27 / 1 / 2015 2.49pm
Summaries of the 2014 Medical Workforce Forum meetings.
The forum discussed the prescribing skills assessment (PSA) and whether it could be used to test the competency of those entering employment in the UK and the complications that could arise.
The point of full GMC registration and the possible options and implications of any changes were discussed.
A representative from Heath Education England gave an update on their recommendations for an emergency medicine recruitment campaign.
Core medical training (CMT) trainee satisfaction & changes to core infection training
The forum heard from the Joint Royal Colleges of Physicians Training Board (JRCPTB) about issues in core medical training (CMT) based on a recent survey. The research found that high stress levels were reported among trainees, and that the majority do not feel ready to progress in their training due to doing similar work to a foundation doctor. The service/training balance was reported to be not right. The JRCPTB suggested improving consultant presence particularly at night, and increasing the use of physician’s associates might help alleviate some of these problems.
The forum recognised some of the problems outlined and agreed something needs to be done. It was stated that Hospital at Night does need to develop and improve in some trusts, and that the HEE Better Training Better Care (BTBC) programme has some good examples that could help in this area. It was thought that breaking down silo working would improve matters.
The JRCPTB presented proposals for a Combined Infection Training programme. The forum was supportive of the proposal and commented that it seemed to fit in with Shape of Training
Medical pay and contract reform
An update was given on the contract negotiations between NHS Employers and the BMA on a new junior doctor contract and changes to the consultant contract. For junior doctors, negotiations had focused so far on high level issues such as work scheduling, safeguards and pay progression. A large data collection exercise is underway so detailed cost modelling can be undertaken. It is HM Treasury policy that pay progression should not be based on time served and the Government has made clear this should be a feature of the contracts.
In consultant negotiations, discussions have taken place around high level principles on seven-day services and linking pay progression to performance. Forum members were concerned that seven-day services would be unaffordable if contracts did not change and commented on the extreme premiums some trusts are having to pay to get consultants to agree to work at evenings and weekends. The forum thought current arrangements are increasingly unworkable.
Appointment of consultants regulations
The forum heard of the problems employers face when dealing with the 1996 Appointment of Consultants Regulations. The regulations do not apply to foundation trusts but are a problem for those that do not have foundation status. Members from foundation trusts have developed their own processes which work well, non-foundation trusts felt the regulations meant an unnecessary cost pressure was placed upon them.
Faculty of medical leadership & management
The faculty of medical leadership & management outlined its structure, current membership, and areas of work and priorities. The role of the faculty is to set the standards for leadership. The forum discussed how performance management is often not applied to leaders and managers and good doctors are not encouraged to become leaders. The forum agreed a joint approach works best and should be encouraged. Overall the forum was supportive of the faculty and hoped it would thrive.
Professional support units
The NHS revalidation support team spoke to the forum about professional support units. The initiative is to look at what support is needed to ensure the responsible officer regulations are met by designated bodies. It was explained that for a number of reasons it is easier for some designated bodies to meet the requirements of the regulations than others. Members of the forum expressed their disappointment in the NCAS process and the time it takes, with the view being that a PSU service could help. There needs to be a national database of experts in remediation and case investigators that trusts can be put in contact with.
It was noted that the Academy of Medical Royal College has drafted a statement around the Francis requirement of having a named clinician above every hospital bed.
An update was given on the prescribing safety assessment (PSA) as UK medical school students have now taken the test and the significance of the results are being analysed. NHS Employers hoped to gather current practice from trusts around prescribing. A number of good systems were mentioned, with effective electronic prescribing and working closely with pharmacists being noted as improving results.
The point of full GMC registration
Health Education England explained the issue and noted a formal consultation will be launched. It is expected that a GMC national licencing examination will complement this work. The time scale of any possible changes was unknown, and it was noted that a change to the Medical Act may be required. The forum discussed the possible changes and had various concerns around funding streams, capability and experience, and governance/accountability. It was noted the foundation programme in its current form is generally well regarded by employers.
