Annex A > Chapter 4 - National Accountabilities and Roles > National regulatory and professional bodies > Educational and training standards
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Educational and training standards
217 The GMC has the statutory function of promoting high standards of medical education, but traditionally, the Royal Colleges and specialist associations have set standards for higher and specialist training:
`Responsibility for the form and specific content of training programmes, and for overseeing the assessment of trainees, rests with the appropriate training body - usually a Royal College, Faculty or joint higher training committee.' [284]
218 Over the period 1984-1995, the Colleges (including the RCSE) awarded Certificates of Accreditation to those who satisfactorily completed specialist training, as a mark of a fully trained surgeon ready for a consultant appointment and independent practice. This certificate was not a mandatory requirement for appointment. [285] However, such accreditation gradually became more generally recognised and was more likely to be required by consultant appointment committees. [286]
`The College [RCSE] ... ensures that the required standards of training are provided by regular inspection and approval of training posts and recognition of individual consultant surgeons as trainers. It can act, and has done so, to de-recognise a training programme or trainer where it considers the required standards of provision or supervision not being met. These arrangements have been in place for many years, applied during the period 1984-95, and continue to operate.' [287]
219 A Regional Medical Postgraduate Dean is appointed by a university; there is, for example, one appointed by the University of Bristol. Postgraduate Deans were mentioned infrequently in evidence to the Inquiry about standards and quality of care, despite the extensive machinery for postgraduate training in every region. Sir Barry Jackson told the Inquiry about the role of the Postgraduate Dean in dealing with recognition of trainers and training posts in relation to surgery:
`The Postgraduate Dean is responsible for ensuring that the educational function of a higher surgical training post is actually carried out, the educational side.' [288]
220 Professor David Baum, the then President of the RCPCH, told the Inquiry that part of the career progress of a paediatrician is:
`... higher training ... in which there is ... an annual appraisal with the Regional Adviser of the College and the Postgraduate Dean'. [289]
221 Whilst a College could point out an institution's deficiencies, de-recognition as a training institution was the only sanction it could apply to it:
`... no Royal College or comparable professional body had statutory powers to impose professional and quality standards on hospitals or individual consultants.' [290]
`If at the end of that inspection and the interviews that take place, the committee is dissatisfied with any aspect of the training, what would normally happen - and I stress "normally" - would be that they would make it clear in a written statement to the Trust concerned that there were deficiencies and that they would not approve that post for training for the next quinquennium, but they would wish to reinspect, reassess the situation within a given period of time, usually 6 months, sometimes a year, after the perceived deficiencies have been corrected and they would then go back and see the post again to check that the deficiencies that they have noted have been rectified. In almost every case - not all, but in almost every case - those deficiencies are rapidly corrected by the hospital concerned, by the trainers concerned, because they do not wish to lose training status. Occasionally, it turns out that those corrections have not been put into place, in which case, in the case of the SAC, they would recommend to the JCST, the Joint Committee, that training, the recognition be removed and in the case of the Hospital Recognition Committee, they would recommend to their parent committee in the College, the Training Board, that recognition should be removed. Very rarely, a committee may come across such a situation which would merit instant de-recognition.' [291]
Educational and training standards - with particular reference to surgery
222 Higher surgical training is controlled and administered by the Joint Committee on Higher Surgical Training (JCHST). It is `joint' in the sense that it represents not only the four surgical Royal Colleges in the United Kingdom and Ireland, but also the relevant specialist associations and the university professors of surgery.
223 So far as basic medical and surgical training is concerned, [292] the Hospital Recognition Committees (HRCs) discharge the functions of the Royal Colleges.
