Organisation of Postgraduate Medical Education

1 Organisation of Postgraduate Medical Education at the local education provider level A NACT UK Document April 2013 Registered Charity no. 295172 Supporting Excellence in Medical Education

2 Foreword This document has been updated by Liz Spencer and NACT UK Council from the original version published in August 2007. The original proposals generated significant discussion and much was implemented across the UK leading to some consistency of nomenclature and practice. Although the majority of the original document is still highly relevant some organisational changes have occurred which necessitated a review. It is timely to recirculate these proposals to clarify the role of the various stakeholders in postgraduate medical education and to continue discussions on developing a learning environment where high quality supervised workbased training is valued and occurs within service delivery and safe patient care. Different structures and funding arrangements exist in the four countries and also in the different regions within England; so not all the suggestions detailed here are relevant or appropriate. Attempting to compile a model to suit all specialties, in all organisations delivering Postgraduate Medical Education, in all regions of England and all countries of the United Kingdom, is predictably challenging. Over the last few years there have been many changes in the organisation and delivery of education and training ; the most recent being the creation of LETBs in England on 1st April 2013. The future of postgraduate training requires engagement with these bodies and involvement of educators with service reconfiguration. These proposals are offered as a starting point for discussion leading to an appropriate local solution. Dr Claire Mallinson Chair NACT UK Acknowledgements The original document was compiled following extensive discussions within NACT UK and many external bodies and individuals. We acknowledge in particular some individual Postgraduate & Undergraduate Deans, COPMeD, The Training Committee of PMETB, Specialty Training Committee of the Academy of Medical Royal Colleges, NAMEM, Medical Workforce Forum of NHS Employers and many Royal Colleges.

3 Organisation of Postgraduate Medical Education Table of contents Page number Executive Summary 4 Background 5 Department of Medical Education 7 Fig.1 Organisation chart of Medical Education Communication between Trust/Board & Postgraduate Dean 9 Fig. 2 Communication Wheel ; linking Trust to Postgraduate School Health Education England & LETBs 10 Conference of Postgraduate Medical Deans of the UK (COPMeD) Management of Foundation Programme 10 Management of Specialty Programmes 11 Fig.3 Professional Spine linking local tutors to Colleges 12 Primary Care & Mental Health 13 Faculty Development 14 Careers in Medical Education 15 Fig. 4: Pathway for career progression in PGME Quality Control 16 Revalidation for Doctors in Training Communication & Governance within the Organisation 17 Pastoral Support & Career Management 18 Undergraduate Medical Education 18 SAS, Trust doctors & Consultants 19 Clinical Skills / Simulation 19 Multi-professional Education 20 Finance 20 References 21

4 Executive Summary a. The purpose of this document is to suggest a terminology and structure that could be implemented, with local adjustment, in all parts of the United Kingdom. Standardization of nomenclature minimises confusion as trainees and trainers move between countries and regions and allows consistent data collection for quality assurance. b. In all Local Education Providers (LEPs) there should be i. a named Executive Director to represent medical education at Board level. ii. a named individual, the Director of Medical Education (DME), should be the Head of the Department of Medical Education, with appropriate resources, and be supported by a Medical Education Manager. This individual will be managerially responsible to the CEO in the LEP and professionally responsible to the postgraduate dean. c. Those leading on the delivery of Postgraduate Medical Education within a LEP should have clear roles and responsibilities and be appointed jointly by the DME and appropriate Specialty or Foundation School. They need support and leadership from their Training Programme Director / Head of School, the Postgraduate Dean and their team to ensure systems of delivery and quality control of training are consistent between specialties and across organisations. Clear lines of communication should exist between all those with leadership roles in Medical Education. d. The structure for medical education within a LEP should encompass medical students, doctors on recognised training programmes, all Trust posts, SAS doctors and Consultants. NHS appraisal, pastoral support and continuing professional development for all medical staff should be included. The organisation should identify resources to support the development of this structure. e. The requirements for education and training should be understood by LEP, integrated with service delivery and valued as part of the organisation s core business. Creating a local learning environment is beneficial for all members of the clinical team and provides high quality patient care. It leads to a competent motivated workforce with enhanced recruitment & retention and a culture of professional support within patient safety and clinical governance processes. f. The generic learning outcomes from clinical governance, complaints and patient groups should become integrated into medical education. The Director of Medical Education should support the organisation in complying with the Standards laid down by all External Regulators regarding the education, training, supervision and revalidation of all medical staff. g. Job Descriptions of all those involved in overseeing medical education and terms of reference of education committees can be found on the NACT UK website.

