1. Developments in the quality assurance of medical education and training in England.

Transcription

1 17 May 2012 Postgraduate Board 11 To consider Quality Assurance: the changing landscape Issue 1. Developments in the quality assurance of medical education and training in England. Recommendation 2. To endorse our approach to developments in quality assurance in England, as set out in this paper (paragraphs 8-35). Further information 3. If you require further information about this paper, please contact us by or tel

2 Background 4. In January 2012, the Department of Health (England) published From Design to Delivery setting out its approach to implementing a new system for organising healthcare education and training. Key features of the new system will include: a. A duty on the Secretary of State to secure an effective system of education and training for people in the NHS. b. A new body Health Education England (HEE) to provide national oversight and leadership. c. A number (probably 10-14) of Local Education and Training Boards (LETBs) to take on the education functions previously exercised by SHAs. The LETBs will be part of HEE and are intended to be employer-led. 5. DH(E) wishes to see a closer relationship between the quality of healthcare education delivered and the allocation of resources to provider organisations. To that end, a new framework the Education Outcomes Framework (EOF) has been developed. At this stage, the framework consists of high-level outcomes but further work is underway to develop more detailed metrics. 6. The development of the EOF begs the question of its relationship to the standards set by the GMC as statutory regulator of medical education and training. And that is part of a much broader issue about how the GMC should relate to the new system so that there is clarity about the respective roles and responsibilities of the GMC, HEE and LETBs. 7. We have had useful discussions with colleagues from DH (E), Medical Education England and other key interests over recent months. This paper is an opportunity to report to the Board on where matters stand, the issues remaining to be resolved and the further work now required. Discussion 8. In discussions since Developing the Healthcare Workforce was originally published we have emphasised a number of key points: a. The extent of the contribution of independent, publicly-accountable professional regulation to ensuring high standards of both practice and education needs to be properly recognised in the emerging plans; in the original consultation professional regulation scarcely received a mention. 2

3 b. As the statutory regulator for medical education and training, Parliament has given the GMC the powers to approve and if required, withdraw approval of - training. Those powers go hand-in-hand with extensive powers to inspect those who organise or provide training, and to require them to provide information to us. That statutory role similarly needs proper recognition. c. The governance arrangements of LETBs need to ensure an independent voice for education where that is required, in order that there is effective quality-management of the provider organisations. d. The GMC will continue directly to hold LETBs to account via a senior doctor the Postgraduate Dean with responsibility within the LETB for medical education and training, but the question of whether that person is on the LETB Board as overall Director of Education and Quality is not a matter for the GMC. e. We support the principle that the funding of education and training should be transparent, with funding linked to quality provided robust and reliable indicators can be developed. However, measures of quality should link directly to our standards and the data we require from the system. This is one of a number of opportunities to deliver improvements within the new framework. f. The relationships between HEE, LETBs and professional regulators need to be clearer and it may be helpful to develop a Memorandum of Understanding between HEE and the GMC and other regulators delineating areas of responsibility and opportunities for joint working. It is also important that HEE takes account of the UK context as a whole, and engages with the other UK countries on matters of mutual interest. 9. Progress in most of these areas has been encouraging, although there remains work to do to promote understanding of the role of professional regulation. However, in a debate in the House of Lords on 8 February 2012, Earl Howe put the Government s position in unequivocal terms: We have no intention of tampering with national standards. Professional regulators will continue to set professional standards. The royal colleges will continue to shape curricula and will work in partnership with Health Education England to ensure that education and training reflect best practice and are of high quality. Professional regulators have a statutory responsibility for setting standards and ensuring those standards are met and maintained. 10. The Government has been similarly clear about the ability of Postgraduate Deans to act independently where there are concerns about the quality of medical education, and to involve the GMC directly as required. Speaking in the same debate, Earl Howe said: 3

