The General Medical Practice and Specialist Medical Education
Training and Qualifications Order 2003.
Response from the Royal College of General
Practitioners
1. The RCGP
welcomes the opportunity to contribute to the drafting of the Order
that will have a profound effect on the future of medical education
in the United Kingdom.
2. The RCGP
as a Royal College for general practitioners across the United
Kingdom is committed to working with the Departments of Health to
modernise the training of general practitioners and specialists. We
look forward to playing a central role in developing and delivering
the future arrangements.
3. We
acknowledge that there is a need for modernisation and change in
medical education. We support the opportunity for restructuring the
statutory authorities involved in the regulation of postgraduate
medical education in primary and secondary care.
4. We
strongly support the proposal to introduce a General Practice
Register and the opportunity to design more appropriate training
and assessment programmes for those training to become the general
practitioners of the future.
5. While we
acknowledge that the Order is designed to be “enabling”, we do,
however, have concerns about omissions from and possible
implications of the Order as it is presented. We wish to raise our
specific concerns, give suggestions for change while also
highlighting the many areas that we support.
6. The
attached response is linked to the series of questions in Section 2
of the Consultation Document. The number attached to the question
refers to the paragraph immediately preceding the question in the
consultation document.
Key Questions
Does the draft Order provide the right framework within which
the standards of postgraduate medical education and training can be
set, maintained, monitored and developed?
Does the Order achieve the policy aims set out in the
“Postgraduate Medical Education and Training Board: Statement on
Policy”?
We are satisfied that the draft Order does provide a framework
that should achieve the policy aims set out in the earlier Policy
Statement, but we continue to have concerns about the arrangements
for appointments to the Board, the accountability arrangements and
the default powers of the Secretary of State.
Question 2.6
Are the arrangements for the structure and composition of the
Board correct?
As a Royal College representing members and fellows across the
UK, we welcome the inclusion of representatives of Northern
Ireland, Scotland and Wales in addition to England.
We support the principle that Board will have representation
from the Medical Royal Colleges, the Postgraduate Deans, and
doctors in training, medical educators, and the General Medical
Council in addition to NHS management and patient
representation.
We do, however, have concerns about the process of appointing
members to the Board described in the consultation document. While
we welcome the reassurances that we have been given that
appointments will be made in accordance with Nolan Principles, it
is not stated explicitly in the Order. We believe that the
Secretary of State should consult widely on appointments to and the
composition of the Board. The first Board will require people
who have a breadth of experience in medical education and training
in both the primary and secondary care arenas. We are
delighted that general practitioners are playing central roles in
establishing the Board through their work on all four steering
groups, but we seek reassurance that general practice will be
adequately represented on the first Board.
The constitution and composition of the two statutory
sub-committees, unlike the main Board are left undefined. The
Statement on Policy indicates that they will be chaired by medical
practitioners, appointed by the Board, and will include a
requirement for both committees to have medical majorities and
strong representation from the Medical Royal Colleges and
postgraduate deaneries. General practice must be adequately
represented on these sub-committees too.
The RCGP looks forwards to continuing to support the
establishment of the Board, being consulted on the composition of
the first Board and sub-committees and working in partnership to
transform medical education across the UK.
Question 2.9
Are the objectives of the Board correct?
The RCGP supports the stated objectives. We would
welcome consideration of a statement on the Board having a
responsibility for safeguarding the health of patients; the needs
of patients are paramount.
Question 2.10
Are the roles and responsibilities of the two statutory
committees correct?
We agree
with the stated roles and responsibilities of the two statutory
committees. There is a great deal of overlap between the two
committees particularly concerning assessment of individuals and
programmes and the effect of assessment on training programmes –
assessment often drives learning. Half of the doctors completing
postgraduate medical programmes will become general practitioners
and 90% of health care is delivered in primary care, it is,
therefore, essential that there is adequate representation of
general practitioners on the two sub-committees.
Question 2.11
Which bodies should the Board be required to consult?
Are there other interests to be included?
We support the Academy of Medical Royal Colleges request to
represent the medical Royal Colleges across the UK, but, we also
request that the RCGP is consulted regarding general practice
education because general practitioners comprise half of the
medical profession but are only a small part of the Academy.
