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Oral and maxillofacial surgery review consultation

October 2007

Letter to Ms Rachel Noble, Policy Officer, PMETB

The BMA welcomes your recent consultation with the medical profession and patients on a certificate of completion of training (CCT) in oral and maxillofacial surgery and look forward to engaging with PMETB on similar consultations for other medical specialties.

It is vital that the interest of specialty trainees and the wider medical profession are represented and the implications for patient care considered. We are pleased that specialist trainees in Oral and Maxillofacial Surgery (OMFS) are now represented on the PMETB review group for this specialty and thank you for considering the oral evidence provided on behalf of the BMA by Dr Ram Moorthy, Chairman Junior Doctors Committee, on Tuesday 18 September.

We believe the issues for remodelling training are far wider reaching than those for a single specialty. Our response looks at the implications of the consultation for the medical profession and patients and more specifically, at the implications for OMFS professionals.

We are aware that there will be an overhaul of dental training, similar to that which has occurred for medical training, through MMC. We believe that there is a need to ensure that training for OMFS results in trainees with the necessary competencies and skills to undertake their role as OMF surgeons.

We note that there is currently no independent regulatory body, responsible for postgraduate basic and higher specialist education and training in dentistry, separate from the body which regulates the profession of dentistry.

Further consultation would need to be undertaken to ensure that there is support from the medical profession and patients before any changes were made to the current requirement for dual primary qualification .We also note that the terms of reference for the working group and the review are wider than the remit of this consultation. We would therefore welcome an opportunity for further engagement on the issues and thank you for inviting us to provide oral evidence to the PMETB OMFS review body on this issue.

It is increasignly important, especially with the ongoing changes to medical education and training, to ensure that there is an understanding of the needs of patients, the service and trainees. This understanding should also extend to the speciality and current training process to ensure that any changes to training for this group of specialists, meets future service requirements.

We therefore provide our comments on each of the consultation questions with these principles in mind.

Sally Watson

1. What is it that oral and maxillofacial surgeons uniquely do?
OMFS professionals have a unique role in medicine and dentistry as they provide a strong and vital link between the medical and dental professions and are an integral member of the multidiscipline team that manages malignancies affecting the head and neck region.

No other nationwide surgical discipline routinely provides care for patients with facial deformity, facial trauma, oral surgery conditions and temporomandibular disorders with full medical knowledge, understanding and competency in these areas.

2. What is the added value of undertaking undergraduate medical and dental training, as opposed to one or the other?
There is considerable variation in the views of medical professionals about the need for OMFS professionals to have undertaken undergraduate training in both medicine and dentistry. Currently the European Union requires that OMFS are dual qualified and registered in medicine and dentistry.

We believe that whilst dental training offers some basic medical training it does not allow trainees to meet the required competencies to make the transition from an undergraduate dental student to the medical training grades. By qualifying as a doctor we believe OMFS trainees are more likely to have a holistic approach to patient care and to understand how the management of patient care is influenced by other factors, including co-morbidity. It is vital that OMFS professionals have gained adequate training, skills and competencies of all diseases and conditions to ensure they are able to provide the best possible level of medical care to patients in their care.

3. What knowledge, skills and competencies should be acquired during postgraduate training in OMFS?
A well defined curriculum for specialist trainees in OMFS already exists (reference1) and has been approved by PMETB (reference 2).

4. Are these competencies best achieved by the current, dual primary qualification approach, or could they be more effective by having a postgraduate training programme entered from either medicine or dentistry, with special modules for those without the requisite undergraduate knowledge or skills?
We believe that the competencies of an OMFS professional are currently achieved adequately through the current model of dual primary qualification in both medicine and dentistry. As described in our response to question 2, we believe it is vital that this group of professionals have gained the medical training, skills and competencies of all diseases and conditions to ensure they are able to provide the best possible level of care to patients in their care.