4 We expect local education and training boards to be able to demonstrate that their postgraduate deans will be able to act independently of any perceived conflict of interest that may arise between training and service priorities. There will be clear checks and balances in place and quality metrics to hold local education providers to account for the quality of the education that they deliver. Postgraduate deans will have all the powers that they have now to respond to concerns about the quality of training, to take action where required to improve standards and to assure the professional regulators and Health Education England that poor performance, if it occurs, is identified and tackled. 11. This reassurance has been helpful. (It should be noted that the Chair-elect of HEE, Sir Keith Pearson, whose appointment was announced by DH(E) on 2 May 2012, has considerable understanding of the contribution of professional regulation to healthcare including from his role as Chair of the UK Revalidation Programme Board for the past three years.) In our ongoing discussions with DH(E) and, as it develops, HEE, it will be important to embed the principles that Earl Howe set out in the operating arrangements for the new system. (DH(E) s April 2012 consultation document Responsible officers in the new health architecture proposes that LETBs should be required to nominate or appoint a RO for trainees: in responding, we will point out the need for it to be explicit that the RO for trainees is, automatically, the Postgraduate Dean, among other things because of the close link between the Annual Review of Competence Progression processes and revalidation.) 12. The next section of the paper looks at two areas of ongoing work: the development of the relationship between professional regulators and HEE and LETBs, and work by DH(E) to develop the EOF. Relationship between the GMC and HEE and LETBs 13. Following discussions at MEE, DH(E) has established a small group chaired by a senior official to look at how professional regulators and HEE should relate to each other. Paul Buckley represents the GMC, the other regulators involved are the Nursing and Midwifery Council and the General Pharmaceutical Council. The group is considering how typical scenarios involving concerns about educational quality in a LETB might in future be dealt with, bearing in mind that there are some differences among regulators in terms of powers and approach. 14. The starting point for the GMC is our powers and duties under the Medical Act As Earl Howe has said, the GMC has the statutory duty to set standards of education and training. We also have duties to secure the maintenance of those standards by determining the outcomes of training and the assessment arrangements to demonstrate those outcomes, and by approving (or withdrawing approval of) programmes of training. 15. Our Quality Improvement Framework, published in 2011, sets out in more detail how we approach this task. The QIF is based on three tiers of responsibility for quality: 4

5 a. Quality Assurance (the GMC) b. Quality Management (Deaneries and medical schools) c. Quality Control (local education providers). 16. The medical Royal Colleges and Faculties make a contribution at all three tiers. 17. The QIF makes clear that our statutory powers are broad and flexible enough to accommodate whatever structures may emerge: the Medical Act does not refer to Deaneries (or other structures) by name and does not need any amendments to apply to the new landscape in England. 18. Thus, we will have the same powers in relation to the new LETBs that we currently have in relation to Postgraduate Deaneries. It will be important that the LETBs fulfil the same role within the QIF as is currently fulfilled by Postgraduate Deaneries, albeit that LETBs will be multi-professional (as indeed some Deaneries have been). Thus, the LETB will be responsible to the GMC, via the Postgraduate Dean, for ensuring that LEPs are meeting our standards, and approval of training programmes run, or commissioned, by LETBs will be conditional on us being satisfied that is the case. It is quite possible that a LETB Director of Education and Quality is not a doctor. In those circumstances, day-to-day liaison with the GMC would most naturally be with the Postgraduate Dean as it is now, but it will be important that LETBs understand that our powers to hold the LETB to account are not dependent on the Dean being registered with us but apply regardless. For example, our powers to appoint visitors to quality assure postgraduate medical education, or to require information to help us discharge our statutory functions, apply to: any body, or other person by whom, or under whose direction or management, any postgraduate medical education or training is, or is proposed to be, given. 19. LETBs will be subject to the same reporting requirements to us as currently apply to Deaneries. Thus, we will require an annual report, according to a predetermined timetabled and updated after six months, setting out how the LETB has undertaken its quality management functions, what issues about educational quality have arisen and the actions in place to address them. We will also require LETBs to report to us as they arise any patient or trainee safety issues through our responses to concerns process. Similarly, we will need to be told immediately if a LETB decides to withdraw medical trainees from a LEP. 20. None of these arrangements should raise any issues of principle so far as LETBs or HEE are concerned, although diagrams about the new system still overlook the overarching role of the regulator (see for example, Annex A, published in January 2012 in From Design to Delivery). 5

6 21. However, they do have operational implications (for example, how and when information about an educational concern is shared with us, the overall reporting calendar, day to day liaison with HEE and so on). These are the issues that need to be thought through in advance and, possibly, reflected in a Memorandum of Understanding. Some practical ways forward could include: a. the role descriptions for the HEE Director of Education and Quality and his/her counterpart in each LETB to include an explicit responsibility for developing effective working relationships with professional regulators b. an annual meeting between HEE and professional regulators about standards, quality, innovation and other strategic-level issues. 22. The MOU might be structured in the following way: a. A preamble including high-level descriptions of the respective roles of HEE, LETBs and the professional regulators. b. Some general principles including shared commitments to protect patients and students and trainees, to promote excellence in healthcare education and to work collaboratively to achieve these goals. c. A description of the functions and powers of HEE, LETBs and professional regulators. In relation to regulators, while there are some differences between them, they generally include responsibility for setting and assuring standards of education and training and standards of practice, approving and withdrawing approval of education and training programmes and/or providers, and approving learning outcomes and/or curricula. d. Arrangements for routine information collection and sharing and visit/inspection planning. This would include arrangements for LETBs to report annually to regulators on their quality management of local education providers (where that has been the practice under current structures and the regulator concerned has powers to require such a report). e. Protocols for handling serious concerns about safety or quality that emerged at any point in the system, demonstrating how a LETB s Director of Education and Quality (and Postgraduate Dean or other delegated individual) would if necessary be able to act independently of the LETB. f. Arrangements for regular communication and liaison (for example, an annual meeting between HEE and regulators). 6