Background 1. Traditionally Postgraduate or Clinical Tutors were full-time consultants who received a sessional payment, to oversee the pre-registration year, the postgraduate centre and its staff and provide pastoral support to trainees and trainers. They were responsible for the local delivery of the Education Contract and provided the link between the Deanery and the Trust; representing the Trust in the Deanery and the Deanery in the Trust. The model was very similar in all 4 countries of the UK. 2. The introduction of the foundation and modernising specialty training programmes with an enhanced emphasis on quality management and external regulation have introduced new structures and systems around the management, delivery and quality control of training. A decade ago many Clinical Tutors had minimal involvement with specialty training or College visits, the role of the College Tutor was not valued by some departments or associated with the Clinical Tutor. Many of the new training programmes involve different specialties and require a corporate overview and liaison with Primary Care and Mental Health. 3. Terminology in the 4 countries and in the various regions of England is increasingly diverse. England, Wales and N.Ireland have Trusts which provide clinical service and PGME and Scotland has Boards. Deaneries in England are in a state of flux some have been dissolved, some maintain their title within the LETBs and many are multiprofessional. The role of the Postgraduate Dean has been clarified and remains. 4. Acute Trusts or Boards are now large organisations (30-60 F1s and 200-350 consultants) across multiple sites. They are increasingly being run as Businesses where national targets, financial balance and external regulation are the priority. The prime focus is the delivery of healthcare. Attitudes towards training and education, support and funding are variable. 5. Many Mental Health Trusts have separated from Acute Trusts, creating both opportunities and problems. Some resources remain shared such as libraries and education centres. Mental Health Trusts share the training of Foundation doctors, GP trainees & others and are responsible for the management of psychiatric specialty training. 6. Directors of Medical Education have replaced the Clinical Tutor to reflect their extended role beyond just overseeing the training of junior doctors. Their responsibilities now cover:- a. the training requirements detailed by the external regulators e.g. Care Quality Commission, GMC etc b. maintaining in new models of working e.g. Hospital at Night, Trust mergers & reconfiguration c. workforce planning issues d. training, approving and supporting trainers e. liaising with other leads in training and education to develop multi-professional education, training records, websites, e-learning, induction & mandatory training and knowledge management centres 7. The Educational Environment within the hospital has changed. Increased clinical workload and more complex systems & processes of delivery of patient care pull consultants away from supervising and teaching their trainees. Training of doctors has become more challenging as within a single department the trainees have diverse learning needs as they are on different training programmes, all of which have more rigorous requirements and are being led by different sections of the Deanery. Tutors use their personal, negotiating and persuasive skills to encourage colleagues to adopt the new requirements of the Foundation and Specialty Training Programmes. The new consultant contract has limited many consultants opportunities for getting involved in medical education. 8. There is now a clear structure for foundation and specialty training with a curriculum based approach and explicit framework of work-based assessments/learning events. The GMC approves named Educational and Clinical Supervisors, with clearly defined roles and responsibilities and lines of accountability. 5

9. The Foundation Programme received central funding, which enabled the appointment of Foundation Programme Directors/Tutors locally. In most places these come under the leadership of the Director of Medical Education and these individuals require education, support, annual appraisal and personal development. 10. There is an increase in medical students in most District Hospitals with an associated increase in undergraduate tutors and Lead Co-ordinators of student placements. The increased emphasis on the transition from final year into foundation training with Preparing for Professional Practice, shadowing programmes and NHS & Trust induction require the DME to liaise more with the medical school and undergraduate leads. 11. The Generic and Professional Skills aspect of the curricula of both the Foundation and Specialty Programmes may alter the type of educational provision required within Trusts. Increasingly, knowledge and skills are being dealt with in the work-place and the subjects covered by the Educational Programme provided centrally are more of a generic nature which requires a co-ordinated, cross-specialty and multidiscipline approach for delivery. 12. The recent focus on Clinical Skills, Simulation and Human Factor training require most hospitals to now provide some equipment and training staff to deliver the practical and communication aspects of the undergraduate and postgraduate curricula. 13. Historically the lines of communication have been confusing and variable between key players in PGME both within the hospital e.g. between College, Specialty and Clinical Tutors and between the hospital, specialty training committees and Postgraduate Dean. This needs to change as the GMC has stated that all organisations providing PGME must have clear structures for supporting medical training programmes, setting out responsibilities and accountabilities for training and for producing processes to address underperformance in medical training. 14. In April 2013 the SHAs in England cease to exist and will be replaced by Local Education and Training Boards (LETBs). The impact of this is not certain but it will require those involved locally in training and education to work collaboratively across professions. The English deaneries will become part of the LETBs. The contract for PGME is encorporated within the multi-professional Learning & Development Agreement (LDA) between the LETB and LEP. 15. In many hospitals there has been a large expansion in middle grade doctors due to the restrictions imposed by the Working Time Directive. Permanent middle-grade doctors are now referred to as SAS doctors (Specialty doctors and Associate Specialists) and Staff Grades have been encouraged to go onto the new Specialty doctor contract. However many of these middle-grade doctors have fixed-term contracts of 6 or 12 months and are called Trust posts or Fellows and receive little pastoral or educational support. 16. Consultants, particularly new consultants, need mentoring, developing and supporting during their consultant career. They have training needs e.g. leadership and management, training the trainers, understanding the appraisal and revalidation processes etc The medical director in large merged organisations where finance and targets are the priority is distracted from this important role of supporting and developing the expanding body of permanent medical staff. In some organisations many of these roles are undertaken, either officially or unofficially, by the Director of Medical Education. 17. The provision of postgraduate medical training is a responsibility of the Trust/Board and requires a Director of Medical Education to ensure its delivery to the required standards and to represent medical education in the future multiprofessional environment 18. Professionalising medical education requires the creation of a structure in all organisations delivering PGME with clearly defined responsibilities and lines of accountability of all involved. 6