We support the list of bodies included in the Order. We
would suggest there may be merit in consulting the widest possible
medical constituency from time to time which should include the
British Medical Association and its General Practitioners
Committee.
Question 3.2
Do other standards need to be included?
Should any of these be removed?
The stated standards should all be included. We would
also recommend that the standards for GP training practices,
placements and trainers should continue to be set nationally by the
Board. We also would request that under bullet 3.2 (C) that
attitudes, values and professional behaviours that are expected by
the General Medical Council are referenced.
Question 3.2
Is it correct to enable the Board to introduce
competency-based assessments and measures?
Yes. We strongly support this move towards competency
and capability based training and assessment for all
specialties.
Question 3.4
Does the Board have appropriate powers of approval? If
not, how should they be amended?
Yes. We do not believe that there should be any additional
powers granted. We are, however, disappointed that Section 5 of the
draft Order is too proscriptive (not sure of the correct spelling
here) and misses an opportunity to modernise GP training programmes
in the spirit of the Unfinished Business document regarding the
review of the SHO grade. In that document it is stated that general
practice should be ”regarded as a specialty equivalent to other
specialties”. We would recommend that the whole of Section 5 is
deleted and that Section 6 is amended to include reference to
specialist and GP training where appropriate.
Question 3.10
Are visiting panels appropriate? If not, how should the
Board quality assure postgraduate medical education and
training?
This part of the Order, unlike much of the document is
detailed and was not discussed in the earlier Statement on Policy.
We support the urgent need to rationalise the visiting/quality
assurance process and would be happy to discuss the merits of the
sampling process operated by the JCPTGP which includes lay
representation.
We understand that the Department of Health has commissioned
research to help inform change and that the Steering group is
working with the Academy and Deaneries on potential models.
We would suggest that it would be wise to reduce the level of
detail laid out in the document in order to enable the Board to
change visiting processes radically based on evidence and further
consultation.
Question 3.10
Should the visiting panels always include a lay person?
Should the legislation set a limit on the number of lay
persons who may form part of the visiting panel?
Should the legislation require two or more lay persons on a
visiting panel?
We strongly support the inclusion of lay visitors on visiting
panels. The RCGP has for many years included lay
representatives on its committees and lay visitors are integral to
the JCPTGP visiting process. Individual lay members have
influenced the decision making of the JCPTGP for many years and
make a very positive contribution to the visiting teams.
In contrast to the Order as a whole, the section on visiting
panels is rather detailed. We believe that it would be wise to
continue the theme of the Order as an “enabling” document and leave
the detail until the Board has made a final decision on how and
when visits should be undertaken. We favour a sampling process
along the lines that has been successfully been developed by the
JCPTGP complemented by a rolling programme of deanery visits to
Trusts and practices. The RCGP is committed to supporting the
development of a more effective and less disruptive form of
visiting as part of the Board in the future.
Questions 4.6 & 4.11
Are all the doctors who should be on the Register able to gain
entry?
Have we included routes to the Register for doctors who should
not be registered?
Patient safety is paramount; it is vital that only doctors
with appropriate knowledge, skills, attitudes and experience are
allowed on the Register. We are content that all doctors who
should be on the Registers are able to gain entry and that the
prescribed routes are satisfactory.
Question 4.12
Should experience be taken into account for all doctors,
rather than only doctors with EEA nationality?
We believe that experience should be taken into account for
all doctors. It needs to be recognised, however, that
additional resources will be required to deliver the workload and
that there will inevitably be an increase in appeals. There
is a difference between the “right to assessment” and the “right to
training”. Clear and transparent guidance must be developed
to ensure that doctors who apply and those who make the decisions
and handle appeals fully understand the rules.
Question 4.14
Should all doctors be entitled to a decision within three
months, rather than only doctors with EEA nationality?
We strongly advise no defined time limit is set until all the
necessary data and evidence has been presented to the Board’s
satisfaction. Only from that time and the evidence complete
should the clock start and under those conditions three months
might be reasonable.
Question 6.2
Are the appeal provisions appropriate?
Do they provide an effective means of redress for individual
doctors and for those managing or offering training?
