The National Health Service Plan, published last week, proposes the biggest expansion in medical education in a generation. Claire Sanders looks at the implications for institutions
Expanding the numbers
The National Health Service Plan recognises that it will not be able to save the NHS without a huge increase in the number of staff. It proposes that by 2004 the NHS will have 7,500 more consultants and 2,000 more GPs, 20,000 extra nurses and more than 6,500 extra health professionals. It calls for 1,000 more medical school places on top of the 1,100 already announced. This is a 40 per cent increase since 1997 - the biggest rise in a generation.
The government plans to reach these numbers by enticing former staff back to the NHS, improving pay and working conditions to keep staff and recruiting from abroad. But thousands will come through universities and colleges.
Teaching a new generation
Sir George Alberti, president of the Royal College of Physicians and a member of the team dealing with the professions that fed into the review, was happy with the review. "We are pleased that the plan is long-term, as you cannot train new doctors or other health professionals overnight, and it will take most of the next decade to achieve the right numbers, but much can be done now."
Sir Martin Harris, chair of the Committee of Vice-Chancellors and Principals health committee, said: "Conditions of service for clinical academics and nurse educators must be at least as attractive as those of NHS colleagues if the recruitment needed is to be successfully carried out."
There have long been concerns that there are too few clinical academics to teach the rising number of medical students. The Council of Heads of Medical Schools is completing a questionnaire on medical academics, and last September, a British Medical Association survey of vacant medical chairs in UK medical schools found that 74 chairs out of 401 were reported as being vacant; almost half of these had been vacant for a year.
The pay of a clinical academic is determined partly by distinction awards and a discretionary points scheme. The plan proposes merging these into a more graduated scheme with increased funding to reward consultants who make the biggest commitment to the NHS.
The plan says that the special provision for clinical academics will remain and - for the first time - be extended to academic GPs. The extension of awards to academic GPs has been welcomed, but there is confusion about how the government plans to improve the lot of clinical academics overall.
Sir George said: "It has long been recognised that the current system has not benefited clinical academics. The discretionary points, in effect local awards, have gone to those most benefiting services on the local NHS. My hope, and my understanding of the plan, is that the government intends a separate system for clinical academics, one that could take proper consideration of research."
Michael Powell, executive officer of the CHMS, said the plan points towards a single system. "We need to know how the new criteria for the single scheme will work. If the focus is on patient care, how will this apply to the role of the clinical academic?" Explicit criteria will be published by the end of the year.
The consultant's contract is being changed to reward those most committed to the NHS. Royal colleges will be able to advise NHS trusts on, but not to veto, the content of job descriptions for consultant posts. Newly qualified consultants will be expected to work exclusively for the NHS for the first seven years of their career.
"It will have to be spelt out what this means for clinical academics," Sir George said. "In general, they do little private work."
Graeme Catto, who moves shortly from Aberdeen University to become vice-principal and dean of the Guy's, King's College and St Thomas's Hospitals medical and dental school, said it was imperative to expand undergraduate medical education. The NHS could not exist without its current numbers of overseas doctors, but it was uncertain whether this supply would continue at its present rate. He warned that medicine was likely to have to "work hard" to make itself attractive to entrants, offering flexible training and career breaks.
Those teaching nurses and other health professionals are already under pressure. One big problem has been ensuring students good clinical placements with the NHS. Two reports - the government's Making a Difference and Sir Leonard Peach's Fitness for Practice - sought to address this issue.
Eileen Martin is dean of the faculty of health at the University of Central Lancashire and chair of the council of deans and heads for UK faculties of nursing, midwifery and health visiting. She said: "Medics have a very healthy funding stream and are resisting plans to see this merged with other funding streams. Nursing needs infrastructure in the form of posts at the clinical directorate level to oversee placements."
Peter Burley, deputy registrar of the Council for Professions Supplementary to Medicine, said: "Some of the professions we represent will find it hard to get placements for students. The government talks of a closer partnership with the private sector but makes no mention of arrangements for students to do placements in the private sector."
"Radical reform is required in NHS education and training to reshape care around the patient," the plan says.
For several years the government has sought to change what it sees as the old hierarchical ways of working in the NHS to a more flexible team approach. The plan acknowledges that this is now happening in many parts of the NHS, but warns: "Best practice can no longer be an option."
The plan proposes changes in how people work. The role of nurses will expand to take on many jobs now done by junior doctors, and the number of nurse consultants will rise to 1,000. A new role of consultant therapist will be introduced to work with senior hospital doctors, nurses and midwives.
A leadership centre will be set up to develop a new generation of managerial and clinical leaders, including modern matrons. Pharmacists will be paid to develop overall services rather than just to dispense prescriptions.
The plan also proposes to create assistant practitioners in radiography to conduct mammograms under supervision. Radiographers will then be freed for tasks traditionally done by radiologists - so increasing the capacity of breast-screening programmes.
Also proposed are 1,000 new graduate primary care mental health workers to help GPs manage and treat common mental health problems.
To ensure staff work together to meet patients' needs, the plan proposes joint training for all health-care professions in communication skills and in NHS principles.
