Introduction
1. To inform discussion and seek the views of stakeholders, this paper sets out three options for addressing the issue of over-subscription to the Foundation Programme – but unlike previous options appraisals on this issue, simultaneously takes account of the overlapping priorities around enhancing quality and patient safety and developing the UK growth agenda with respect to international medical students.
Background
2. The HEE Mandate includes the following commitment:
“HEE must ensure that medical trainees who are competent and able to complete training programmes successfully are supported to secure full registration.
The existing system needs reform, so that there is a clear and sustainable path which enables all suitable graduates to secure full GMC registration. Department of Health and HEE will work with partners, including the other UK health departments, the GMC, medical schools, employers and trainees to set out a reformed approach by autumn 2013 with a view to an introduction in autumn 2014. This objective will be updated to reflect progress when the mandate is refreshed in autumn 2013.”
3. In other words, a solution is required to the issue of the predicted continued over-subscription to the Foundation Programme. Most stakeholders agree there is a “moral obligation” to ensure that all graduates of UK medical schools have the opportunity to obtain full registration with the GMC (by successfully completing the first year of the Foundation Programme) so that they are able to practise medicine in the UK and progress their training . However, how this can be delivered is complex and, despite considerable debate, has yet to be resolved. Department of Health and Health Education England officials have been consulting with stakeholders to discuss a range of options, but none of these provides a straightforward solution and there is a lack of consensus on the best way to take this forward.
4. In these discussions, it also became clear that this should not be considered in isolation as there were overlaps with other key issues – in particular:
- the patient safety and quality agenda – this questions why there should be an aim to fund places for all, including the lowest ranked and by definition least suitable, applicants; and
- there are potential benefits to “UK-plc” in encouraging more international students to study at UK medical schools. However, under the current system, this runs counter to the aim of ensuring all graduates of UK medical schools obtain a place on the Foundation Programme as it increases the competition for such places.
UK Dimension
5. Postgraduate medical training, including the Foundation Programme, is organised and regulated on a UK-wide basis. Consequently, although HEE is leading work on this issue, a UK-wide solution is sought and there will be appropriate consultation and discussion with partners in the other UK Administrations.
Context – scoping the issues
Foundation over-subscription
6. The Foundation Programme was over-subscribed in 2013 – to ensure all eligible applicants were placed and the “moral obligation” met, HEE and the Devolved Administrations agreed to fund the creation of (around 160) additional programmes to meet demand.
7. Firm predictions of future demand are difficult as a number of factors could influence the final position, but based on best estimates such over-subscription is expected to continue for at least the next three years.
8. This may change over the longer term as medical school intakes have been reduced (by 2% in England and 6% in Scotland) and there is now more robust pressure to ensure medical schools do not exceed their intake targets (as happened in previous years).
9. On the other hand, demand may rise as a result of:
- increased numbers of applications from graduates of EEA medical schools – particularly given EEA expansion and economic difficulties in some Member States;
- the result of an Employment Tribunal appeal (due on 2 October) – if DH loses, eligibility to apply to Foundation training would be extended to graduates of medical schools in a further 16 EEA nations and any fully registered doctor; and
- the possible development of private medical schools in the UK (the GMC is considering proposals (currently at different stages) from the Universities of Buckinghamshire, Central Lancashire and Aston) and other schemes involving UK medical schools in partnership with overseas Faculties. If these prove successful there may be more in the longer term, which would make a commitment to create Foundation places for all graduates unrealistic.
HEE Options Paper on Over-subscription to the Foundation Programme – response from the Royal College of Physicians of Edinburgh to the Scottish Government
The Royal College of Physicians of Edinburgh has contributed significant evidence to the Shape of Training review and understands that the imminent report is likely to make recommendations relating to the point of registration. It is important that the decision about registration, which may well be among the more controversial in the report, is not made in isolation of other recommended changes in training.
Moving registration to the current point of graduation will help to resolve the communication and supervision challenges that are developing as more graduates move from their home medical school for foundation training. However it is a somewhat cynical resolution to the “moral obligation” to allow undergraduates to complete their training; the inevitable attrition as lesser able students fail to achieve foundation places may still result in retention problems later if the more able (including international) trainees leave the UK.
Doctors passing through the foundation programme successfully will go on to specialist training posts and some will opt for SAS type roles but it is unclear what posts would be available for registered doctors without the benefit of foundation training and whether they would be able to reapply. This implies that to stay in medicine, UK resident medical graduates failing to achieve foundation places would have to move abroad. It is unclear how this would bring benefit to “UK plc”.
The College believes that all students accepted into UK Medical Schools should be enabled to complete their training to the end of the foundation programme (FY2). The UK must not deter high quality applicants from applying to medical school by making career prospects look unreasonably bleak at the end of a long and expensive undergraduate course. Medical schools must also be challenged to balance numbers admitted with the capacity of the UK to deliver foundation training.
The patient safety issues of bringing forward registration should not be understated in terms of the demands on medical schools to change their curricula and to develop transition placements towards the end of the undergraduate course to ensure the clinical competence of their graduates. The options paper leans more towards capacity than patient safety and quality of care which is of prime concern to the College.
The challenge of developing and piloting an effective national screening examination will be significant and delay implementation, leaving the NHS with the over supply problem in the interim unless further effort is made to generate training capacity.
Lifting the cap on international students, whilst attractive commercially and possibly for global influence, runs the real risk of excluding perfectly adequate UK graduates who have invested in their education and are more likely to remain in the UK and the NHS following training. Poorly performing undergraduates should be identified early and supported to improve or helped to move into more appropriate careers. This would reduce waste. Also encouraging overseas applicants into foundation training will be unpredictable and introduce yet more volatility into the system.
Given the vagaries of workforce planning generally, and the drop in medical student numbers (particularly in Scotland) the College believes it would be more sensible in the shorter term to ‘manage the current system better’ (option 3).
RCPE, 29th October 2013