project definition, project plan and risk register for Specialty Training selection and recruitment in 2008; to implement Specialty Training selection and recruitment in 2008 in accordance with the agreed project plan; to devise and implement necessary processes for selection and recruitment, including arrangements for host Boards, application form design, short listing and interviewing, offers/allocation to programmes and other HR related matters; to agree, with the Scottish Government, relevant workforce numbers; to manage overall communications; to manage the relationship with regional workforce planners, Specialty Boards and Scottish Deaneries; to liaise with wider stakeholders; and to establish relevant sub-groups.

Members
Chief Executive of NHS Education for Scotland, co-chair
Chair of Scottish Association of Medical Directors, co-chair
Members drawn form the current membership of the Scotland Delivery
Management Steering Group ( MSG)/Scottish Association Medical Directors Group

It is expected that the Selection and Recruitment Delivery Board will establish sub-groups on Human Resources and on Communications.

As explained above the governance arrangements for MMC have been clarified on both a Scottish and UK basis and there is extensive input from the NHSScotland to guide and steer policy development and implementation. In relation to the setting and agreeing of training numbers, NES Specialty Boards are now involved at an early stage to ensure there is sufficient time for agreement of not only the broad direction of travel, but also the specific numbers. Decision on the overall numbers is taken centrally by Cabinet Secretary and advice is provided on that by officials in Health Workforce, based on evidence provided by NES and the Specialty Training Boards.

Questions:

1. In your view, are the current governance arrangements sufficiently robust? What further structures and actions, if any, should be taken to improve governance arrangements in Scotland?

2. What are your views on what can be done by Scotland at UK level to meet the recommendation made by Sir Tooke to "Redefine and reassert principles underpinning postgraduate medical education" to ensure UK consistency where appropriate?

3. What other work do you think should be undertaken in Scotland to improve i) the organisational structure of postgraduate medical education; and ii) the career framework, in Scotland?

As delivery of improved patient care is our aim we first need to determine the needs of the population and the role doctors play in meeting those needs, in the modern Scottish NHS. We agree with Sir John Tooke's recommendation that there is the need to define more precisely the varies roles of the doctor. Our view is a more fundamental piece of work is required to define the different roles of the consultant, registered specialist, General Practitioner and doctor in training. Doctors should be trained to the level that allows them to meet patient needs of a certain degree of complexity, and models of service delivery should be built around patient needs, which is delivered by trained doctors rather than doctors in training.

A fundamental review of the role of doctors within the modern NHS is a significant piece of work but it is our opinion that much of the evidence and thinking that is necessary to deliver this change is already available to varying degrees within the service and the profession. Synthesising that intelligence and understanding to create a methodology for redesign based around patient centred services, delivered by trained doctors is within reach in many services and specialties.

We will ask a multi-professional NHSScotland group, led by the service through the Scottish Association of Medical Directors ( SAMD), supported by the Workforce Planning Unit in the Scottish Government Health Workforce Directorate ( SGHWD) to begin this work in the first half of 2008. They will be asked to determine the basic building blocks that are required in a service delivered by trained doctors as part of multi-disciplinary delivery teams, and to develop a methodology that will allow local services to plan their medical workforce in that way. The group will engage stakeholders through a series of multi-professional workshops across the country.

Questions:

4. Do you agree there is a need to review the role of the doctor before we can move to a healthcare system delivered by trained doctors?

5. Currently doctors in training are an integral part of service delivery. Do you consider that in future doctors in training should be largely 'supernumerary' to service requirement?

6. In your view do all services need a judgement safe/unsupervised doctor? If not, which services are the exceptions? How should we take discussions on this issue further?

7. Do you agree with our approach towards defining the role of a trained doctor? In your view, what other work should we be doing to improve definition of the role of the doctor and/or to improve medical workforce planning.

Workforce Planning

Medical Workforce Planning

The National Workforce Planning Framework for NHSScotland was published in 2005 and set in place a workforce planning cycle to allow workforce projections to be made to deliver our objectives for improved patient care, that meet service requirements and are underpinned by clear and affordable service and financial plans. This process is becoming more refined and developing year-on-year as the evidence-base, capability and expertise grows in NHSS, thus enabling NHSScotland to secure the workforce needed to respond to changes in services to serve patients' needs and to support the shift in the balance of care towards more community provision of services. While progress has been steady it is acknowledged that there is still some way to go and NHS Boards will need to continue to develop comprehensive workforce plans to reflect future service provision and reconfiguration. Work is underway to take forward an integrated approach to workforce, service and financial planning at local, regional and national level to deliver the Better Health Better Care Action Plan: the strategic service plan for NHSScotland. The recently issued Local Delivery Plan and data requirements guidance also includes supporting financial and workforce planning information for the first time.

