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A question of quality: education, training and NHS reform

Changes to postgraduate education and training were branded an after-thought to the wider NHS reforms when they were first unveiled two years ago.

Employers were seen by critics of the proposals to be taking on a poacher-turned-gamekeeper role in assuming local responsibility for juniors’ training in England, while the plan to abolish postgraduate medical deaneries was heavily opposed.

But after the government’s self-imposed pause for thought, reflections are making way for reality as the plans first proposed in the white paper Liberating the NHS: Developing the Healthcare Workforce head towards implementation.

From next April, the plans will come into effect, with LETBs (local education and training boards) taking on the management and commissioning of medical education and training and workforce planning.

Most of the 13 LETBs have been operating in shadow form for some time now, and the authorisation process to set up their governing bodies — the boards that will determine local education and training needs — began this month.


BMA lobbying

The BMA junior doctors committee was among the representative bodies saying the reforms required further work. It has been vigorously lobbying for improvements in a number of areas. JDC chair Ben Molyneux says the potential positive results of the changes must not be overridden by short-term service needs.

He says: ‘LETBs have the potential to drive local reform and improve training, but unless they are well supported and supervised, with plenty of professional — especially trainee — input, there is a real risk of short-termist employer-led approaches, conflicts of interest and trainees being sidelined.’

The BMA also fears insufficient supervision could compromise patient care.

LETBs will be overseen by HEE (Health Education England), the new NHS organisation that became a statutory body earlier this month. HEE will be accountable to health secretary Jeremy Hunt, who has ultimate responsibility for the delivery of education and training. This differs from the original proposals; BMA lobbying led to an amendment being tabled to the Health and Social Care Bill, ensuring the secretary of state’s responsibilities.

Poacher-gamekeeper role

As Department of Health director of medical education, Professor Sowden has responsibility for education and quality during the HEE transition until his imminent retirement. He expressed concerns about the potential poacher-gamekeeper role of employers at a JDC debate in February 2011.

Professor Sowden was director for education and quality during the HEE transition until his retirement this month. He thinks the governance arrangements that have now been put in place for LETBs and HEE will go some way in preventing employer conflicts of interest.

Professor Sowden says: ‘I find the governance and accountability that have been put in place very encouraging, and [am impressed by] the system that supports this, particularly LETBs’ ability to call their systems to account, and HEE’s ability to performance-manage LETBs.

‘I think what we do not know is whether these systems will work in reality, and I think what we will find is that it works very well in some areas because people genuinely get it and the LETB becomes self-governing … 

‘In [other] areas they are going to struggle, and part of that is because there’s still a misunderstanding about what’s going on. Some people seem to [think] it’s giving certain trusts overt control over education and training.’

Vision and leadership

A HEE spokesperson says the authorisation process will help assess whether boards are fit to take on responsibility for leading local healthcare education and training and the associated expenditure.

The spokesperson says: ‘To gain authorisation, LETBs will need to demonstrate vision and leadership, meaningful engagement with key partners, good governance, effective financial control, organisational capability and outcome-led improvements.

‘The authorisation process will ensure that LETBs are multi-professional and representative across all healthcare sectors. As part of their constitutions, all LETBs will have stringent processes in place to manage potential conflicts of interest, including guidance on when issues should be escalated to HEE.’

All LETBs will have an independent chair whose job it will be to ensure the value and quality of education and training commissioned. They should also ensure decisions are not affected by conflicts of interest.

The boards will include healthcare providers and representatives of primary, secondary and community care and the education sector.

Deaneries saved

Dr Molyneux says a close eye must be kept on the work of the boards, especially with the changes to the deanery-led structure to training.

Deaneries were initially slated for abolition under the education and training plans, but lobbying from organisations and representatives that included the BMA led to the government confirming that their functions would continue within the new set-up.

Dr Molyneux says: ‘Quality management — ensuring training on the ground is up to scratch — is a key function of deaneries, and we need to ensure that objective, unbiased reviews of education and training continue.

‘With employers much more heavily involved with LETBs than they ever have been with deaneries, we need to keep a very close eye on emerging conflicts of interest and fall hard on any attempts to circumvent this through withholding of “commercially sensitive” material.’

In most areas, particularly outside London, board areas will generally match old deanery and SHA (strategic health authority) boundaries.

Hub and spokes model

The West Midlands LETB will work on a ‘hub and spokes’ model, with the LETB board — including the deanery — as the hub, and the spokes comprising LETCs (local education and training councils) and the Mental Health Institute, each chaired by a chief executive sitting on the LETB board.

The LETCs are replacing the five workforce locality boards, which effectively constitute the geographical shape of the PCTs.

West Midlands postgraduate medical dean Elizabeth Hughes says: ‘We are very clear we have one LETB, we are a multidisciplinary deanery, but the postgraduate medical and dental functions will continue in the hub.

‘We will not divide it five ways, because it’s clearly not productive or desirable in terms of the deanery to trade work that will continue as now.’