Department of Medical Education 19. In large merged organisations, the delivery of postgraduate medical education to about 300-400 trainees, on almost 20 structured training programmes, needs to be well organised and co-ordinated to ensure robust education, high quality safe patient care and wise use of limited resources. 20. The GMC has stated that in all organisations with postgraduate trainees (Acute & Mental Health Trusts and independent treatment centres), there should be a named individual responsible for ensuring the delivery of high quality postgraduate medical education and training. This individual will be referred to in this document as the Director of Medical Education or DME. The DME should provide professional leadership and vision for the organisation on medical education issues and develop and monitor a local medical and dental education strategy. The DME should work closely with the Postgraduate Dean and Specialty Schools/Boards to develop tutors and educational supervisors, ensure sharing of good practice between specialties and to deliver the wider educational agenda. 21. The DME should be appointed jointly by the CEO of the Trust and the Postgraduate Dean. The DME should be assisted by one or more Deputies as necessary depending on the size of the organisation. 22. The DME should be involved in the appointment of all those engaged in the delivery of PGME locally e.g. Foundation Programme Tutors/Directors, Programme Tutors and College/Specialty Tutors etc. The number and configuration of tutors will depend on the size of the organisation, number of hospital sites and distance between sites. The current Clinical Tutor funding could be used to create an appropriate local model. All tutors should have clear roles & responsibilities and be accountable for them to the DME see Fig. 1. 23. The Department of Medical Education is led by the DME and managed by the Medical Education Manager and a team of administrative staff. The Medical Education Manager should be appointed by and be accountable to the DME. They are responsible for the recruitment and management of their administrative staff, overseeing the educational facilities and work closely with medical staffing, the library service and other trainers locally. They liaise with the Deanery Administrative Team and other regional and national colleagues via the National Association of Medical Education Managers (NAMEM). 24. Where PGME is delivered in several hospitals within one Trust attempts should be made to merge medical education systems across sites, with unified policies & procedures and cross-site working to ensure a sense of cohesiveness and sharing of best practice. This may entail a change in roles of tutors and administrators. 25. Educational structures within Mental Health may need to be organised differently as there is only one Speciality per Trust, with relatively few post-graduate trainees at each hospital and often large geographical areas. Whereas all the structures above need to be replicated within each Mental Health Trust, on a smaller scale, many Mental Health economies may wish to create a virtual post-graduate centre, serving all the various localities where trainees work, managing study-leave budgets, mandatory training, ARCPs, rotation logistics and other Post-Graduate services for all trainees irrespective of programme. 26. The PGME budget should be managed by the Medical Education Manager to ensure the specific training needs of these medical postgraduate students are met. Wherever possible training should be delivered locally and across individual specialties. 27. Medical education is delivered in Acute, Mental Health, Community and Primary Care Trusts. PGME staff in each area should work closely with each other to ensure that the expertise of trainers and the experiences of trainees are known, documented and shared. A number of competencies and learning opportunities are common across these areas and the tutors & PGME staff need to ensure that there is regular communication throughout. 7

8 Postgraduate Dean Identified Director/Chief Executive Director of Quality & Clinical Governance Multi-professional Education Leads Clinical Skills / Simulation Lead Postgraduate Schools Foundation School Specialty Schools GP School Specialty Tutors Director of Medical Education Undergraduate Lead Medical Education Leads of other LEPs, Mental Health, GP Tutors etc Programme Tutors Foundation Core Medical Training Core Surgical Training ACCS Medical Education Manager SAS Tutor Working relationship Line management Postgraduate & Undergraduate Administration Fig. 1: Organisation Chart for Department of Medical Education

Communications between Trust/Board and the Postgraduate Dean 28. The DME and team require leadership, direction and support from the Postgraduate Dean and team. The Postgraduate Dean should meet regularly with the local DMEs to hear the challenges of the workplace, inform and involve them in strategy and ensure collaborative working across provider organisations. The new LETB structures in England incorporate the Deanery and the role of the Postgraduate Dean is changing into a more multidisciplinary role. In some areas the Postgraduate Dean has become the Director of Quality (DEQ) of the LETB. The regional DMEs should ensure representation on the LETB to promote PGME. 29. Clear lines of communication must exist between the LEP and the Postgraduate Schools/boards. Fig. 2 demonstrates how College/Specialty Tutors are the link between the Specialty Training Committee and Training Programme Directors at the Deanery and the Medical Education Committee, Director of Medical Education in the Organisation. Consideration should be made to include a DME on School Boards. 9 Fig. 2: Communication Wheel; linking Trust to Postgraduate Schools. The College/Specialty Tutors communicate with their Training Programme Director at Deanery level (blue) via the Specialty Training Committee and with the Organisation (red) via the Medical Education Committee.