The removal of LATS
The forum heard information on the history of LAT posts and the various changes to the system since their introduction. The distribution of LAT posts varies depending on region and specialty. The various problems associated with LAT posts were outlined, including how specialty training numbers are skewed (by specialty and location) and educational supervision is more difficult to maintain as there is less opportunity for observation over time if someone undertakes a series of LAT posts. This leads to problems for the service, patient safety and education.
The forum agreed that most trusts are battling with this issue and recognised the problems outlined. The forum thought the current contract provided a perverse incentive in that trainees doing the same LAT post year after year, continue to receive pay progression, despite a lack of progression. It was agreed that letting struggling doctors float around the system was not ideal, and that these doctors should be identified early on in their careers.
It was also suggested that the service need should be assessed before engaging a LAT and all options should be looked in to. The forum discussed the problems trusts face with out of programme experiences and it was thought more of a scheduled timetable would help employers in this regard.
It was suggested that work with academics needs to be done to see what OOPEs are appropriate for each specialty, if every specialty benefits from a trainee having a PhD, and what numbers of PhDs are needed in certain specialties.
It was thought if LAT posts were withdrawn this would have to be done gradually. The forum agreed that the period of grace clause in the current contract is a problem.
National Clinical Assessment Service (NCAS)
The new director of NCAS presented to the forum on the history and services of the organisation and the desire to be more responsive and give trusts feedback faster, which had been highlighted as a problem in a recent review. The forum explained the various issues they had experienced using the service including excessive time taken to resolve cases (leading to expensive backfill costs), differentiation in outcomes, and lack of engagement and cooperation from the doctor. NCAS stated the service needs to be fit for purpose, service driven, and allow more ownership of the whole process.
The forum felt that maintaining high professional standards (MHPS) should be reviewed to make it less prescriptive and more permissive.
Pay and contract reform
An update was given on the ongoing contract negotiations between NHS Employers and the BMA for a new contract for doctors in training and possible changes to the consultant contract.
Employers would prefer a rate of pay for the different stages of training, rather than automatic progression. A data collection exercise is still ongoing to look at working hours under the current contract to ensure the new contract awards the right pay rate for different working patterns and hours. Banding arrangements in the current contract do not reward what employers need, and this is a key driver for change in the new contract.
There remains an imperative from employers to reform the consultant contract to ensure it is affordable, flexible and sustainable in the long term. The forum felt Schedule 3 Paragraph 6 was a major problem in the current contract and that it must go. The clause effectively means that consultants only work weekday days and trusts cannot schedule work for other ‘premium times’. A side effect of the opt out is that consultants or, in their absence, locum consultants can push up the cost of premium times in return for agreeing to work. The forum also felt that pay progression and performance management in the current contract is a problem.
Emergency medicine update
HEE updated that so far this year fill rates are up. The new emergency medicine run through programme looks to be a success with a high percentage of trainees choosing this option. Additional work on transferring competencies from other specialties (core surgery for example) in to emergency medicine is ongoing. A number of additional ACCS posts have been agreed this year and for further years if required.
Gaps at ST3/ST4 remain due to the time lag in training, so a worldwide recruitment campaign was run by HEE which attracted a high number of candidates, some of which were interviewed. The trained doctors will go in to SAS grade posts.
Forum members were asked to help in locating the lists of third panel members for consultant job planning appeals, formally held by the SHAs.
The forum was asked if the prescribing safety assessment (PSA) was accepted by employers as an adequate assessment of prescribing capability. The forum thought this was an important issue which needs to be properly assessed. Consultant and pharmacy working practices have to change, but all doctors in training should have basic prescribing knowledge from day one.
