Final report: Barts and the London School of Medicine and Dentistry (Queen Mary University of London) Malta MBBS programme Barts and the London School of Medicine and Dentistry Malta MBBS programme This visit is part of the GMC's remit to ensure medical schools are complying with the standards and outcomes as set out in Promoting Excellence: standards for medical education and training. For more information on these standards please see: Promoting Excellence: standards for medical education and training Review at a glance About the School Medical school University Dates of visit Barts and the London School of Medicine and Dentistry Queen Mary University of London 7 March 2017 London 14, 15, 16 March 2017 Malta Programmes considered Areas explored Number of students Malta MBBS programme Planning and management/oversight of the course, the quality of the local education providers overseas, quality management and control of the course and overseas placements, teaching and assessment, feedback, clinical placements, meeting curricular requirements overseas, academic and pastoral support, careers advice, facilities. Up to 50 students due to start from September 2017. The recruitment of students was ongoing at the time of the visit.
Number of local education providers Local Education and Training Board Last GMC visit To be determined at the time of visit. Health Education North Central East London 2012 as part of the London regional review Significant concerns identified We have concerns about: The lack of alignment of educational cultures between the Maltese (local) education providers and the School. This including a lack of mechanisms for feedback, to raise concerns and exchange information; Clinical placement capacity in some settings; Quality management by the School and quality control systems with Maltese (local) education providers. Barts need to make a number of significant short and long-term changes, to ensure the programme meets GMC statutory standards under the Medical Act 1983, as outlined in Promoting excellence: standards for medical education and training. Actions required and GMC s remit : We have required that Barts: By 31 July 2017 Provide evidence that the educational cultures of the Maltese education providers is further aligned to the UK arrangement, particularly in primary care settings. This should include evidence of clinical educator training, mechanisms to raise concerns and provide feedback and educator and student appraisal arrangements. We expect to receive further evidence of this on an ongoing
basis when students start. Provide evidence that the clinical educators in all primary care settings have received general practitioner tutor development. Provide evidence to demonstrate that the safety of students will be adequate at all times, including the issuing of a panic alarm system in high risk areas such as mental health settings. Provide more granular information on the numbers of students on clinical placements, particularly in specialties with potential capacity issues, such as paediatrics, mental health and obstetrics and gynaecology. This should include the numbers of clinical educators and Barts students who will be in each placement and the numbers of University of Malta students who will be at each placement at any one time. Evidence of strengthened quality management systems within Barts and quality control mechanisms with the Maltese education providers, to provide more detail. This should include: - Identification of educational leaders within each local education provider, including primary care providers; - Evidence of more formal links between Barts and the local education providers; - Evidence of formal appraisal feedback mechanisms between organisations and between students and teachers. This evidence has been submitted and the analysis will feed into the quality assurance activities of the academic year 2017-2018. By 31 January 2018 Provide evidence that the educational cultures of the Maltese education
GMC s remit providers are further aligned to the UK arrangements, particularly in secondary care settings. This should include evidence of specific clinical educator training numbers, registrant attendees/engagement, by specialty/gp and LEP, mechanisms to raise concerns and provide feedback and educator and student appraisal arrangements. We expect to receive further evidence of this on an ongoing basis when students start secondary care placements. Please note that the GMC holds a list of bodies entitled to issue medical degrees. They must demonstrate that they meet the relevant statutory standards and outcomes set by the GMC. The GMC has the power to take steps to remove a body from this list if it considers that its statutory standards are not being met. 1 With respect to the above actions, please provide evidence by the respective deadlines. If you are unable to provide acceptable evidence by the respective deadlines this may result in the GMC suspending future quality assurance activity in relation to these programmes in order to achieve compliance with our statutory standards. Suspension of future quality assurance may also involve a recommendation that Barts does not graduate any students via these programmes and instead transfers relevant students to its Home MBBS Programme for graduation purposes. Once we have received the requested evidence, the analysis will feed into the quality assurance activities for the academic year 2017-2018. 1 Disclaimer: This report reflects findings and conclusions based on evidence collected prior and during the visit.