Health Education England & Local Education & Training Boards 30. Health Education England (HEE) was created out of the previous Medical Education England and is responsible for the education, training and professional development of all NHS healthcare staff. Commissioning of education and training will be devolved to LETBs. HEEs will oversee the standards of education and training and hold LETBs to account. 31. HEE is responsible for leading the planning and development of the whole healthcare and public workforce. Although LETB 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 to provide a national perspective ensuring that the country as a whole is training the right workforce to meet future healthcare needs. 32. There are a similar number of Local Education & Training Boards (LETBs) as previous Strategic Health Authorities with a very similar geographical coverage. A LETB will include the deanery and all LEPs it is anticipated that many of the private and third sector organisations providing healthcare will become education providers and host medical training posts in the future. 33. The Director of Education & Quality (in many areas this is the Postgraduate Dean) of the LETB will be responsible for the quality management of education and training and will be holding the LEPs to account. 10 Conference of Postgraduate Medical Deans of the UK (COPMeD) 34. COPMeD represents the Postgraduate Deans and LETBs within the UK including Dental Deans and General Practice Deans/Directors. COPMeD s aims include managing the delivery and outcomes of postgraduate medical and dental education to the highest possible standards and to ensure that these standards are comparable across the UK. 35. COPMeD meets quarterly to discuss issues of a UK-wide nature. English Deans meets more frequently to maintain consistency as the LETBs are created across England. The variation in geographical size determines a differing model between organisations; the model being developed in London is of necessity different to that adopted by most provincial deaneries. The important aim of maintaining and promoting equivalent high quality specialty training in all 4 countries in the UK remains a principle. Management of the Foundation Programme 36. The Foundation Programme involves the whole local healthcare community and encompasses Primary Care, Mental Health, and the Acute Trust. One of the Trusts (usually the Acute Trust) should host the Foundation Programme, have overarching operational management of the programme, receive management funds from the Deanery/LETB, employ the trainees, manage the study leave and expenses. A Foundation Programme Committee is responsible for the local management, development and quality control of the Foundation Programme. 37. Foundation Programme Directors/Tutors should be jointly appointed by the DME of the Host Trust and the Deanery Foundation School and are managerially responsible to the DME. They are developed and supported in their role by both the Foundation School Director and by the DME. There should be one session of Tutor time per 30 Foundation Trainees. They should have dedicated time in their job plan and they (or their department) should be reimbursed for this role. Job descriptions are available from The Foundation Programme Reference Guide. 38. One of the Medical Education Administrative Team should be identified to support the Foundation Programme Tutors and trainees and liaise with the Deanery-based Foundation School. There should be sufficient managerial, secretarial and IT support provided.

39. Foundation Programme Tutors should be accountable to the DME of the Host Trust but liaise professionally with the Foundation School. They should attend Foundation School meetings, feeding back locally via the Foundation Programme Committee. 40. The education programme, portfolio, system of end of year sign-off, educational supervision and career advice should be agreed collaboratively between the Foundation School and local organisations delivering the Foundation Programme. 11 Management of the Specialty Training Programmes 41. The Trust is responsible, via the Education Contract, for the delivery of all specialty training programmes within the organisation and should, via the DME,:- a. create a structure locally to ensure that specialty training happens according to the requirements of the programme b. support College/Specialty Tutors and Supervisors in their role c. ensure communication between College/Specialty tutors to share good practices between specialties. There should be a Medical Education Committee Fig. 2. 42. Postgraduate Schools/Boards have been created jointly by Deanery and College. The Head of School is supported by various Training Programme Directors (TPDs) who have a Specialty Training Committee (STC) for each specialty programme. In the Trust each specialty requires an educational lead for local co-ordination, for communication with STC within the Postgraduate School and to be responsible for ensuring the quality control of the programme. These are College/Specialty Tutors. Fig. 2 demonstrates this relationship. (It is acknowledged that certain specialties wish to retain the term College Tutor, and that in certain specialties e.g. pathology the College Tutor has CPD responsibilities.) 43. For the Core Programmes, e.g. Core Medical Training (CMT), Core Surgical Training (CST) & Acute Care Common Stem (ACCS), there may be a TPD in the Deanery structures. At Trust level there should be a nominated Tutor to co-ordinate these two-year programmes; this may be one of the College/Specialty Tutors or for large programmes a designated Programme Tutor. In Mental Health Trusts these Tutors may overarch several Trusts to maximise and tailor educational opportunities 44. The appointment of these local tutors should be in line with the principles laid down by the Academy of Medical Royal Colleges paper ie. a joint appointment by the Trust and the specialty. They are managerially accountable to the local DME and professionally responsible to the Postgraduate School for the delivery of their programme. 45. Specialty Training Programmes are managed regionally in Postgraduate Schools/boards and delivered locally in the individual Trusts and departments. All Programme and College/Specialty Tutors should have strong professional links to their specialty schools (or boards) within the Deanery structures and centrally with the relevant College or Specialty Society. The Colleges should continue to provide guidance and advice on issues around education and training. Fig. Three demonstrates that professional communication occurs from the clinicians locally to their respective specialty body. This enables specialty training to be strong, relevant and owned by the profession; depicted by the professional spine. 46. The College/Specialty Tutors should ensure that the educational, pastoral & career planning needs of all trainees in the department are addressed and that those involved in supervising and assessing trainees understand their role in and the requirements of the specific programme for their trainee see The Gold Guide. 47. Supporting a trainee in difficulty may necessitate a collaborative approach involving local expertise e.g. DME, Medical Director, HR etc and School / Deanery expertise e.g. Trainee Support Unit. The complex nature of these issues necessitates an individual approach but meetings should be clearly documented and collated.