The forum thought that the ward-based pharmacist should be supervising doctors in training prescribing and take an educational role, and that processes relating to high risk drugs should be looked at. It was suggested that prescribing competence can vary significantly in new doctors. Attitude and culture around safety are important in this area as well as knowledge. There was consensus that E-prescribing is a great help and reduces errors.
Code of practice for the provision of information
The forum acknowledged that this is an important issue for doctors in training but some information is not always easy to provide. It was thought the main things doctors in training want to know are their start date, when they will be on call, information on holidays, and how much they will be paid. Employers are happy to accommodate providing this information where it is available, however they cannot provide information they do not have as a result of it not being passed on from the deanery function. In addition, doctors themselves can cause delays by withdrawing at late notice, taking up OOPEs, requesting to go LTFT, and requesting swaps. All of which means that rotas needs to be re-written. In addition, there will always be exceptional circumstances such as sick leave or maternity leave where work patterns will need to be altered.
HEE outlined the estimated costs and current arrangements in place across the LETBs for the reimbursement of interview expenses for specialty training. It was discussed how changes to recruitment processes over the years (eg, the introduction of national systems) and the way that the T&Cs are worded, mean the current position is outdated. Current practice is inconsistent around the country.
Forum members considered that in other professions and staff groups, interview expenses are not guaranteed, but the rotational nature of trainees should be a consideration. The purpose of paying the expense needs to be established, is the system designed to allow someone to attend an interview who otherwise would not be able to afford to, or are expenses paid for some other reason, such as to raise moral amongst new starters. Employers agreed they would want to have discretion to pay expenses and equity should be applied across all staff groups. Consideration should be given to the academic foundation programme where several interviews are required
The value of the doctor in training
The Academy of Medical Royal Colleges presented a new charter for doctors in training, and was seeking support from employers and other stakeholders in implementing the charter. It was hoped the charter reflects both the rights and responsibilities of doctors in training, achieving the correct balance between service and training and ensuring there is correct induction and supervision.
The forum thought that this was a good document but ultimately implementation is down to local culture and leadership and management. The GMC introducing certain standards will mean boards will have to take note. It was thought that educational governance was important and there needs to be a recognised partnership between trainees and deanery functions.
It was suggested some of the content of the charter could be included at medical schools so that doctors in training begin foundation training knowing their responsibilities. The trainer must be a valued and recognised role, which perhaps is not suited to all consultants. The GMC must enforce values based leadership for doctors.
It was agreed that communications will have to be clear and informative if the document is to be actioned, and as it is essential the document reaches the right audience, trainees could promote the document amongst their own cohorts.
European Working Time Directive (EWTD) consultation
The European Commission (EC) had undertaken an impact assessment of possible changes to the EWTD, and there are two ongoing studies, one on the general impact and one on the impact to the health sector and flexibilities or changes. Researchers have interviewed NHS Employers and individual trusts.
A separate consultation is also underway by the Department of Health which is looking at gathering opinion from relevant stakeholders on what is working, what is a problem, and what are the priorities.
Pay and contract reform
The forum discussed the letter sent on 31 July from the Chief Secretary to the Treasury to the Doctors and Dentists Review Body (DDRB), which outlined the Government's position on NHS pay, and also that the Minister may ask DDRB to consider contract reform, depending on the progress of negotiations.
Detailed work is still ongoing in juniors negotiations and some progress has been made. We know that pay for time served or any variation of this will not be approved by HM Treasury. The forum wanted to ensure that working at nights in busy specialities would be incentivised in some way. It was stated how money cannot solve the supply issue where there are shortages of certain staff groups.
In consultant negotiations, the main issues have been focused on helping to deliver seven-day services and the barriers to this, for example Schedule 3 paragraph 6 and the rates and time of out of hours versus plain time. It was stressed that as with the junior negotiations, we are working in a cost neutral environment. The forum thought that if there was no progress on an amended contract employers would have to start looking at local measures such as ensuring objectives for pay progression are met and better job planning.
