The state of medical education and practice 2011

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The state of medical education and practice 2011

The state of

    medical education and practice in the UK



Foreword 05

    Executive summary 06

    Introduction 08

Chapter 1: A diverse and changing profession 12

     Key information 12

     Box 1: Facts for 2010 12

     The medical register and licensing 13

     The medical profession is highly diverse and is changing significantly 15

     The number of female doctors is set to overtake male doctors 15

     Training and workplaces will need to accommodate shifting requirements 19

     The average age of doctors is falling 19

     The changing age demographic has implications for the profession and service delivery 20

     More than a third of registered doctors qualified outside the UK 21

     The proportion of overseas qualified doctors in the UK has been lower in recent years 22

     Doctors practising in the UK completed their undergraduate medical studies in a wide 23

     range of countries

     24 Doctors who gained their PMQ overseas have a different profile by age and gender

     The medical profession is ethnically diverse 26

     Doctors work in many different medical specialties, sub-specialties and areas 29

     of special interest, each with their own clinical standards

     Specialties vary by size and attract disproportionate numbers of trainees 30

     Men and women make different specialty training choices 31

     Conclusion 32

     A note on data 33

    Chapter 2: The key role of education and training in supporting good medical practice 34

     Key information 34

     Box 2: The GMC‟s role in medical education and training 38

     Good medical education is essential to good medical practice 39

     Medical education is being delivered in a changing environment 39

     Box 3: Recent reports published in medical education an overview 39

     Is training producing competent, confident doctors? 40

     Are curricula consistently aligned to service demands and changing patterns 41

     of healthcare?

     Medical schools need to ensure that graduates are well prepared for clinical practice 41

     Foundation doctors need exposure to training across all care settings and in 43

     multidisciplinary teams

     Postgraduate training needs to respond to the needs of health service and workforce 44



     46 Doctors not on formal training programmes need access to training and CPD

     There are some inconsistencies in the delivery of medical education, which may 47

     impact on good medical practice

     Pressures of service delivery can compromise protected time for education 47

     Clinical supervision is variable 48

     The learning environment affects medical education 49

     Characteristics of individuals can affect experiences and outcomes in medical education 50

     Conclusion 51

     A note on data 52

    Chapter 3: Variations in the standards of medical practice 53 Key information 53

    The fitness to practise process stages 53

     Triage 53

     Stream 2 53

     Stream 1 53

     Box 4: Overview of the fitness to practise process 54

     Standards of medical practice vary 55

     The role doctors play in health systems is crucial to good medical practice 55

     A small number of UK doctors fall seriously short of expected standards 57

     Reporting of complaints is increasing 59

     There are common and persistent areas of concern 61

     Box 5: Categories of concern 61

     Different concerns need different responses 63

     There is variation in patients‟ experiences of medical practice 64

     There is variation in practice between groups of doctors 66

     We receive and need to follow up on more complaints about male doctors 67

     We receive and need to follow up on more complaints about older doctors 68

     We need to investigate more complaints about doctors qualifying overseas 69

     Ethnicity is not a factor in the number of complaints made or investigated 71

     There are differences in numbers of complaints between specialties 72

     Conclusion 74

     A note on data 75

    Chapter 4: Achieving better medical practice 76

     A changing profession 76

     Professionalism and leadership are crucial to good medical practice 77

     Professional guidance must be embedded in everyday practice 78

     Revalidation and employers have a key role in supporting good medical practice 79

     Good Medical Practice is about more than setting minimum standards 79

     Regulatory bodies need to redefine how they work 80

     Professional regulation and system regulation must work well together if patients are 80

     to be protected


     We are building stronger relationships with the public 81

     Doctors must take responsibility for raising concerns, and need to be supported to do so 81

     Overseas qualified doctors need better support 82

     All doctors practising in the UK must have adequate English language skills 82

     Doctors need to be equipped to deal with changing healthcare needs 83

     Medical practice needs to meet the healthcare demands of the future and the changing 83

     expectations of patients

     Medical schools‟ recruitment processes need to be fair and transparent 84

     We need to improve our understanding of medical education 85

     Better information would support medical students and trainees in making career 85


     Next steps 86

    References 87

    Glossary 100

    Acknowledgements 108



    The GMC holds a large amount of information which in many ways gives us a unique overview of medical education and practice in the UK. Until recently we have not routinely analysed and shared that information. However, we think it is important that we should do so because it is likely to be of interest to the medical profession, the public and policy makers. This document marks the first and important step in that process.

    We collect information mainly as a consequence of carrying out our statutory functions: maintaining the Medical Register; regulating undergraduate and postgraduate medical education; and investigating doctors whose fitness to practise has been called into question. In addition, we collect data given to us voluntarily: e.g. ethnicity, age and area of practice.

    This document sets out much of what the GMC knows about the medical profession and for completeness we have drawn when appropriate on data from other sources. We anticipate that many in the medical profession and beyond will find the information contained within the report of interest and importance. We hope that the demographic data about the medical profession will prove of interest and assistance to those who engage in the important but inexact task of workforce planning. There is much to celebrate about the state of the medical profession in the UK: the respect and trust bestowed on doctors by the public is unparalleled in any other developed nation. At the same time, there is evidence of unacceptable and largely unexplained variations in the quality of care and we hope that our fitness to practise data will help shed light on relevant factors and the direction of future research. Similarly, while the quality of medical education and training is generally high, there are variances that need to be better understood and explained.