She says the difference is that the line of reporting will be to the managing director of the LETB rather than to the SHA.

In London, the deanery, which is currently responsible for more than 12,000 doctors and dentists in training, will be split into three LETBs.

Unique formation

BMA North Thames regional JDC chair Tim Crocker-Buqué says: ‘London is unique in terms of the formation of the LETBs, because almost everywhere else the LETBs have taken over the geographical [form] and remit of the deaneries. The thing that’s different about London is the deanery covers all of the capital’s [thousands of] trainees, and now it’s divided into North West London, North Central and East London, and South London.’

Dr Crocker-Buqué is concerned about the impact on deanery services such as transfers for trainees who need to relocate due to changes in personal circumstances, support for trainees in difficulty, and careers advice.

‘Trainees in difficulty have got to be looked after by somebody with expertise, and there are only a small number of people who are able to deal with that,’ he says. ‘It does not make any sense to separate that three times and train three times as many staff to deal with this.

‘I think it duplicates quite a lot of [work] that was being done fine by the London Deanery. It’s wasteful in many different ways.’

Trainee representation


The BMA has concerns about the representation of doctors on LETBs.

The JDC has written to every LETB, asking if they will have trainee representatives on their boards.

Dr Crocker-Buqué says: ‘HEE guidance on how to set up a LETB does not say anything about how you should have trainee representation on your board at any point. It just says you must have engaged with stakeholders including trainees.’

He adds: ‘If you do not involve the trainees, you don’t know what kind of training you are delivering.’

Professor Sowden says HEE chief executive Ian Cumming is ‘insistent that LETBs must represent trainees and students because that is what the training system is there for’.

‘I think LETBs should spend time getting views from the wider community and ensuring that is fed into the system. I would see that as being more productive,’ he says.

The West Midlands LETB will have trainee representative at different levels, Dr Hughes says.

‘We really want enthusiastic trainees, particularly at LETC level … From the [perspective] of the LETB board, I think that’s a real opportunity for trainees doing leadership roles,’ she says.

User group promise

In London, Dr Crocker-Buqué reports that the North Central and East London LETBs have said they will have trainee representatives, and South London will have a user group, which he says is ‘a good start’.

The JDC has also heard that trainees will be represented on the postgraduate medical and dental executive committee in Yorkshire and the Humber.

For the Wessex LETB, the regional JDC rep has been invited to join the LETB Partnership Council. A response from the West of England and South West Peninsula to the JDC letter did not mention trainee involvement.

Medical academic leaders are also keen to be involved with the LETBs, and have called for universities, as employers of doctors and providers of medical education, to be represented on them.

The boards will take over responsibility for SIFT (service increment for teaching), which is part of the multi-professional education and funding levy funding stream, and pays for the teaching of undergraduate medical and dental students on clinical placements. Previously, SIFT was jointly managed by NHS trusts and medical schools.

Commissioning role


BMA medical academic staff committee co-chair Michael Rees says LETBs could also have wider educational commissioning roles.

‘Education covers graduate education as well as postgraduate training, so LETBs may also get involved in commissioning courses for continuing professional development and research and management training, as well as education training,’ he says.

LETBs will also host health innovation and education clusters or academic health science networks, and so will have a role in promoting research links.

Professor Rees says: ‘It is important that there is strong academic input with LETBs, so they follow principles of excellence in education and research, and help integrate research into the NHS. It is important to develop an NHS that has education and research as one of its core functions.’

Continuity critical


While lobbying on details continues behind the scenes, much of the emphasis is on ensuring a smooth transition.

Dr Hughes says: ‘Business continuity is critical. We have got trainees to train, assess and recruit, and rotas to organise. All of that has to continue. Our priority is to ensure that is not disturbed, because that is destabilising for everybody.’

Professor Sowden adds that if trainees notice a ‘huge difference’ then the transition management would have failed.

That sentiment is echoed by Dr Molyneux, who says: ‘The JDC has been working hard at every level from the DH to local employers to ensure that there is no negative impact on any trainees from LETB reforms. If we are successful, then no trainee should notice the transition from deanery to LETB.’

National tariff will see funds follow trainees


A national tariff along with levies on providers will be the future funding system for medical education and training. Money would follow the student or trainee.

The government announced last month that a tariff for non-medical education and training and undergraduate medical placements in primary care would be introduced in April. Work on the postgraduate tariff system is continuing.

The tariff is intended to be linked to quality, and the BMA has emphasised that it should not just be activity-based — as the NHS service tariff has proved.

The government is also planning to replace the MPET (multi-professional education and training levy), which includes a number of funding streams contributing to junior doctors’ salaries, undergraduate clinical placements and non-medical education and training. The plan is to replace it with an education and training levy on providers.

The BMA has always argued that the MPET should be ringfenced to prevent trusts raiding it for other purposes.

Doctors leaders believe any further levy should also be ringfenced by HEE, and come from a centrally imposed levy on all secondary and tertiary care providers.