We do not believe that it is currently possible to achieve the relevant skills and competencies in medicine without achieving a primary medical qualification. There would need to be further consultation with the medical and dental profession were changes to be made to the requirements for dual qualification.

5. Are there alternative models for streamlining training?
The competencies for specialist training in OMFS are clearly defined as outlined in our response to question 3. Further consultation would be required regarding the pathway leading to entry to specialist training in OMFS.

We recognise and support OMFS professionals concerns about the length of training required of them and the potential overlap in training which occurs for those who are dual qualified. Undergraduate medical students must complete a minimum number of hours prior to gaining registration with the GMC. If OMFS training was streamlined to enable trainees to undertake accelerated training in medicine, then trainees may not fulfil the registration requirements as recognised by the GMC. The European Union also requires that OMF surgeons are dual qualified and registered in medicine and dentistry. The issue of skills transfer outside of the NHS would also arise as registration would not be recognised within the rest of the EU.

We believe that further consideration should be given, that subject to the necessary safeguards, trainees attaining the required competencies are able to enter training at the most appropriate level to their previously acquired skills.

A full evaluation of alternative models of training should be undertaken, including exploring the Australasian/US systems where employment of OMFS trainees in part-time posts whilst completing their medical training is recognised and accredited towards their medical degree. Further consultation with the medical, dental and regulatory bodies would be needed were such a model proposed.

We believe however, that the requirement of completion of training should continue to require the following; satisfactory assessment reports, a satisfactory final report from consultant trainers, satisfactory logbook at the end of the training period and success in the Intercollegiate Specialty Examination in Oral and Maxillofacial Surgery. We believe registration should remain with the GMC.

A priority of further streamlining of training must be to ensure that trainees fulfil the requirements for full registration with the GMC. We favour a model of training which ensures that trainees are able to gain the necessary skills, competence and experience, without unnecessary duplication of training and education, which enables them to practise competently and ensures patient safety.

6. What are the requirements of OMFS for:
a) patients
Patients should expect to see a specialist who has the necessary training, skills and competencies to treat them. As a minimum requirement for all OMFS professionals, as with all doctors practising in the UK, we believe there should be adherence to the professional standards outlined in the GMC’s requirements of ‘Good Medical Practice 2006’.

The GMC’s guidance is addressed to doctors, but is also intended to let the public know what they can expect from doctors. We believe all OMFS professionals should adhere to these professional standards.

b) the service
As outlined in our response to question 1, OMFS provides a unique service for patients in that it covers a wide range and specialist range of oral and facial conditions. As with all medical specialties it has changed considerably in response to reform and new advances in medical techniques. There is a requirement for OMFS consultants to be present in multidisciplinary teams for some routine and more specialist procedures which recognises their unique skills and their specialist role.

Further work should be undertaken to identify and review the requirements for patients and the service.

7. Are these requirements currently being met as efficiently as possible?
We are unable to comment on this question and believe it is best responded to by service users and providers who are able to evaluate the impact of OMFS requirements on patients and the service.

It should however be noted that currently there is no workforce data available on the implications of any change in the structure of OMFS and the service this speciality provides within the NHS or any data on a change in the number of OMFS professionals and what affect this might have on patient care and service delivery.

8. Is there a continuing need for specialists to hold dual registration?
As we have outlined in our response so far, OMFS is a medical specialty under the remit of PMETB and the GMC. We believe that OMFS professionals must hold full medical registration with the GMC.

Currently there is no independent regulator for postgraduate basic and higher specialist education and training in dentistry separate from the body regulating the profession of dentistry.

At the present time we believe that there is a need for OMFS professionals to hold dual registration.

References
1 http://www.iscp.ac.uk/Syllabus/Overview.aspx?enc=IkC9R8V0UhqYwUJWLf7uSFGHkUwSFKIosHepYhBHhX0=
2 http://www.pmetb.org.uk/fileadmin/user/QA/Curricula/Copy_of_Definitive_list_of_specialties_and_subspecialties_as_at_31_August_2007.pdf