Introduction 1 Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Barts) are proposing to deliver a five year MBBS programme in Malta commencing in September 2017. The programme will be entirely delivered on Malta and Gozo. At the time of the visit we were informed that they aimed to recruit up to 50 students in the first year. There are potential plans to increase this to 60 students in subsequent years. 2 GMC staff and specialist associates have been considering the application for the new programme since 2015. In March 2017, we met with a variety of members of Barts staff and their stakeholders during visits to London, Malta and Gozo. Summary of findings 3 The GMC team were of the view that if Barts make a number of short and long-term changes, the programme should meet GMC standards outlined in Promoting excellence: standards for medical education and training. 4 The majority of our concerns relate to quality management and quality control processes, particularly how Year 1 will be implemented and how learning cultures will be aligned across learning environments prior to students starting. This alignment includes basic assurances as to the safety of students, e.g. ensuring a system for panic alarms in high risk areas such as mental health settings. 5 Barts must urgently undertake further work with its partners to ensure all processes are fully mapped and documented, and students have comparative, safe experiences. 6 Progress in these areas is fundamental if the GMC is to support the programme by providing quality assurance. We will monitor the school s progress in meeting our requirements following a further document submission on 31 July 2017. New requirements We set requirements where we have found that our standards are not being met. Each requirement is targeted, and outlines which part of the standard is not being met, mapped to evidence we gathered during the course of the visit. We will monitor each organisation s response to requirements and will expect evidence that progress is being made. Promoting Excellence paragraph Requirements
1 PE 1.2 The educational culture in the Mater Dei Hospital must align to the Barts and the London School of Medicine and Dentistry arrangements. 2 2 PE 2.2 Quality management mechanisms at Barts and the London School of Medicine and Dentistry and quality control mechanisms with local education providers in Malta and Gozo require further work and detail. This should include: - Identification of an educational leader within each local education provider, including at primary care providers; - More formal links between Barts and the London School of Medicine and Dentistry and the local education providers; - Formal appraisal and feedback mechanisms between organisations and between students and teachers. 3 PE 2.2 More granular information on the numbers of students in clinical placements must be made available to provide a clear picture of the numbers of students from Barts and the London School of Medicine and Dentistry and the University of Malta and the numbers of clinical educators in each place at any one time. Currently this level of detail is unclear. 4 PE 5.1 Paediatrics, mental health and obstetrics and gynaecology are areas requiring more detailed clinical educational capacity mapping as part of Barts and the London School of Medicine and Dentistry s stress-testing and risk mitigation work. New recommendations We set recommendations where we have found areas for improvement related to our standards. Our recommendations explain what an organisation should address to improve in these areas, in line with best practice. Promoting Excellence paragraph Recommendation 2 The students will not be in secondary care placements until the 2018-19 academic year.
1 PE 1.2 Barts and the London School of Medicine and Dentistry will need to show how they are introducing a learning culture that is consistent and clear across all learning environments. 2 PE 1.2 Barts and the London School of Medicine and Dentistry will need to demonstrate their ambitions for interprofessional learning. 3 PE 1.2 We would like to see how opportunities for students to use the Mater Dei Hospitals skills centre for learning are being developed. 4 PE 3.1 Barts and the London School of Medicine and Dentistry will need to demonstrate how they are ensuring clinical teachers meet necessary standards so that students receive a consistent experience with the London students. 5 PE 4.1 The primary care representatives at the Mosta Polyclinic had not yet received general practitioner tutor development. All GP educators need educator development before students arrive. 6 PE 4.1 Barts and the London School of Medicine and Dentistry demonstrate how they are progressing secondary care educator development, and specifically Education Leads, including how they will work with local education providers to ensure tutors receive adequate training and development. 7 PE 5.1 The implementation of the Barts and the London School of Medicine and Dentistry curriculum and change will require further work, particularly with clinical teachers. The need for curriculum alignments between Barts and the London School of Medicine and Dentistry and the University of Malta curriculum, particularly Years 3 to 5, will require you to demonstrate strong collaboration at operational levels. Areas the team consider to be working well We highlight areas that appear to be working well. Promoting Excellence paragraph Area working well 1 PE 1.1 The educational environment at the Karin Grech Hospital showed real potential for undergraduate teaching.
2 PE 1.1 The rotating general practitioners system within Gozo General Hospital is a system the team felt could provide good educational opportunities. 3 PE 2.2 There was an enthusiasm and willingness at all levels amongst stakeholders to engage with the new programme. 4 PE 2.2 The joint committee between Barts and the London School of Medicine and Dentistry and the University of Malta appears to be working well so far, this is something to demonstrate continued progress with. 5 PE 3.1 The Foundation Year 2 doctors in training at Gozo General Hospital reported positive experiences and said they felt listened to. 6 PE 3.1 The respective student support leads at both Barts and the London School of Medicine and Dentistry and the University of Malta appear to be working proactively together to provide a shared approach 7 PE 4.1 The Barts and the London School of Medicine and Dentistry ambitions for general practitioner tutor development are promising. 8 PE 5.1 The development of the first year curricular delivery appears to be well-progressed.