7 23. We will report back to the Board as discussions in the DH(E) and regulators group progress. We may also wish to publish a revised edition of the QIF once HEE and the LETBs are in place (in shadow form from October 2012, but fully operational from April 2013), so that the QIF reflects the new nomenclature and structures in order that there is no misunderstanding in the system about what we expect. This will be particularly important in the light of our planning of quality assurance across undergraduate and postgraduate medical education in London this autumn, at a time when the shadow LETBs are beginning to assume their responsibilities. EOF 24. From Design to Delivery describes the purpose of the EOF in these terms: Setting clear outcomes for the education and training system will enable the allocation of education and training resources to be linked to quantifiable, quality outcomes. 25. Similarly, Earl Howe linked the EOF to the commissioning of education and training. He was very clear that the EOF is not an alternative set of educational standards to those that we (and other professional regulators) set. 26. Those statements are extremely helpful. It is important, however, that regulatory standards continue to be seen as the key driver of quality and safety in the system, complementary to the outcomes in the EOF rather than over-lapping with, or even subsidiary to, them. 27. As matters stand, the high-level EOF outcomes have been identified. None of those outcomes is in any way in conflict with our standards, on the contrary, they are supportive of them and broad enough to be compatible with a wide range of other standards and metrics, including our own. The EOF is also very helpful in supporting the development of a climate in which having responsibility for education and training is a privilege to be earned conditional on demonstrating quality, rather than an assumed right. 28. The priority now is to ensure that the indicators that will sit below the EOF, and the data that evidence them, is so far as practicable compatible with our standards and the QIF processes (but bearing in mind that the EOF is multiprofessional and will need to fit with the work of other regulators). DH(E) have said that there will be a particular focus in 2012/13 on two topics: a. Board (that is, LEP Board) engagement in the Education, Training and Workforce agenda b. safe supervision of students and trainees. 29. Both topics are covered in The Trainee Doctor (Domain 7, mandatory requirements , and Domain 1, mandatory requirements ). Medical Indicators Education Commissioning for Quality 7

8 30. In terms of developing the more detailed indicators and the associated data to support them, there is an opportunity to build on work in 2010 and 2011 in which the GMC was involved which led to a document called Medical Indicators Education Commissioning for Quality. The document was developed by a task group which was set up by MEE s Medical Programme Board and chaired by Professor Jacky Hayden One of the strengths of that document was that it explicitly built on, and was fully compatible with, our standards, and, although it was established by MEE, adopted a broad approach drawing on information from outside England. Importantly, the indicators were also linked explicitly to the GMC s standards for training, to ensure alignment. Work on the indicators was paused while other parts of the new system were being developed, but is now being revived. 31. The draft indictors are grouped under two categories: a. indicators of the quality of the education environment b. indicators of the quality of the outcomes from education and training. 32. More detail about the draft indicators is provided in Annex C. Human Factors metrics 33. A separate stream of work, led by a working group chaired by Sir Stephen Moss Chair of Mid Staffordshire NHS Foundation Trust - has seen the development of draft metrics to enable the wider adoption of human factors in healthcare. The metrics include matters such as board level responsibility for human factors, a trust-level human factors strategy and evidence of human factors in staff induction programmes. The metrics, which are currently indicative, are intended to be integrated within established clinical and educational frameworks. Next steps 34. The quality assurance landscape is complex and fast-moving. In terms of the GMC s priorities, we will continue to make the case publicly for the application of our standards as the key driver of the quality and safety of medical education and training in the new system. We will also continue to work closely with other professional regulators on scoping how we can work most effectively with HEE and the LETBs, including developing a MOU on information sharing and other operational activity, and we will reflect the outcome of that work in our QIF. 35. Looking to the medium term, we will be reviewing our educational standards as part of our comprehensive review of QA. This is an important piece of work which will need to take into account: a. what the relationship should be between the GMC s ethical and educational standards following the publication later this year of a new edition of Good Medical Practice 8