Focusing on medical workforce planning, medical specialty training numbers are controlled using a national supply and demand model. The purpose is to determine the number of training places each year to meet demand in 10 years time instead of leaving this to unplanned market forces. The model takes account of various pieces of information including projected demand from NHS Board workforce plans, current staff, the number of leavers, attrition and retirement rates. In addition to the evidence provided by the national model, advice is also sought from NHS Education for Scotland ( NES), Specialty Training Boards and NHSS to determine final numbers. Over the coming period we will be working closely with NES to improve this process and to ensure better transparency and consistency across the range of data sources.

Since 1996 the medical consultant workforce in NHSScotland has grown by around 31% from 2557 WTE (whole time equivalent) to 3459 WTE in 2006. NHS Board workforce plans indicate further expansion over the next decade but to a more modest extent. As we move towards a service delivered by trained doctors, NHS Boards will need to review their workforce plans to ensure that they are making best use of the whole workforce and that workforce plans are affordable within the Scottish Spending Review allocations. This may well involve redesigning services and developing new ways of working based on multi-disciplinary team approaches.

Funding for training is also provided by the Scottish Government. As medical training numbers change, we will review and clarify funding arrangements to ensure the use of public funds continues to support national priorities and provide value for money.

Undergraduate medical students

For 2008/09, the number of undergraduate places have now been set. For undergraduates, supply training numbers will remain at 834 (with an additional 66 places for overseas students), which is level with the intake target for 2007/08. We will also hold the number of undergraduate students retained in Scotland from the St Andrew's University medical training programme at the same level as this year to allow a wider review of medical supply to be undertaken. For the 2008/9 new student cohort at St Andrews, this means that up to 55 students will be retained in Scotland following their initial training.

Further modelling of future workforce requirements is needed to inform the number of undergraduate places needed to meet future workforce needs. We know that Calman recommended in 2004 that Scottish medical places should be increased by 100 to around 950 graduates per year. The arguments for this increase were based on expected continued growth in the overall medical workforce as predicted in the Wanless report in 2001 and on historic trends of significant levels of Scottish medical graduates leaving Scotland for work in other parts of the NHS across the UK and further afield.

However, increased output from medical schools elsewhere, particularly in England where places have increased from 3,749 in 1997 to 6,451 in 2007 in order to achieve greater self-sufficiency, will mean fewer opportunities for Scottish graduates to move out of Scotland, as well as more competition from graduates from across the rest of the UK to fill gaps that doctors leaving Scotland create. Similar changes are occurring in other developed countries, for example with Australia planning to almost double increase in medical school output between 2004 and 2016.

The evidence shows that Scotland is moving into a period of oversupply. However, there remains significant debate around the scale of this. Undergraduate supply training for the medical workforce will be considered further during the coming period as the role of the trained doctor is clarified and used to inform workforce plans, as the transition phase for MMC implementation is completed, and as NHS Boards further develop their integrated workforce planning processes.

Postgraduate medical training

Our core aim is to balance supply with NHS Board workforce demand. However, the training intake numbers for 2008 provide for a relatively steady state across each of the specialties recognising that we are still in a transitional phase for Modernising Medical Careers. Although there has been some increase in the number of postgraduate specialty training posts across a broad range of medical specialties this year to support implementation of MMC, for the majority of specialities this coincides with a corresponding reduction in the number of fixed term training posts. The overall impact is that there has been a small increase in overall training numbers to support implementation of MMC and to ensure that we have the right number of doctors in place to meet service delivery requirements.

In addition, the length of General Practice training programme rotations has been changed to ensure GPs spend more time in primary care during their training. To support this change in GP training, a further investment of £10m has been allocated to NHS Education for Scotland for 150 additional posts to ensure that there is continuity in service provision and medical training while GPs in training spend longer in primary care.

Question:

8. In your view do you consider it appropriate that the Scottish Government determines medical training numbers ? If not, which other organisation/body would be more appropriate and why?