Appendix 1: Visit team Dates of visits 7 March 2017 London 14, 15, 16 March 2017 Malta Visitor Visitor GMC Staff Professor Gillian Needham Dr John Dormer Alexandra Blohm (present at all March visits) Angela Hernandez (present at the London visit)
Appendix 2: Abbreviations Barts GMC MBBS QMUL Barts and the London School of Medicine and Dentistry General Medical Council Bachelor of Medicine and Surgery Queen Mary University of London
Queen Mary University of London, MB BS (Malta) Programme Response to GMC Report 2016-17 Most of the GMC s equirements are couched in terms of showing evidence of progress in certain areas. Inevitably, this means we identify areas in which we will continue to work to meet our shared objectives and thus contain aspirations as well as achievements. 1) Provide evidence of strengthened educational culture of the Maltese educational providers and their alignment to the UK arrangements. This should include evidence of clinical education training, mechanisms to raise concerns and provide feedback and educator and student appraisal arrangements. This should specifically be in place in primary care settings prior to the students starting. We then expect to receive further evidence of this on an ongoing basis when students start. Evidence of clinical educator training: The provision of both non-clinical and clinical educator training is key to the successful implementation and delivery of our curriculum in Malta. All educators in Malta have access to the same training and support opportunities as colleagues in the UK. GP tutors have attended a compulsory session called Introduction to the Barts Curriculum and a basic Introduction to Teaching, akin to the Introduction to Teaching in Primary Care (ITTPC) course we deliver in the UK. 23 GPs attended one of two training days delivered in Malta on 4 th and 5 th July 2017 and gave the sessions very positive feedback. Objective assessment confirmed that the teaching outcomes of the sessions had been met. Trained GP Tutors teaching students have had further briefings and attended a workshop on reflective writing alongside their allocated students at the beginning of term. These ensure that students and their GP Tutors have a shared understanding of the Medicine in Society module and what is expected of them, especially from an assessment perspective. GP Tutors were introduced to the teaching methods used at Barts and the London by a series of workshops offered by our faculty from July 2017. The programme will be offered on a rolling basis three times per year to ensure new GP tutors are trained and existing tutors are refreshed. A training session is planned at the end of January for the clinical Student Selected Component (SSC) tutors. Parallel workshops will be run for Medicine in Society in Year 2 and for the Extending Patient Contact course in Spring 2018. Going forward, there will be module-specific training for experienced tutors taking on teaching in Years 3, 4 and 5 with annual new tutor training. Recognising some of the cultural differences between the UK educational context and how we plan to achieve alignment in Malta, we also delivered Problem-based Learning (PBL) training on 5 th and 6 th July 2017. Eleven clinicians from Gozo General Hospital attended a curriculum briefing and interactional two-part PBL training sessions (four hours).