9 b. the opportunity for further alignment between the standards frameworks of the professional regulators, and the scope for joint visits/inspections (perhaps starting with inviting another professional regulator to send an observer on one of our visits where their contribution might add value) c. learning from the Francis Inquiry (now expected to report in October 2012) d. the further development of the EOF. Recommendation: To endorse our approach to developments in quality assurance, as set out in this paper. Resource implications 36. None from this paper. The principles we have agreed will underpin our review of QA include proportionality, working with others and adding value. Equality 37. The principle of fairness, equality and consistency is at the heart of the QA review. Communications 38. This paper will be published on our website. Working with DH(E) and other regulators we will develop a communications strategy to promote the MOU, assuming we develop it. 9

10 11 Quality Assurance: the changing landscape Annex A A1

11 11 Quality Assurance: the changing landscape Annex B B1

12 11 Quality Assurance: the changing landscape - Annex C Extract from MEE Task Group report (2011) on Draft Medical Quality Indicators 5. Quality Indicators the educational environment 5.1 An effective educational environment depends on the quality of the leadership, the quality of patient care, the nature of the infrastructure, and the preparation and support of trainers so that they are able to deliver their educational role. 5.2 Many characteristics have been described of an organisation where learning is part of the culture and where educational governance is given due importance. The presence of these characteristics could be used as an indirect measure of the quality of training offered in a medical training post or student placement. An organisation which displays all of these characteristics is more likely to deliver high quality training. As experience of using the quality metrics is developed it will be important to collect evidence to support clarity about which factors are the most important. 5.3 The Group have identified a range of indicators, under the following headings, as the best measures for judging the quality of the educational environment: - Board-level Engagement in Education and Training - Clinical Leadership/Clinical and Trainee Engagement - Safe Supervision - Team working - Selection, Appointment and Review of Trainers - Provision of Educational Infrastructure - Time for Trainers to Train - Time for Trainees/Students (Support for Learning and Reflection) - Individual Review meetings C1

13 - Local Mechanisms for Learning through Audit including Significant Event Audit. - Local Education Audit student/trainee feedback on their training experience - Supporting Learners in Difficulty 6 Quality indicators Outcome-based measures of undergraduate and postgraduate medical education 6.1 The purpose of medical student undergraduate education is for the student to attain a recognised medical degree, which permits entry into Foundation Programme training and consequently full registration with the GMC and licensure to practise medicine in the UK. The specific curriculum followed by medical students is unique to each medical school but must meet the GMC requirements set out in Tomorrow s Doctors, where the outcomes are set out for all UK medical graduates. Variation also exists with respect to the assessment methods used by medical schools during undergraduate training. 6.2 The purpose of approved training programmes in postgraduate medical education and training (PGMET) in the UK is for the trainee to acquire first full registration with the GMC and then attainment of the Foundation Achievement of Competence (FACD), for doctors completing the Foundation Programme, and then the CCT or equivalence routes to specialist registration for those completing Specialty Training. These are global outcomes, measuring the entirety of the programme in question. In order to measure individual posts, it is possible to identify interim milestones that the trainee has to reach along the way to the FACD or CCT that might be attributable to the post, such as the completion of modules, passing of examinations or ARCP/RITAs success rates. Quite often there will also be specific goals set for a given post, attainment of which might be measured. 6.3 The Group considered the following potential outcome based metrics to be used alone or in combination to assess the delivery of quality training in undergraduate and postgraduate medical education. The measures include: - Attainment of specific targets for the post - Workplace-based assessments - Experience gained - National professional exam performance - ARCP/RITA success rates - Patient outcome measures 7 Data Requirements 7.1 The indicators can be supported by the use of data that are already available either through standard Deanery or other quality processes, such C2

14 as ARCPs, or through the GMC, such as the training surveys. The Group recognised that there was potential for inter-trainee variation and quality changes over time and therefore proposed that an LEP should not be judged from a single set of data but through analysis of trends over a period. This period will need to be discussed and agreed. 7.2 The actual mechanism for assessing each indicator along with possible data sources will need to be developed in the next stage and there are a number of ways this could be achieved and presented in a way that is easy to understand. It could for example be presented using either a dashboard RAG rating or best practice rating system. 7.3 The principle of utilising shared data between the regulator and commissioner(s) is recommended. It was also proposed that good practice should be disseminated. C3