12 Centre HEE Academy of MRCs Royal Colleges Specialist Societies Region LETB COPMED Postgraduate Dean Specialty Schools Local Education Provider NACT UK Director of Medical Education Specialty / College Tutors Fig 3: Professional Spine linking local tutors to Colleges. Specialty Training programmes, as designed by the Colleges and approved by GMC, are delivered and quality managed via Deanery and local organisation structures. Strong professional relationships exist naturally between local Specialty Tutors in the LEP with their Postgraduate Schools/Specialty committees regionally and their College/Specialist Society centrally messages pass up and down the vertical professional spine by reflex. Overseen by our professional regulator the GMC. Accountability / performance management of individuals occurs horizontally at local provider or Deanery level; answerable ultimately to HEE in England.

Primary Care 48. The inclusion of Primary Care in the Foundation Programme as well as the significant increase in GP trainee numbers and associated hospital-based Clinical Supervisors requires regular communication between the local GP Tutors & School and the DME & team of tutors. Suitable representation from the GP Education Team is required on both the Foundation Committee and the Medical Education Committee. 49. The model of supervision will be determined locally by the Programme Organiser but is likely to be one educational supervisor, a GP Trainer, for the 3 year programme. There should be a named clinical supervisor for each hospital-based placement. The requirements for ST1 and ST2 are defined in the curriculum and the GP Training Programme Organiser should liaise with the clinical supervisors to ensure they understand their role within the programme and the assessment framework. 50. The MEM and administrative staff should support the GP programme management and locally delivered educational activities but may require financial negotiations with the GP School for this work. 51. The DME should work closely with the GP Tutor/Team on areas of common interest regarding permanent medical staff such as Faculty Development, Peer Appraisal and Mentor Schemes and generic skills such as leadership & management. The DME and MEM should encourage and facilitate CPD activities for GPs within the hospital setting. 13 Mental Health 52. The inclusion of Mental Health in the Foundation Programme requires communication between the Mental Health DME and the DME responsible for overseeing the Programme. Suitable representation from the Mental Health Team is required on the Foundation Committee. 53. Mental Health Training Schemes are often arranged across a wide geographical area, where trainees may access educational opportunities right across the Deanery. DMEs of Mental Health Trusts should work collaboratively with Deanery-wide educational structures to ensure smooth transition of trainees between settings and Trusts, and to assist in overall manpower planning. 54. PGME administrative structures are likely to be required both within-trust and between- Trust structures. In many cases these are in an early stage of implementation, but there needs to be clarity about individual roles and responsibilities. 55. Finance negotiations with Deaneries relating to the development of independent psychiatric PGME centres are at an early stage. Mental Health Trusts need to consider the possibility of PGME Centres and facilities across several adjacent Trusts. They (MHT) also need to have explicit arrangements with Acute Trusts about access to libraries and educational facilities. 56. Mental Health and Acute DMEs should work closely on areas of common interest regarding permanent medical staff such as Faculty Development, Appraisal and Mentor Schemes and to facilitate CPD activities for Doctors within their respective settings. 57. Mental Health DMEs should explore the possibilities of shared educational opportunities with other Mental Health Trusts, such as Medical Student & trainee induction, basic skills training and mandatory training for CNST requirements.