Prof A N Warrens On the 2 nd and 3 rd August 2017, we delivered the first two Clinical Educational Supervisors courses using our established UK framework. Initially, we will train the consultants on Gozo but then go on to cover clinicians at Karin Grech/St Luke s and Mater Dei Hospital. Peer observation of teaching is an important part of quality assurance and professional development in teaching practice. It is a requirement of Queen Mary staff that peer observation is carried out annually and discussed at appraisal with line managers. As part of faculty development, training will be given in peer observation and constructive feedback to Malta faculty. At the time of writing, four Gozo clinicians have been peer observed in PBL sessions and lectures. There is a rolling programme of peer review and feedback for all teaching staff. Evidence of mechanisms to raise concerns: Barts and The London takes very seriously the requirements to maintain patient, student and faculty safety at all times and has in place in London robust reporting mechanisms for all persons to report any concerns as required. These are being replicated in Malta. Explanation and discussion of these arrangements with students form part of their induction week and staff are made aware of the policy and processes during their training. We already have evidence that students know how to raise concerns and have done so in an appropriate fashion. Evidence demonstrating the provision of feedback: The Bristol Online Survey (BOS) is the anonymous electronic evaluation tool that students complete after each module of the MBBS and contains questions about their educational experience (both classroom and in the clinical environments of hospital and primary care) and their teachers. It is a reliable way for students to evaluate teaching and for staff to gain feedback on their teaching practice, as analysis of the results is returned to teaching and year leads within two weeks of close of the evaluation. BOS is seen by the Head of Quality in Teaching and Learning as well as module and year leads before it is sent on to individual teachers. It highlights problems and issues quickly to allow supervising staff to intervene. Malta students will participate in BOS and their feedback will be analysed as part of the whole student experience. Issues will be investigated and managed by staff at the Malta campus to ensure a speedy response to feedback. The feedback loop is closed by staff who will report back on issues that have been dealt with to the Student-Staff Liaison Committee which has been set up in Malta. Feedback to students is provided in a range of ways. Both formative and summative feedback are provided by faculty during students modules and attachments and after examinations. QMUL Malta faculty have been Page 2 of 6
Prof A N Warrens introduced to our systems of receiving and giving feedback and assessment procedures. Students meet with allocated mentors formally three times each year but can meet more frequently if necessary. During these meetings mentors may well go over any feedback students have received to check for understanding and learning. Evidence demonstrating educator appraisal arrangements: In line with our quality assurance systems in the UK, a suitably qualified Education Lead for each Local Education Provider (LEP) (whom we designate Associate Dean) will undergo an educational appraisal annually with the Dean for Education, or his nominated deputy. Among other things, this will allow us to ensure a culture of continuing professional development. The Associate Dean in each LEP is responsible for the clinical educational appraisal arrangements of the Educational Supervisors (i.e. those with an overarching educational supervisory role, perhaps over a whole academic unit), and they, in turn, for the appraisal of the contribution of individual Clinical Supervisors. This appraisal follows the guidance as set out by the GMC concerning the educational standards and domains (1-4 for Clinical Supervisors and 1-7 for Educational Supervisors). All Local Education Providers (LEP) will be visited annually by a team of senior staff from the medical school and will complete a self-evaluation form to inform the visit. At these visits, the team will also meet with students privately to discuss their learning experience. Furthermore, all the Associate Deans will attend termly meetings to discuss educational provision and quality. These meetings are well established in the UK and provide opportunity for planning and problem-solving as well as sharing of good practice. An identical process will be established in Malta. BOS evaluation covers all clinical placements and provides a reliable system of evaluation of teaching as previously outlined, particularly in triangulation with the Student Staff Liaison Committee. Evidence of student appraisal arrangements: All students will benefit from the implementation of the Barts and The London mentor scheme on Malta. This is designed to help students make the most of their time at medical school. Mentors are an accessible and consistent first point of contact for students, who can help and guide them. Students are able to discuss with their mentor any problems they might have, both academic and personal. Where appropriate, mentors can then direct students to other sources of academic, pastoral and careers guidance. Mentors will provide personal and professional references to support student applications, as well as offering support and advice for more general activities. Steps have been taken to ensure that those providing pastoral support for students are not also involved in their academic assessment. Page 3 of 6
