Leading the medical education reforms

Authors: Ingrid Torjesen 

Publication date:  06 Nov 2012

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Ingrid Torjesen talks to Ian Cumming, Health Education England’s first chief executive, about the forthcoming changes to postgraduate medical education

“Health Education England exists for one reason alone, and that one reason is to improve the quality of care delivered to patients.” These are the words of Ian Cumming, chief executive of Health Education England (HEE), the organisation that will become responsible for the education, training, and professional development of all NHS healthcare staff from next year.

“We have to produce highly skilled, highly competent doctors in the right number in the different specialties to ensure that we can provide high quality care,” he adds.

Changes to medical education

On 1 April 2013 HEE will take over all of the workforce functions of the strategic health authorities and some of the Department of Health’s and will become responsible for leading the planning and development of the whole healthcare and public health workforce.

Commissioning of education and training will be devolved to local education and training boards (LETBs), which will include healthcare providers, as will the work of postgraduate deaneries. The role of HEE will be to oversee the standards of education and training and hold LETBs to account.

Cumming is quick to emphasise, however, that deaneries themselves are not being abolished, as initially set out in the white paper on workforce reforms; they are simply being subsumed into LETBs. “The deaneries are LETBs, LETBs are deaneries; they are one and the same thing. The same people will continue to deliver the same function,” he says. “At a local level every single one of the deaneries will continue to do what the deaneries do at the moment.

He adds, “Certainly with regard to the way that individual junior doctors interact through the training system there won’t be any changes,” although he qualifies that slightly by saying “no immediate” changes. “Until and unless we make a conscious decision to change something, nothing changes, that’s my first rule of managing the transition,” he emphasises.

Focusing on quality in a time of transition is something that Cumming is used to. For the past year this former chief executive of West Midlands Strategic Health Authority has been national director for quality at the Department of Health, responsible for keeping the NHS in England focused on quality after the clustering of the strategic health authorities in preparation for their abolition on 1 April.

The wider healthcare reorganisation isn’t the only backdrop to HEE’s work. There’s also the so called “Nicholson challenge”—the savings of £15bn to £20bn that the NHS is expected to make by 2014. “The running costs for HEE are going to be lower than the system that we are moving out of,” Cumming points out, and the staff will be smaller, because HEE, which will initially have a £5m budget (a big part of which will go on junior doctors’ salaries), has to take its share of management cost reductions as part of the challenge.

But he is confident that bringing the functions of several organisations together into one team will increase efficiency. “We’re not actually stopping doing things, and there is no intention that we should cut any programmes,” he emphasises.

Quality assurance

In future, trusts that host posts for medical trainees will have a much greater role in decisions about workforce planning and training because they will be actively involved with LETBs. This new role for trusts has concerned some in the medical profession, who believe the approach to be at odds with the primary functions of trusts as deliverers of services and as employers. They fear that training funds could be diverted to service provision and that any concerns raised about the quality of training in those organisations would not be dealt with adequately.

Employers will be involved in LETBs because it is important to take their views into account when assessing what the workforce demands and needs will be in the future, Cumming says, but he is adamant that he expects junior doctors in funded training posts to be trained. “[These doctors] are not delivering a service with training as an afterthought if there happens to be time,” he asserts.

“Each of our LETBs will have an annual agreement with HEE that is very clear about what their responsibilities are and what they have to deliver,” he adds. “The director of education and quality in each of our LETBs will be holding the providers of education and training to account and making sure that people are receiving the highest quality education and training.”

“Putting it bluntly, I will have to attend [the House of Commons] Public Accounts Committee and account to parliament for how we are spending money on the education and training agenda, not on the delivery of service agenda.”

Where concerns about the quality of training provided by a particular service provider are raised, that service provider would not be involved in the decision as to whether it retained its training posts, he promises. “If we have got poor standards of education, poor standards of training, we need to find a way of turning the tap off.”

And although LETBs will have responsibility for workforce planning at a local level, HEE will aggregate this information and combine it with information from sources such as the Centre for Workforce Intelligence, he says, to take a national perspective to ensure that the country as a whole is training the right workforce to meet future healthcare needs.

Private sector training

With more NHS services likely to be provided by private and third sector (voluntary and community) organisations in the future, Cumming expects some of these organisations to host medical training posts.

“Certainly for the foreseeable future the vast majority of our education and training is going to be delivered in NHS hospitals and GP primary care type settings, that’s a given, but I am absolutely not ruling that out, and would potentially want to look at the opportunities for training in all environments,” he says.

“If there is a unit in which we have got skilled, competent trainers delivering a service, we wouldn’t have a problem with training being delivered in that environment if the local people responsible for the quality of education believe it should be delivered there and it’s a good training opportunity,” he explains.

And he adds that this is a necessary step, considering the direction that the NHS is taking. “Turn the clock back a few years to when we had the start of the independent sector treatment centres. One of the challenges we had in those days was that clearly if those organisations were taking some of the easier cases—say orthopaedic—out of our local hospitals, yet not taking the training, it then actually became much harder to train people, particularly in the early stages [of their careers].”

Key benefits

So, what in Cumming’s view will be the main advantages of the new system? This will be the first time that the country has had an organisation that focuses on leading the education, training, and development agenda of all healthcare staff, he says, and that presents a “fantastic opportunity.”

“In addition to the work that we do with professionally qualified staff in the NHS, we want to have a real focus on the Agenda for Change [the banded pay system for non-medical NHS staff] bands 1 to 4—our support staff—because they are absolutely fundamental to the quality of care that we deliver. And in many parts of the country we don’t spend as much as we should do on their education and training and development needs,” he says.

But this is exactly the kind of change that has concerned the medical profession: a concern that resources for medical education and training could be diverted to other professions and the calibre of training for junior doctors watered down.

Cumming is eager to see more training of doctors alongside staff from other disciplines but is keen to avoid the “tokenism” whereby, particularly at undergraduate level, trainee doctors and nurses are thrown together for a lecture, often on a Friday afternoon, that “delivers absolutely nothing for the doctors and absolutely nothing for nurses, and in my mind doesn’t work.”

But he adds, “Clearly when everybody qualifies and starts working on a ward, or wherever it may be, they are working as a team. So I fundamentally do believe that we need to do much more in terms of getting people used to working together as a team before they end up in real jobs in the NHS.”

Rather than lectures focusing on the “softer skills” to a multidisciplinary audience, he wants to see more multidisciplinary problem solving exercises. For example, all the people on a trauma team, which would include the anaesthetist, specialist in emergency medicine, radiologist, nurses, and perhaps paramedics, could receive practical training on a real life clinical situation.

Final steps

With less than six months left to prepare before going fully live, HEE’s immediate priority is building the foundations of the organisation: recruiting staff and ensuring that the appropriate policies and procedures are in place and that the buildings are fit for purpose. “Our objective by 31 December is to confirm every single person in post for HEE and have sorted out all the employment type issues. Then we start to think about a very high level strategic plan for the first three years for HEE—what’s going to matter to us and how we prioritise,” Cumming says. Setting this plan will entail engaging with stakeholders from NHS organisations; partnership bodies such as the BMA, royal colleges, and the General Medical Council; and academic partners and stakeholders.

And when April comes, one or two things may be done quickly, Cumming reveals. “For example, I have a personal view that we should be interviewing every single person coming into university who aspires to be a doctor or nurse, because I don’t believe we can test interpersonal skills if you don’t.”

But for now, he says, “The absolute number one thing is safe transfer of functions so that nothing goes wrong.”

Competing interests: None declared.

Ingrid Torjesen freelance journalist London

 ingrid_torjesen@hotmail.com