Faculty Development 58. Modernising Medical Careers (MMC) requires a curriculum based approach to postgraduate training with identified learning objectives, personalised job planning, constructive regular feedback and work-based assessments. This requires departments business managers and individual consultants to be aware of the change in culture required to ensure maximum learning in a shortened training programme and a Working Time Directive (WTD) compliant 48hour week. Both MMC and WTD challenge the apprentice model, which can be maintained if all involved utilise every learning opportunity. The DME and team should take every opportunity to inform departments, clinical teams, and individual consultants and trainees of these changes to alter attitudes to learning & training. 59. An Educational Supervisor is the named practitioner who is overseeing the educational requirements, achievements and personal & professional development of an individual trainee during that post/placement/programme (to be defined locally). They are responsible for performing all Appraisals - both educational and the annual NHS Appraisal. They require protected time clearly identified in their job plan, usually as SPA time 0.25 PA per trainee. 60. A Clinical Supervisor is the named clinician responsible for overseeing the clinical performance of an individual trainee within a clinical placement. They are responsible for observing practice, performing work-based assessments and providing feedback. They require time within their clinical workload for these tasks and it is important that the department s business managers are aware of these requirements. 61. The GMC has published Standards for Training in The Trainee Doctor and has recently set out a plan for recognition of Educational and Clinical Supervisors in PGME. Local systems should be in place by July 2013, which will be recognised by the GMC in July 2016. This has led to various Train the Trainer and Faculty Development courses being delivered at both Deanery and Hospital level. 62. The LEP should have a database of clinicians experienced/trained in educational and clinical supervision and record attendance at meetings, faculty development programmes and mandatory supervisor training. The DME should support all Tutors and Supervisors as necessary and help them to develop in their educational role. 63. Clinical Supervision, particularly of more junior trainees, is provided by the multiprofessional clinical team which includes other consultants, SAS doctors, more senior registrars, senior nurses, pharmacists etc who should all understand their role in supporting, assessing and giving feedback to junior doctors. Feedback from the team, on the doctor s clinical performance, should be collated by the Clinical Supervisor; the Placement Supervision Group in the Foundation Programme is one way of achieving this. 64. Trainees are required to undertake reflective practice, self-directed learning, identify learning needs and set their own learning objectives. Supervisors may require help developing their trainees in these areas. 65. Trainees should be involved in the learning process of others. Training opportunities should be provided for Specialty Registrars in assessment, appraisal and giving feedback. 66. Trainees should be involved in the management of training programmes and representatives invited to attend the Foundation Programme Committee and Medical Education Committee. 14

Careers in Medical Education 67. There has been no clear structure of career progression for those wishing to develop themselves in the area of medical education. Clarity of roles and the creation of Job Descriptions and Person Specifications provide, for the first time, an opportunity to provide this guidance. Fig. 4 details a suggested pathway. 68. Career management is increasingly being discussed at all levels. The structured training programmes result in doctors acquiring specialty status and consultant appointment at a younger age than previously. This type of pathway enables career planning through the Consultant years. 15 Director of Medical Education Trust/division Postgraduate Dean Deanery Deputy Director of Medical Education Trust/division Associate Dean or Head of School Deanery Training Programme Director Deanery Programme Tutor (CMT/FP etc.) Trust/division Specialty Tutor Trust/division Education Supervisor Trust/division Fig. 4: Demonstrating a pathway for career progression in Postgraduate Medical Education

Quality Control 69. All postgraduate medical training programmes require information/evidence to be collected to demonstrate compliance of the programme to the GMC standards detailed in The Trainee Doctor. The GMC has the responsibility for quality assurance of PGME and expects the Postgraduate Deans to have quality management processes in place to ensure that local quality control by the LEP of the training delivered is robust, aligned with the multiprofessional agenda and adheres to the GMC standards. 70. Deanery inspections are likely to concentrate the Trainee & Trainer Surveys, the quality control information and the outcome of training e.g. assessments, progression etc. Feedback to LEPs and departments will lead to an action plan which should be monitored. 71. Local quality control should be transparent and accountable. Trusts and departments should demonstrate a high level of commitment to their quality of training, be encouraged to monitor their own performance and aim to increase the quality of training as well as ensuring that it meets national standards. This requires a co-ordinated approach across both specialties and programmes, and Specialty Tutors may need support with these tasks. 72. There must be a well-defined governance structure within the Trust/Board to ensure that trainees are incorporated into and adhere to the national and local policies and procedures which govern all aspects of their employment. 73. Trainees must be encouraged to engage with the educational process (manage their own training) and comply with both employers and deanery quality management processes (attend induction & mandatory training, complete GMC Trainee Survey & required training evaluations, attend Deanery & School QA visits & interviews etc). 74. Robust processes should be in place for the support and management of trainees whose conduct, health, progress or performance is giving rise for concern. Individual educational supervisors may require guidance by Tutors/DME. Local guidelines should be available (see NACT UK Managing Doctors in Difficulty) and support from the Deanery, Occupational Health, Human Resources and NCAS as necessary. The DME should be available to advise on individual cases. 16 Revalidation for Doctors in Training 75. Different models exist in the 4 countries as to exactly who is the Responsible Officer (RO) for trainees and details are available from the GMC website. In essence a doctor in training who is satisfactorily engaged in meeting their curriculum and assessment requirements and participating in the ARCP process will be recommended for revalidation by their RO. 76. Triangulation of the information provided in the trainee s portfolio concerning serious incidents/events and complaints/concerns is necessary and systems are under development within LEPs to collate individual incidents for reporting back to the Deanery. 77. Educational Supervisors should be reviewing the trainee s achievements and progress during regular appraisals. The trainee should declare any involvement in any untoward incident or complaint, reflect on it in their portfolio and raise it for discussion at appraisal. The Supervisor should objectively document the discussion in the portfolio and on the Educational Supervisor Report which is essential information for the individual s ARCP.