Prof A N Warrens However, a central component of the scheme is a yearly appraisal conducted by the mentor. Based on a review of written material (the portfolio) accrued over the previous year, this is compulsory. The appraisal currently does not contribute to students academic progression or ranking but we have plans to introduce a more rigorous student appraisal system in London with the employment of new software within an e-portfolio. Once this has been piloted in the UK it will be rolled out for our students based in Malta. 2) Provide evidence that the clinical educators in primary care settings have received general practitioner tutor development: This has been covered in detail and in the answer to the previous question. 3) Provide evidence to demonstrate that the safety of students will be adequate at all times, including the issue of panic alarm systems in high-risk areas such as mental health settings: QMUL Malta Ltd is required to operate within Maltese health and safety (H&S) legislation and Occupational Health standards for Healthcare Workers. H&S legislation in the UK and Malta is often pan-european. The QMUL H&S governance structure will be adapted for use by QMUL (Malta) to ensure that there is appropriate oversight and governance of all H&S issues affecting students in Malta. This will include reporting of all incidents and near misses through QMUL processes in addition to maintaining local records. The QMUL Student Safety Policy will be adopted for use within Malta, which will take into account the local conditions for students. Crime rates are very low in Malta generally and in Gozo in particular but students will need to maintain their personal safety and be made aware of the risks associated with driving in Malta in addition to the usual tourist-related crime that is typical of a Mediterranean island. Students will also need to be aware of water and cliff safety in the course of any adventurous leisure pursuits that are part of the benefits associated with living in Malta. In addition, we will follow standard operating procedures concerning clinical student safety whilst on attachments. Occupational Health (OH) screening, equivalent to that provided by QMUL, will be made available to students through a Service Level Agreement with the LEP and will include provision for screening following a sharps or needle stick injury. The approach to be adopted will follow the process used by QMUL OH Services. Competent persons from QMUL (Malta) will undertake a risk assessment of activities relating to clinical placements, including an evaluation of transport to and from placements, activities during placements and any local considerations and contexts. Risks identified will be assessed and actions implemented to isolate or minimise the likelihood and consequence of an adverse event occurring. For example, panic alarms have been issued to students. In addition to personal panic alarms, Mt Carmel Hospital is currently fitted with panic alarms. Page 4 of 6
Prof A N Warrens The residential and education accommodation have been assessed by competent persons from QMUL, including our Health and Safety and Fire Officers. A significant amount of work has been undertaken to ensure that they meet UK standards. This work is nearing completion. Students have attended clinical placements within primary care from their first weeks and received an appropriate induction including personal safety issues. This is standard practice in London and is being replicated in Malta. 4) To provide more granular information on the numbers of students on clinical placements particularly in specialties with potential capacity issues such as paediatrics, mental health and obstetrics and gynaecology. This should include the exact number of clinical educators and Barts students who will be in each specific placement and the number of University of Malta students who will be at each placement at any one time: This information has been provided in detail to the GMC. We have demonstrated how many Barts students will be at each site for each attachment in Years 3, 4 and 5 for each week of the academic year. Using information kindly provided by the University of Malta, we have shown in parallel the number of University of Malta students who will be present in the same clinical unit on the same site, again by week of the academic year. Finally, we have related that to the availability of academic staff for each speciality. On this basis, we believe it will be entirely possible to provide the students of both universities a very high quality clinical experience. However, this is something we will be keeping under close scrutiny on a very regular basis as the course rolls out. A hospital-based Clinical Placements Supervisor will be employed to coordinate the various placements at the hospitals. 5) Evidence of strengthened quality management systems within Barts and quality control mechanisms with the Maltese education providers, to provide more detail. This should include: Identification of educational leaders within each local provider, including primary care providers: Educational leaders and an Associate Dean are to be appointed in each locality. Dr Robert Sciberras has been appointed as Associate Dean (Gozo General Hospital). Drs Gunther Abela and Mario Sammut support Dr Stephen Wise as lead for general practice and have provided excellent operational support. PBL facilitators from GGH have been recruited. Page 5 of 6
Prof A N Warrens Evidence of more formal links between Barts and the local education providers All the General Practices being used, Mater Dei Hospital and Mount Carmel Hospital are owned by Government, who manage them much more directly than does Government in the UK. This group of clinical sites are similar to a multi-site UK Trust. Hence, it is unclear how best to develop formal contractual relations with each site. This is currently under discussion. We see an analogy with a multi-hospital Trust (such as Barts Health) where the Trust is treated as a single LEP for contractual purposes but each site has its Associate Dean for organisational and quality-assurance purposes. VGH owns the other two sites, Gozo General Hospital and Karin Grech/St Luke s Hospital. They have an identical contractual obligation to us though their contract with the Maltese Government. Evidence of formal appraisal feedback mechanisms between organisations and between students and teachers: The Malta-based Steering Committee provides an excellent forum for the feedback between, on one hand, QMUL and VGH, and, on the other, QMUL and the Maltese government. In addition, Barts has a seat on the Medical Board of VGH. As in London, a staff-student liaison committee has been established to facilitate the liaison between students and teachers. There will also be other such fora including the annual Staff-Student Congress and regular meetings between the Dean and Student President. 6) Provide evidence of the strengthened educational cultures of other Maltese education providers and their alignment to the UK arrangements this should include evidence of clinical educator training, mechanisms to raise concern and provide feedback and educator student appraisal arrangements. This should be specifically in place and secondary care settings prior to the students starting these placements. We then expect to receive further evidence of this on an ongoing basis when the students start secondary care placements. This is covered above and will be replicated specifically for Years 3, 4 and 5. Page 6 of 6