224 The JCHST's `A Manual of Higher Surgical Training in the United Kingdom and Ireland' sets out the scheme of higher surgical training:
`The Scheme of Higher Surgical Training is controlled and administered by the JCHST representing the four surgical Royal Colleges in Great Britain and Ireland, the relevant Specialist Associations and the University Professors of Surgery. The JCHST is the advisory body to the surgical Royal Colleges with regard to Higher Surgical Training and award of the Certificate of Completion of Specialist Training, supported for the day to day management of the scheme by the Specialist Advisory Committees (SACs). The JCHST and the SACs are administered by a secretariat at the Royal College of Surgeons of England.' [293]
225 Sir Barry Jackson described the respective roles of the JCHST, SAC and HRC:
`A. The Hospital Recognition Committee is run solely by the Royal College of Surgeons, but part of its complement would include invited members representing a range of specialties. It is responsible for monitoring similar to the Joint Committee on higher surgical training, the training and the posts for what is known now as basic surgical training. That is the training that all trainees receive in the generality of surgery, sometimes called "common trunk training", before embarking on a specialist training in one of the nine recognised surgical specialties such as orthopaedic surgery, cardiothoracic surgery and such like. It has a very similar role at basic surgical training level as the JCHST you have referred to has at higher surgical training level, and it is responsible also for ensuring that the training the basic surgical trainee obtains is suitable and appropriate for them to be eligible to sit an examination in the generality of surgery, which used to be called the FRCS [Fellowship of the Royal College of Surgeons] and is now called the MRCS [Membership of the Royal College of Surgeons].
`Q. So if one were looking at the accreditation of teaching posts and teaching positions within Bristol, one would be looking firstly at the role of the Hospital Recognition Committee for basic surgical training, and then at the specialist level, looking within the field of cardiothoracic surgery, it would be the specialist advisory committee with particular responsibility for that field which would be responsible for the appropriate accreditation?
`A. That is absolutely correct, yes.' [294]
226 The main means by which the Royal Colleges regulate medical education is through the SAC's inspection of training posts. Sir Barry Jackson described the system in relation to cardiothoracic surgery thus:
`Cardiothoracic surgery is a relatively small specialty and therefore the SAC itself acts as the training committee and interviews all higher surgical trainees at least once during the course of their training. The SAC also arranges regular inspections, normally every 5 years, or more frequently where necessary, of programmes and posts where training is carried out. At all such inspections trainees have confidential interviews with the visitors at which time they can comment on the quality of the training post and their trainers. All trainees are subject to annual assessment by their trainers and all trainees are required to complete training post assessment forms so that the relevant training committee and the SAC gets feedback from the trainees.' [295]
227 The reporting process further explains the relationship between the bodies:
`... the report of each SAC inspection would be reported to the parent Specialist Advisory Committee in full session, which in turn would report to the Joint Committee on higher surgical training ... .' [296]
228 A limitation on Royal Colleges' inspections (SAC and HRC) is simply that they were not designed to monitor the clinical quality as such of the training clinician or institution:
`Q. Would you say that the inspections are mainly designed to make sure that trainees have adequate clinical experience and supervision, or would you say they were designed to examine the quality of the care in the hospital?
`A. The former.' [297]
229 To a question about the regard paid by SAC visitors to the quality of surgery performed by a consultant involved in training, Sir Terence English, past President of the RCSE, said:
`A. It was not a requirement as such. It was perhaps something - well, it certainly did not receive as much attention as the quality of the training which the individual was receiving.
`Q. Quality of training was the whole purpose of the visit?
`Q. So inevitably, quality of outcome would not, could not, receive as much consideration as that, but I think what you are telling me - I want to be sure I am right about it - is that whether formally or informally, it was the expectation of all concerned that those visiting the unit would ask about quality of outcome, or quality of surgery?
`A. I think the reality of it was that generally, throughout surgery, it was not regarded - it was not common to enquire specifically about mortality at SAC visits. I am not sure about that, but as a generalisation, I think that is true.' [298]
230 The quality and effectiveness of visits at Bristol in respect of cardiothoracic surgery were evidenced by what was said about two visits within a week of each other, the first on behalf of the SAC by Mr David Hamilton and Mr Julian Dussek (8 July 1994) and the second on behalf of the HRC (therefore dealing with more junior doctors in training) by Miss Leela Kapila and Mr P May (13 July 1994). The detailed evidence is set out later, to the effect that obvious features of the layout and facilities were mis-stated in the former report, which also bore such similarity to the report five years earlier, to bear the inference that the text had merely been copied, without there being any fresh consideration of its contents. Such was the difference between the factual circumstances recorded in the two reports, that the co-ordinating of information between them was called into question.