17 The Place of Medical Education within the Organisation 78. The GMC has stated that in all organisations with postgraduate trainees (Acute & Mental Health Trusts and independent treatment centres) there should be a named Executive Director representing medical education on the Board. Several Trusts have now included medical and dental training under their HR/Training & Development Directorates, thus taking forward their Multi-professional educational agenda. Other Trusts have a Department of Medical Education under the Medical Director. The exact model/structure is not important, however a knowledgeable informed Director at Board level, representing medical education, is essential to ensure that the required standards and outcomes are achieved and the delivery of high quality medical education and training is supported by the Trust. 79. The organisation should value the delivery of high quality education and training and integrate it within Clinical departments so that training becomes part of the Trust s Core Business. Clinical Directors should work closely with College / Specialty Tutors to ensure the correct balance between trainers having time to supervise & assess trainees whilst managing patients in the clinical area. This collaborative working is especially important with the current service reconfiguration to maintain the training provision. The role of the Specialty & Programme Tutors should be valued and respected within the department and education should be on the agenda for all Directorate/Division meetings. Regulation should be seen as a means to improve practice and not a tick-box. 80. The DME should support the organisation to demonstrate compliance with the Standards laid down by External Regulators regarding the education and training of medical staff. The DME should be a member of the Clinical Risk/Governance Committee and co-ordinate information required by the Deanery and for other purposes e.g. CQC. 81. Close working relationships should exist both centrally and within departments; between the PGME staff and those involved in the management and administration of training in other disciplines e.g. training department, clinical skills, nurse & AHP education etc. There should be a Multi-Professional Education Committee, chaired by an Executive Director, dealing with both training and workforce issues and linking into the LETB. 82. PGME staff should work closely with Medical Staffing and the HR department, assisting with recruitment and induction. There should be a shared database across the sites within the organisation and into the Deanery. In some areas the Lead Employer model is being adopted for doctors on short rotational placements to reduce the personnel burden. 83. The DME should be involved within the organisation in looking at different models of working e.g. Hospital at Night. Although the firm structure is difficult to sustain with shift working, the development of multi-professional clinical teams and the creation of a supportive learning climate can assist the trainee in maximising all learning opportunities. Appropriate supervision, handover and the opportunity for post-night debrief can help to make the most of learning opportunities at night. Whereas Medical Staffing should ensure the rotas are WTD complaint, the DME should ensure that they are educationally acceptable. It is recommended that no less than 70% of total hours worked should be daytime hours for the post to be suitable for training. 84. Suggesting new ways of working creates training needs for the individuals who take on these expanded roles. This may be nurses expanding their role or it may be doctors requiring specific training for their role in the night team e.g. leadership skills. Much of this training needs to be done locally by doctors.

Pastoral Support 85. The loss of the firm structure, hospital accommodation and, in many places, the doctors mess has reduced the ad-hoc peer support of particularly junior trainees. Active alertness to signs of stress in trainees is a responsibility of all members of the multi-disciplinary team. A system of pastoral support for trainees should be available within the programme, directorate or Trust and trainees informed at induction how they can access it. A mentor or buddy scheme may be in place and accessed either as a routine or when required. The Postgraduate/Clinical Tutor Role of providing trainee support outside the individual s department has been a successful model and should not be lost due to the creation of the DME and the more robust structures of PGME. 86. All tutors may require support at some stage when faced with challenges from individual trainees, pressure from management/service delivery, dealing with difficult educational supervisors etc. There should be a culture created to encourage assistance and help from the DME and Deanery as required. This is increasingly necessary as we move into a culture of appeal, criticism and even legal action. 87. Support networks for both trainees and trainers could extend outside the Acute Trust with links to Mental Health and Primary Care Trusts. 18 Career Management 88. All medical students, trainees and permanent medical staff require assistance with their career management and planning. For the majority this can be managed at appraisal, although education supervisors and peer appraisers may need guidance and assistance with regard to what additional resources are available and how to access them. 89. All organisations should have a named individual co-ordinating Careers Advice who should have received training for the role. He/she should be supported by Careers Advice processes at the Deanery, and should be consulted as necessary, particularly by Foundation trainees who are having difficulty selecting a specialty. 90. Career management sessions should be part of both Undergraduate and Foundation Programme teaching sessions. The training departments within the Trust should have resources which can be accessed to assist with this. Undergraduate Medical Education 91. Most District Hospitals have seen a significant increase in medical students and require a structure for managing undergraduate education with links to the local Medical School. It is suggested that this structure is managed under the umbrella of the Director of Medical Education to ensure close collaboration and joint working. 92. The Lead for Undergraduate Medical Education within the Organisation should work closely with the Director of Medical Education on faculty development, clinical skills and be involved with the Foundation Programme & Medical Education Committees. He/she should liaise with those leading on pre-registration courses in other health professions, identify opportunities for inter-professional learning and attend the Multi-professional Education Committee. 93. Resources for undergraduate education should be considered with those available for postgraduate medical education to merge the faculty responsibilities for the delivery of both undergraduate and postgraduate training at departmental level. 94. The DME and Foundation Programme Tutors should work with the Undergraduate Leads to support medical students with career guidance, preparation for the Foundation Programme and their individual career management.