The Academy of Medical Royal Colleges has set up a working group to take forward this work on their juniors’ charter.
The Snowy White Peaks report has been discussed amongst London HR directors and a small working group has been set up.
Pay and contract reform
NHS Employers outlined how the BMA has walked away from contract negotiations before their conclusion. Employers still feel there is a compelling case for change for both the juniors and consultant contracts, and the BMA stating that the Government/NHS Employers were risking patient safety with new contractual arrangements was untrue.
Employer opinion supported by the HSJ barometer is that a centrally designed contract and terms and conditions, with local flexibilities to implement are what is wanted. Employers would not welcome widespread local bargaining on all topics. It was thought a number of things on offer during negotiations would be attractive to doctors, but not to the BMA negotiators. The forum felt patient safety is being put at risk by consultants not being present at times when they need to be, and as a result juniors having little supervision when they need it.
NHS Employers is preparing to submit evidence to the DDRB in December 2014, gathering as much additional feedback as possible in the meantime.
The forum discussed how to make the best use of the 2003 consultant contract given that these issues will not be solved in the near future, with DDRB not submitting its report to the Government until July 2015. It was agreed the 2003 contract is not implemented properly in some places, and some wider non-contract related reforms may now be needed to services. The forum reiterated how Schedule 3 Paragraph 6 continues to cause severe financial problems.
The forum discussed how the status quo cannot continue, employers and the Government know that the current situation is unsustainable. The forum noted its disappointment at the BMA's actions.
Better Training Better Care (BTBC)
HEE updated on the Better Training Better Care project, outlining the origins and background to the BTBC project following on from the Temple and Collins' reports. Full details and materials are likely to be available from HEE after Christmas including a ‘leadership document’. GMC inspections on training quality are going to use the BTBC pilots as examples of good practice, and the NHS Litigation Authority has also shown interest in the BTBC pilots from a safety point of view. HEE wants to emphasise the ‘quick wins’ that trusts can achieve through the pilot projects. All of the pilot projects are value for money, improve safety, and involve simple things.
An update was also given on the technology enhanced learning (TEL) project. A hub will be launched in spring which aims to pull together the various e-learning resources available. The aim is not to re-invent the wheel but to be the Google of health e-learning, reducing the duplication of resources and increasing quality.
The forum agreed it was great that the BTBC project had pulled all of this good practice together nationally, and hoped that the project would keep up the momentum it has gained.
GMC review of the list of registered medical rractitioners
The GMC has commissioned an independent research consultancy who joined the forum to discuss the GMC’s list of registered medical practitioners (LRMP). The GMC is keen to review the LRMP to ensure it provides the right level of information to users of the list, and to see if there is any appetite to add anything or improve the list in any way. The forum fed back to the researchers who will be submitting a report to the GMC this year.
NHS Employers outlined work around a charter for SAS doctors, and other work on developing the SAS grade. The SAS charter was originally a BMA document that NHS Employers has been helping to re-draft including the obligations of a SAS doctor as well as SAS doctor expectations. It is hoped that HEE and the Academy of Medical Royal Colleges (AoMRC) will also sign up to the charter. NHS Employers is working with HEE, the BMA and the AoMRC, in partnership to deliver four regional events for SAS doctors, looking at their development and sharing best practise across the country. SAS doctors are an important part of the workforce making up around one in five of the medical workforce, and a high concentration are thought to work in emergency medicine and the acute specialties. The forum thought that a key message was that being a SAS grade was a worthwhile career and a good alternative to being a consultant, and that getting the best out of appraisal was important for both sides.
Forum members mentioned that an issue is being raised locally by the BMA where they are encouraging trusts to agree to give SAS doctors an additional two days of leave. NHS Employers confirmed that this issue has been raised nationally and has not been agreed.
Update on legal case around holiday pay
NHS Employers updated forum members on the recent legal case around holiday pay, and advised that further legal advice from Capsticks will be published in the near future.