9. Please outline any suggestions you have to improve the process for determining the level of controlled medical training numbers.

10. Do you have any further views or comments on postgraduate training in Scotland?

11. Historically Scotland has trained many more doctors than needed by NHSScotland at a senior level ( Calman Reviewwww.scotland.gov.uk/Publications/2005/06/2992339). In your view do you think that Scotland should be trying to align the number of training places with the number of trained doctors required by NHSScotland?

Scottish Advisory Committee on the Medical Workforce ( SACMW)

The Scottish Advisory Committee on the Medical Workforce ( SACMW) has only two remaining roles. The approval of staff grade posts - the only posts subject to national control - and the regrading of Staff Grades to Associate Specialists.

Staff grade posts are created for the delivery of service and provide valuable input. There should be flexibility for Boards to be able to create and fill these posts. This is especially true during the current period of transition. It is our view that national controls on the creation of service posts should be relaxed during the transition period.

Associate specialist post regradings go through an extensive local process that involves professional, deanery and service management input to ensure that funding is available, and that the regrading offers benefit to the service as well as to the individual doctor concerned. If all stakeholders are in agreement on regrading then an application is made to SACMW to approve. We believe that Boards should have the freedom to regrade according to the guidance without need for national approval.

We recommend that roles currently fulfilled by SACMW should be remitted to local NHS Boards with immediate effect.

Question:

12. Do you agree with our view that the remaining roles of the Scottish Advisory Committee on Medical Workforce could be remitted to NHS Boards?

Commissioning and Management of Postgraduate Medical Education and Training

Scottish structures are already in place for commissioning and managing postgraduate medical education. NES with stakeholders are developing educational governance arrangements in support of MMC, including a review of its Medical Directorate and Service Level Agreements ( SLAs) with NHS providers.

We recognise that strong links between postgraduate deans and medical schools are vital and this is reflected in our Scottish structure, clearly linking the four NES deaneries to the four graduating medical schools.

As NES develop the educational governance arrangements for MMC implementation, they will be working in partnership with NHS Boards to interpret with them how to best develop the Director of Medical Education role in their Board area. Scotland has fourteen territorial NHS Boards including three Island Boards (the smallest NHS Orkney) and four with University Teaching Hospitals, covering a range of geographies, populations, ranges of services and specialisms. On this basis, one solution will not fit all and NES are working closely with Regional Planning Groups to determine where a regional approach to some of the policy implementation may best serve local health system needs.

Questions:

13. Do you agree that the development of Directors of Medical Education and flexibilities around regional arrangements will add value and clarity to responsibilities for postgraduate medical education at service level?

14. What are you views on this role for NHS Education for Scotland, which is different from the organisation in the other UK countries?

Streamlining Regulation

We support the further alignment of GMC and PMETB policy and process. The publication of the White Paper Trust, Assurance and Safety followed a UK wide consultation by the Department of Health ( DH) on the recommendations of two reviews - of medical and non-medical regulation - undertaken in the wake of the Shipman Inquiry. The response to that consultation from the Scottish Government ( SG) was informed by stakeholder events held across Scotland.

SG liaised with DH on the drafting of the White Paper, whose policy intentions are aimed at providing for safer patient care across the UK and enabling the public and patients to be confident that the health professional who cares for them is practising to nationally agreed standards based on an ethos of high quality care. The Paper also re-affirms the commitment of all four UK countries to UK-wide regulation, but recognises that implementation of its policies may vary across the UK due to the different structures and systems in place in the four countries. It sets out plans for changes to current regulatory systems which will:

• Establish a three board model for the GMC, covering undergraduate education, postgraduate education, and continuing professional development.
• Establish a Network of GMC Affiliates, initially at regional level in England, and possibly at a national level in the other 3 UK countries Scotland has indicated its intention to await the results of the English pilot before deciding whether this is a role that is needed in Scotland.
• Ensure that all statutorily regulated professions have revalidation arrangements in place which demonstrate continuing fitness to practise.
• Establish a new independent body to adjudicate in fitness to practise cases, in the first instance for doctors and opticians.
• Ensure that the national professional regulators are seen to be independent and impartial.
• Make changes to the Council for Healthcare Regulatory Excellence, which oversees the regulators, to enable it to take on a stronger and more independent role in providing expert advice on professional regulation.
• Establish a new General Pharmaceutical Council for the regulation of pharmacists and pharmacy technicians and the registration of pharmacy premises.
• Improve the information held on the regulatory bodies' registers.
• Develop criteria to determine which roles should be statutorily regulated in the future.

