Final Report > Chapter 25: Competent Healthcare Professionals > The systems for assuring competence > Postgraduate medical training

Postgraduate medical training

40 Historically, for doctors, the GMC has set the outline of the curriculum for undergraduate medical education. Medical schools have then stipulated, by virtue of students' having passed the required examinations, that they were sufficiently competent to be registered as medical practitioners. Responsibility for the organisation of the next stage, the training of specialists and GPs, rests with the various postgraduate deans. Their job is to ensure that the training complies with the requirements laid down by the various Royal Colleges. Thus, ultimately responsibility lies with the Royal Colleges. This responsibility in relation to hospital doctors includes, among other things, setting the curricula and examinations to qualify as a specialist, and visiting individual trusts as part of a process to accredit them as suitable for the training of specialists. Postgraduate medical training is specific to doctors, as being a necessary prerequisite to being appointed to a career (specialist) post, although, of course, further training is also required of nurses and others before they may take up certain specialist positions.

41 Clearly the patient is entitled to expect that the Royal Colleges, in carrying out their responsibilities for the supervision of postgraduate training, will place the wellbeing of the patient at the centre of their concerns. In this way the public can be confident that the system for assuring professional competence is secure.

42 The evidence which we heard about the BRI in Bristol suggested that, in the past at least, this was not always the case. Visits to inspect the BRI as suitable for training purposes were sometimes less than rigorously conducted. [18] Moreover, the relationship between approval as a training hospital and the consequent ability of the hospital to attract staff and provide a service, meant that decisions on training took on a significance which went much further than issues of training. If approval was withheld, a hospital could not attract junior staff. The service provided, therefore, either had to be curtailed (rarely seen as an available option), or offered with overstretched staff. This latter consequence is what happened as regards paediatric cardiology in Bristol. In general terms, the likely impact of withdrawing training recognition was all too evident to visiting inspectors from the Royal Colleges, but they faced a genuine dilemma. It is not hard to imagine circumstances in which approval of a hospital for training purposes was as much driven, for good reasons, by the idea of maintaining the viability of a service as by the need to guard standards of training on the public's behalf.

43 We are not persuaded that to leave the crucial task of approving and supervising postgraduate medical training to the Royal Colleges alone is in the public interest. We believe that to obtain and maintain public confidence, ways must be found to involve others in the process, through some appropriate body. We note the proposal in para 8.28 of `The NHS Plan' to create a Medical Education Standards Board (MESB). The aim is to replace the existing, somewhat fragmented and, as has been suggested, less than ideal system, and to provide a co-ordinated, coherent, robust and accountable approach to postgraduate medical education (which we take to mean training). We believe that this is the right way forward. Crucially, the new Board will include members from the NHS and the public, as well as from the Royal Colleges. The Royal Colleges do have a legitimate role and one which perhaps only they can carry out, in assessing elements of professional competence. But the force of the proposal is that they should be brought into a larger and more accountable system. We agree. We agree further with the principle stated in `The NHS Plan' that the Board's task will be to `ensure that patient interests and the service needs of the NHS are fully aligned with the development of the curriculum and approval of training programmes'. [19]

44 The MESB, although an important and welcome development, will, despite the Board's title, touch on only one element of the continuum that comprises a doctor's education, training and professional development, namely, the training element. Supervision of undergraduate medical education, as we have said, is a matter for the GMC and the universities. Supervision of continuing professional development for doctors, as we shall see, is shared between the Royal Colleges and the employer. This degree of fragmentation does not serve doctors well; it makes it difficult to ensure that the principles of good medical practice are embedded into all aspects of a professional's lifelong education. Such fragmentation also makes it difficult to introduce changes which apply to all doctors currently in practice, and not just the newly qualified. For this reason, we support greater co-ordination of all the activities which make up the continuum of doctors' education, training and development. The GMC is probably best placed to do this, with its responsibility to ensure that doctors meet generic standards of professional practice throughout their working life. By taking the lead in co-ordinating these efforts, the GMC could ensure that expertise is shared, and crucially, help to ensure that all the policies on training of the various bodies are in alignment and capable of adjustment to meet the changing demands that society places upon doctors. It follows that the MESB should be a subgroup of and report to the GMC.

45 Just as there is a case for vertical integration of responsibility for the components of a doctor's lifelong education, the same case, we believe, applies to nurses and midwives, and to the professions allied to medicine. In each case there should be one body charged with oversight of all aspects of education, training and professional development, to ensure that the respective components are appropriately integrated.

46 So far, we have addressed the need for proper systems for each of the respective groups of healthcare professionals. It is crucial now to point to the fact that there is no single body which stands above the detail to provide consistency and overarching strategic direction for all professional groups. The Government has announced its intention, in `The NHS Plan' (para 10.15), to establish a UK Council of Health Regulators. The Council's role, on which we comment more in detail later, will be to help to co-ordinate activities and to act as a forum in which common approaches across the professions could be developed. Developing common approaches to education, training and development should be one of its priority areas. This is a particularly necessary and relevant role for the future of the NHS, as the boundaries between the various professions in a number of respects have started to merge and to overlap. It would also provide leadership and direction for the implementation of the common themes for education and training which we referred to earlier.

47 So far, we have considered the initial education and training of healthcare professionals. But assuring competence does not stop there. Other systems are needed to help to assure their competence at other points in their careers, and to ensure that the interests of patients and the needs of the NHS are taken into account.

Footnotes

[18] See Section One, Chapter 16

[19] `The NHS Plan'. London: Department of Health, 2000. Para 8.28