SAS and Trust Doctors 95. A SAS Tutor should be appointed by the DME to oversee the education and continuing professional development of the SAS doctors, which includes Associate Specialists, Staff Grade and Specialty Doctors. Support should also be provided for fixed-term Trust post doctors either by the SAS Tutor or by Specialty Tutors within each department. 96. Finance has been given in England & Wales for the professional development of the SAS doctors in leadership, assertiveness, teaching etc. Courses are provided as well as individual support with mentoring and coaching. All Deaneries now have an Associate Dean (or equivalent) to oversee the SAS budget and assist the SAS tutors. Those performing SAS doctor Appraisal should be made aware of the opportunities available to ensure SAS doctor engagement and uptake. 97. Doctors wishing to be considered for entry to the Specialist Register via CESR should be supported with a named Educational Supervisor to ensure regular review and assistance to collect the relevant evidence required for their application. Resources are available from the SAS Tutor and from the Deanery to assist with this. 19 Consultants 98. The DME should be involved in overseeing the education and continuing professional development of Consultants. a. Although the Medical Director is responsible for establishing a system of NHS appraisal the DME should be involved in the process, to help educate doctors how to prepare for appraisal, develop their portfolio and achieve their personal development needs. They may assist with the training of the Appraisers, facilitating the Appraiser Support Group and in the QA of the process. b. Study Leave and resources should be available to ensure that consultants are able to satisfy their specialty requirements and for achieving professional development in line with Trust and department requirements. c. Those taking on Specialty Tutor and Educational/Clinical Supervisor roles require initial training and on-going educational development and support. Local courses and meetings should be arranged to inform and motivate consultants and other senior members of the multi-professional clinical team in their role of providing supervision, assessment and teaching. d. New consultants should be offered a mentor and taught leadership skills. Clinical Skills / Simulation 99. The leadership of simulation within any organisation should be clearly aligned with the other educational structures present within that organisation. It requires liaison with a great deal of established working groups, across a number of professional and inter-disciplinary borders. In view of this it is important that the holder of this post is not obviously identified with one professional or speciality group. The role requires skills in education and in management of a service. It is difficult to achieve for the busy clinician without appropriate administrative support and time within their job plan

Multi-professional Education and Training 100. PGME is now the remit of the LETBs in England, NES in Scotland, WAG in Wales and NIMTDA in Northern Ireland. In England there is a Multi-professional Learning and Development Agreement between the LETBs and the LEPs. Those involved in medical education will need to work closely with Training Leads in other professions e.g. Nursing and AHP Education as well as within the organisation i.e. Lead for Training, Lead for Leadership and Organisational Development etc. There should be a Multi-professional Education Committee chaired by a Board member. Membership and Terms of Reference of such a committee are suggested on the NACT UK website. 101. The opening in many areas of Multi-professional Education Centres has led to the loss of control by PGME over room access and reduced opportunities for income generation. This together with the recent reduction in MADEL has caused many PGME departments to suffer financial difficulties. A co-ordinated multi-professional approach to the LETB for funds is likely to be more successful than individual bids. (not applicable in Scotland) 102. The current provision of educational opportunities should be mapped across specialties and disciplines. Collaborative programmes and opportunities for development should be identified both within the Acute Trust and with partner organisations such as Mental Health and Primary Care. The more explicit curriculum in professional and generic skills, in both foundation and specialty curriculum, creates these opportunities. 103. The new specialty programmes emphasize work-place learning opportunities and the clinical team should be engaged in facilitating this to the benefit of all within the team regardless of discipline. The recent emphasis on Multi-disciplinary Team meetings (MDT) are an example of case based learning opportunities. This supports the culture of a learning environment in organisations involved in training and education. 20 Finance 104. Historically Clinical Tutors received One PA of pay (most as Additional Responsibility Allowance) in their salary direct from the Trust to ensure the satisfactory delivery of the Education Contract as well as one session paid by the Deanery from MADEL. The appointment of DMEs has varied considerably around the countries, deaneries and LEPs regarding the financial contribution made by the Trusts. DMEs are leaders of medical education and do duties outside their prime responsibilities of delivering the Deanery Education Contract and are, for a variety of reasons, used as an educational expert by the Trust. The suggested remuneration to oversee specialty trainees is one PA per 30 trainees - funded jointly by Deanery and Trust. The funds should be placed in the Postgraduate Budget to be used by DME to create a local fit for purpose structure. 105. If the DME is expected to oversee the professional development, study leave, appraisal and mentor process for Consultants additional funds of One PA per 100 consultants, should be made available from the Trust. 106. Arrangements for undergraduate support should already be available from the SIFT budget.