231 Sir Terence told the Inquiry about the difficulty of co-ordinating training visits:
`Q. And so far as giving a complete picture of the service, not only the more important, as you describe it, senior trainees, but also the less important junior trainees, who in the Royal College would, as it were, look at or be likely to look at the 2 reports, put them side by side and say, "Well, we have a problem here which has to be sorted", or something to that effect?
`A. That, to my knowledge, did not happen. The SAC, as I explained earlier, was very much an intercollegiate committee. The Hospital Recognition Committee was strictly under the aegis of the Royal College of Surgeons in England looking at training in England and Wales alone. And the whole question of which units should be recognised for training, which should be warned if they were falling down in their training, was dealt with very separately. That may be an error, but that is the way it was. I think it would have been difficult to try and co-ordinate the two. Having said that, if there was a problem in a particular unit that was brought to the attention of the College, then I would hope that both reports would be looked at critically.
`Q. What I think you are telling me - please confirm if it is the case - is that any cross-referencing between the reports would occur by accident rather than design, except if there were a particular query about a particular unit?
`A. In essence, I think that is correct.' [299]
232 The lack of co-ordination in visits from Royal Colleges was recognised by Professor Strunin as a drawback of the system:
`This is one of the criticisms of the College visits, of course: there is no co-ordination. I have to say now, if we encounter serious anaesthetic problems, our visitors are instructed to ask the Medical Director whether they have had a visit from any other College recently, because often there are problems in other specialties. The Medical Director does not always wish to tell us that, of course, which is a problem. There is no co-ordination at the moment. That is about to change as well, because it is obvious that visit after visit is unsatisfactory, and there are moves to see whether these can be brought together... .' [300]
Educational training standards - proposals for change
233 Sir Barry Jackson emphasised that `the [Royal] Colleges and the specialist associations are reconsidering all aspects of inspection, [and] training processes'. [301]
234 Amongst ideas being considered is that there should greater co-ordination between HRC and SAC visits and between visits of different SACs, or that visits should be broader in what they look for and to whom they speak. Professor Strunin was questioned on this:
`Q. ... do you think some formal method of co-ordination could be helpful and practical?
`A. I think it would be helpful. The practicalities of it are not quite as straightforward as might be. There is also of course the role of post-graduate dean, and some of the things we look at in visits we are going to devolve to the post-graduate deans. Our college, and I suspect others will do the same, would wish to reserve the right to visit anyway, because of course the post-graduate deans may also find themselves compromised on occasional issues and we would wish to come as an outside body and look at that specifically.' [302]
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Footnotes
[284] WIT 0062 0012 Mr Scott
[285] WIT 0048 0003 Sir Barry Jackson. Sir Barry Jackson's statement continues, however, `With the introduction of the European Specialist Medical Qualifications Order (1995), it became mandatory from 1 January 1997 for an individual seeking appointment as a consultant to be entered on the new Specialist Register of the General Medical Council'
[286] T28 p.3-5 Sir Barry Jackson
[287] WIT 0048 0004 Sir Barry Jackson
[288] T28 p.24 Sir Barry Jackson
[290] WIT 0047 0027 - 0028 Royal College of Surgeons
[291] T28 p.10-11 Sir Barry Jackson
[292] `The Hospital Recognition Committee was strictly under the aegis of the Royal College of Surgeons in England looking at training in England and Wales alone.' Sir Barry Jackson T17 p.57, but other Royal Colleges (including the Royal College of General Practitioners) have an HRC
[293] JCHST, `A Manual of Higher Surgical Training in the United Kingdom and Ireland', p. 1 (May 1996); WIT 0048 0038 Mr Jackson
[294] T28 p.7-8 Sir Barry Jackson
[295] WIT 0048 0012 Sir Barry Jackson
[296] T28 p.15 Sir Barry Jackson
[297] T28 p.140 Sir Barry Jackson
[298] T17 p.27 Sir Terence English
[299] T17 p.57-8 Sir Terence English
[300] T14 p.132-3 Professor Strunin