The Order seems to encourage appeals against decisions of the
Board. There is also an ultimate appeal to a court or
Sheriff. We believe that that appeal should be to a higher
national court or appeal body. While there is a need to be fair,
patients must be protected. Training of appeal body members
is essential. The experience of appeals against JCPTGP
decisions indicates that appeal body members need to be trained and
have an excellent grasp of the issues; we are seriously concerned
that county courts or sheriffs would not have the required
knowledge base and as a consequence may deliver verdicts that could
expose patients to risk.
Question 7.3
Does the Board need further powers in relation to making
charges?
Do the suggested powers go too far?
We agree that the Board should be able to charge for
certification and for hospital and programme quality assurance
visits. But, individual trainees should be charged only once
and the fee should be the same for any trainee from any
specialty.
Question 7.5
Are the rule making powers extensive and flexible
enough?
Do they go too far?
Should there be greater scrutiny of the Board’s rules?
We welcome the potential for flexibility indicated in
paragraph 7.4. There are currently differences in priorities
in the delivery of health services across the four countries – and
such differences are likely to continue. It seems sensible to
allow the possibility of flexibility in training to ensure that
young doctors are trained fit for purpose, albeit within the
context of a UK framework. Current examples of such
differences include the greater significance of remote and rural
needs and the development of intermediate care in Scotland.
Otherwise these proposals appear to be satisfactory and do not
go too far. The Board’s rulemaking should be subject to scrutiny.
The rules should adhere to the principles of good regulation as
espoused by the Better Regulation Task Force e.g. principles such
as transparency, consistency, fairness and proportionality. They
should also form part of the quinquennial review of the Board’s
activities.
Question 7.6
Are the default powers appropriate?
If not, what should happen where the Board fails to fulfil its
functions?
We believe that the Board should be adequately protected from
undue interference from the Secretary of State. While we
support the need for default powers in serious situations where the
Board has failed to fulfil its functions, we suggest that they
should only be used after consultation with both Houses of
Parliament (as in the case of the Council for the Regulation of
Healthcare Professionals).
Question 7.8
Is the annual report a sufficient yearly accountability
measure?
Is further public accountability required?
Given the major changes in the structure of delivering quality
assurance of postgraduate education implied by the new Order, we
would suggest a review at the end of the first two years of the
Board’s existence and at the end of the fifth year.
These reviews and the statutory quinquennial reviews should
include perceptions of clients (doctors) and key stakeholders such
as the NHS, Deaneries and Medical Royal Colleges.
Question 7.11
Should the content of the quinquennial review be specified in
legislation?
Should the legislation say how the Review is to be
conducted?
Should the legislation specify the Review body?
We are content that the content of the review and how it is
conducted need not be specified in the legislation. We do,
however, believe that the review should be conducted by a body
independent of the Secretary of State and open to the scrutiny of
the Health Select Committee.
Question 8.5
Are the transitional arrangements sufficient?
If not, what needs to be included?
Does the Secretary of State need additional powers?
The RCGP is committed to continuing to participate
constructively in the PMETB Steering Groups which are tasked with
establishing the PMETB.
We are committed to ensuring that GPs continue to be trained
and certified during the transition period. We seek
reassurance that the JCPTGP’s staff (who are employed by the RCGP)
will be supported during the transition period and beyond; they are
essential to the smooth transfer of activity to the PMETB.
Similarly, the RCGP’s staff involved in Joint Hospital Visiting
provides an essential function supporting the quality assurance of
hospital training posts across the UK; we seek assurances that
funding will continue to be provided to the RCGP during the
transition period to ensure that our quality assurance programmes
can continue. We also look forward to offering our support
and expertise to the PMETB when quality assurance mechanisms are
modernised.
We trust that these comments are helpful. We are committed to
making the PMETB a success and look forward to working closely with
the Departments of Health to improve the quality of education and
training for doctors across the UK.
Acknowledgements
We are grateful to the following for their contributions to
this response:
Professor Steve Field (Chairman of RCGP Education Network),
members of the Education Network Steering Group and members of the
College’s Council Executive Committee. The Royal College of
General Practitioners
December 2002