It is anticipated that implementation of the White Paper in Scotland will have the following impact:

• The commitment of the Devolved Administration in Scotland to UK wide regulation will continue.
• Some of the White Paper proposals will need to be adapted in order to work well in Scotland; both for devolved (where considered necessary) and reserved areas.
• The different structures, systems, processes and accountability mechanisms in Scotland will be taken account of in terms of operational practicalities.
• Health professionals will be able to move easily around the UK.
• There will be a clear focus on patient safety.
• There will be improvement in healthcare service delivery.
• Public confidence in health professionals will be raised.
• Health professionals and employers in Scotland will have confidence in the statutory regulators

Questions:

15. What are your views on the recommendation to merge the General Medical Council and the Postgraduate Medical Education Training Board?

Structure of Postgraduate Medical Training

The structure of postgraduate medical education ( PGME) needs to be shaped so it can deliver the workforce fit for the future. There are attractions in the report's recommendations for change but we are unclear how structures can be designed before the fundamental issues of future roles are addressed.

Our view is that there is little doubt that a future training structure should consist of a period of more general training followed in some cases by a period of greater specialisation. We think that the goals of each of these periods of training should be determined by the needs of patients and the services designed to meet those needs.

In our view, the restructuring of PGME should follow as a consequence of determining the training needs of the future workforce rather than medical roles being determined by the training the workforce has received.

We believe that in Scotland it will be possible to produce a blueprint of the future shape of the medical workforce and that by summer 2008 that vision will be beginning to take shape. In that case we should avoid conclusions about the correct structure for PGME until we have greater clarity.

Until that clarity is achieved we believe we should attempt to minimise change in the system.

In Scotland, NHS Education for Scotland are accountable for the educational governance of postgraduate training to standards required by the regulatory bodies - Postgraduate Medical Education Training Board ( PMETB) and General Medical Council ( GMC). They share this responsibility with NHS Boards for the trainees within their employment and with universities for the first year of postgraduate training. NHS Boards are responsible for the quality control of PGME as it occurs in their provider environments and should have a Board level officer accountable for this function who might be a Director of Medical Education.

NES have discussed the development of the infrastructure for postgraduate medical education and training in Scotland in a number of fora, including the Scottish Association of Medical Directors ( SAMD) and The Academy of Royal Colleges and Faculties in Scotland. Principles on which to move forward were generally supported. Their consultation paper " The Governance of Postgraduate Medical Education and Training in Scotland" sets out how these principles may build on current arrangements and be developed further and implemented, providing an overview of provisions for governance of postgraduate medical education that would be required. Full details available from www.nes.scot.nhs.uk .

NES is planning an internal review of their Medical Directorate, particularly around roles and responsibilities within/across Deaneries to meet PMETB standards. A project Board has been established and workstreams are being developed to be rolled out throughout 2008.

Questions:

16. Do you agree with our view that changes to the structure of postgraduate medical training should await further discussion on the future shape of the medical workforce and that we should minimise that change until that is clearer? If not, why not and what are your suggestions?

GP Training

The Royal College of General Practitioners ( RCGP) are keen to work towards an extension of the mandatory training period for GPs from the current 3 years to 5 years. While the SG would support in principle the exploration of a move towards a 5 year training period for GPs in the UK, this would require assessment of the educational rationale for this, what would be the context and content of extended training and the funding and resource issues including the availability of trainers and training practices (suitable premises). There would need to be a demonstration of clear benefit to the NHS and patients in extending the training period to such a great extent, given the cost and capacity implications. It may create recruitment problems if fewer training doctors were attracted to general practice because of the longer training period and a potential shortage of trained GPs in the transitional period would need to be managed.

Questions:

17. What are your views on the length of General Practice training and why?

General Questions

18. Do you think that any of the proposals set in this consultation document will raise any specific issues for any of the equality groups (including race, disability, age sexual orientation, gender or religion and belief)?

19. Do you have any other comments you would like to make?

Your comments and views are welcomed. Should you have any queries or require any further information about any of the issues raised in this paper, please contact Kerry Chalmers attookeconsultationresponse@scotland.gsi.gov.uk

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