The government also proposes a common foundation programme to enable students and staff to switch careers and training paths more easily. This will mean that nurses or midwives who want to become doctors will not have to start their training from scratch.
Such a curriculum is a big challenge for universities, Sir Martin said. "It will need to suit students from a wide range of educational backgrounds and prepare them for work in a variety of health-care environments."
Sir George argued that a core curriculum group would have to be formed to take a "fairly radical look" at what is taught and how.
Others were wary of quick change. "I prefer," Mrs Martin said, "to talk about interdisciplinary education rather than multidisciplinary. It is important that we develop insights into each other's work, but we must not all be reduced to the lowest common denominator. It could destabilise the higher education sector if we are all forced to teach different disciplines in the same classroom."
Nursing education and training has already been through major reform. Making a Difference emphasised improving access, developing practical skills earlier and providing stepping off points at the end of the first year. By autumn 2001, 85 per cent of all nurse training organisations will be operating these arrangements - by autumn 2002, they will be standard across England.
The plan says similar principles will be applied to education and training for other health professionals and health scientists.
Medical education has been undergoing reform since the publication of the General Medical Council's recommendations in Tomorrow's Doctors in 1993. The plan says: "We will wish to see consideration of options for overseeing medical undergraduate curricula considered as part of the radical review of the role of the GMC, together with proposals for shortening the medical undergraduate course to three years for existing graduates and four years for others."
Mr Powell said: "It is not clear how a shortened undergraduate medical course will comply with the European Union directive on professional qualifications and mobility, which requires doctors to study for 5,500 hours or six years."
Expanding on the plan, Sir George said: "The idea is to move to a four-plus-two system, where the house officer years form the last two years of the academic period of training."
As part of reforms to postgraduate medical education, the plan wants to see a big rise in the numbers of specialist registrars.
From 2002, the government will centrally fund all specialist registrar posts - if agreement can be reached with the medical royal colleges and other bodies on curriculums and criteria for training recognition. The senior house officer grade will be modernised to provide a broader educational experience and a smaller workload. New arrangements will be introduced progressively from September 2001.
The plan proposes a new body, the Medical Education Standards Board, to provide a "coherent, robust and accountable approach" to postgraduate medical education. This will replace the separate bodies for general practice and hospital specialities. Members will be drawn from the medical profession, the NHS and the public. The board will accredit NHS organisations as training providers.
Staff without professional qualifications are not overlooked: "We will guarantee all such staff access either to an individual learning account of Pounds 150 a year or dedicated training to NVQ levels two and three." National occupation standards will be developed for this group of workers.
The government will invest Pounds 140 million by 2003-04 to support training and development.
Taking research to the front
"Working with the private sector and other partners we will commission NHS research and development in new centres of excellence. These medical knowledge parks will evaluate all aspects of the emerging developments in genetics, from the laboratory testing to the requirement for counselling of patients. They will bring together NHS research, the private and charitable sectors alongside frontline NHS staff and patients," the plan says.
"This is very much blue-sky thinking," Sir George said. "The details are yet to emerge."
The plan also says that a new policy on research governance in the NHS will be published by the end of the year.
"By April 2001 we will have developed ways of streamlining the work of research ethics committees while preserving all the necessary safeguards. This will allow faster and more effective recruitment of patients into clinical trials," the plan says. Sir George said this would involve a vast amount of work for clinical academics, and provision must be made for NHS consultants to participate fully in the work.
The plan proposes a new cancer research network, details of which the Department of Health has published. The idea is to integrate cancer research at a national level, doubling the number of cancer patients entering trials over three years. The government will tender for an organisation to lead the network, and a decision will be made in the autumn.
Mrs Martin identified a gap in the plan. "There is no funding system for research into nursing and midwifery. If the government wants to move towards an evidence-based approach, this will have to change."
Working with social services
The plan proposes a new level of primary care trusts to better integrate health and social services.
Regulating the profession
The regulation of the clinical professions and individual clinicians needs to be strengthened.
As a minimum, the plan says, the self-regulatory bodies must become smaller, add more patient and public representatives to their membership, streamline procedures and develop real accountability to the public and the health service. The DoH this week published its proposals to replace the UKCC for Nursing, Midwifery and Health Visiting and the four National Boards with a new Nursing and Midwifery Council and the Council for Professions Supplementary to Medicine and its 12 uni-professional boards with a new Health Professions Council. There is a three-month consultation period on the proposals.
The plan proposes a UK Council of Health Regulators, which will include the GMC, the successor bodies to the UKCC for Nursing, Midwifery and Health Visiting and the Council for Professions Supplementary to Medicine, along with the General Dental Council, the General Optical Council and other councils. "Were concerns to remain about the individual self-regulatory bodies, its role could evolve," the plan says.
The plan intends a review of requirements for re-registration in nursing and says proposals will be published for the effective regulation of health-support workers.
A National Clinical Assessment Authority will be set up to advise quickly on action if there are concerns over a doctor's performance.
Implementing the plan
A modernisation action board will be in place by September. In the autumn, it will agree and publish an implementation scheme.
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