    This is the first of what we intend to be annual reports and reflects our commitment to extending our leadership role and being more outward-facing.

    Professor Sir Peter Rubin

    Chair, GMC


Executive summary

    This is the GMC‟s first report on the state of medical education and practice. It uses GMC and other data to provide a picture of the medical profession in the UK and to identify some of the challenges that persist. We believe we need to be a more proactive regulator. This report is a step in helping us achieve this. Our aim in publishing this report is to promote discussion and debate on issues and trends that require attention or further analysis.

    Key findings

    The profession is diverse and changing (chapter 1)

    ; There is an increasing number and proportion of female doctors.

    ; Most commonly, doctors are in their early 30s.

    ; More than a third of registered doctors completed their primary medical qualification outside the


    ; The medical profession is ethnically diverse compared with the UK‟s general population.

    ; The medical specialties in which doctors work vary enormously in size and are not always

    aligned to service needs.

    Medical education plays a key role in supporting good medical practice (chapter 2)

    ; Medical education and training need to be more responsive to changes in healthcare needs, the

    organisation and delivery of care, and the shifting expectations of patients.

    ; There is a tension between service delivery and protected time for education and training, and

    this has been exacerbated by Working Time Regulations.

    ; Trainee doctors need high quality supervision and positive role models with strong leadership

    skills. Yet there is variation in trainees‟ experiences of supervision.

    There is unacceptable variation in the standards of medical practice (chapter 3)

    ; In 2010 we assessed around 1 in 70 of all registered doctors although many concerns were

    subsequently unproven.

    ; The GMC receives proportionately more complaints about male doctors, older doctors and GPs.

    ; In 2010 the top three types of concerns were about: clinical investigations or treatment; respect

    for patients; and communication with patients.

    ; A small number of doctors are falling seriously short of the standards expected of them. Almost

    1 in 3,000 registered doctors were struck off.


Achieving better medical practice (chapter 4)

    We have set out six areas for further debate and action.

    1 Professionalism and leadership are crucial to good medical practice. Revalidation, when

    introduced, will help by bringing every conversation about a doctor‟s practice back to the

    standards set out in Good Medical Practice. We have also set up a new team to help employers

    ensure medical leadership is supported in the workplace.

    2 Regulatory bodies need to redefine how they work. The GMC needs to proactively encourage

    good practice as well as take action when problems arise. And professional and system regulators

    need to work more closely together.

    3 Doctors must take responsibility for raising concerns and need to be supported to do so. There

    needs to be a culture change around this. The GMC will do what we can to support this, but there

    are actions for employers too.

    4 Overseas qualified doctors need better support. They need to be properly inducted to UK practice

    and employers need to be confident they can speak and understand English to a good enough


    5 Doctors need to be equipped to deal with changing healthcare needs. We believe postgraduate

    training should be reviewed to ensure it is flexible enough to allow doctors to move between

    specialties. Doctors also need a higher level of core competence than training programmes

    currently allow.

    6 We need to improve our understanding of medical education. In particular we need better

    outcomes data so that we can be assured that medical students are entering the workforce with

    consistent, and the right, skills and knowledge. In 2013, we will evaluate the impact of our

    updated standards for undergraduate education, Tomorrow‟s Doctors (2009).



    Modern technology has improved our ability to collect data on the medical profession, but without effective analysis it is of limited value.

    This report begins a process of using and analysing our data to stimulate debate about how we and our partners should work to make sure the profession can be even more effective, and what needs to be done to achieve that.

    iIt uses GMC and other data to provide a picture of the medical profession in the UK.

    We hope that the report will contribute to a better understanding of the challenges the profession faces and the wider role it can play in promoting high quality healthcare. We also hope it will help us to reflect on what we have learnt, and enable us to share the data, knowledge and insight we have gathered through our work so we can better protect patients.

    We regulate all stages of medical practice, from undergraduate medical education through to retirement from practice. The evidence and the data in this report are necessarily limited and partial, although we have drawn on other sources to provide a fuller picture or greater insight. Together, the data provide a clear view of the changing shape of the profession in the UK, shed light on some of the most serious problems with doctors‟ practice and reveal how well medical education and training is preparing the next generation of doctors. We hope that by sharing this information and our analysis of it we can open and contribute to debate about the future of medical practice and education in the UK. Publishing this report annually will allow us, over time, to analyse changes and developments. The report covers three main themes.

    ; A diverse, changing profession (chapter 1) describes the current composition of the profession,

    and trends over time.

    ; The key role of medical education in supporting good medical practice (chapter 2) assesses how

    effectively the current medical education and training system equips doctors to provide a safe,

    high quality service that responds to society‟s needs and values.

    ; Variations in the standards of medical practice (chapter 3) looks at what works well currently

    and where there are concerns about variation in performance.

    ; The final chapter, Achieving better medical practice (chapter 4), considers what changes may

    be required to meet existing and future challenges.

Medical practice is changing

    The healthcare needs of the UK‟s population and the environments in which care is delivered are

    changing rapidly. The role of doctors is also evolving.

    1, 2, 3, 4Emerging public health issues highlighted by the UK‟s Chief Medical Officers‟ reports, combined

    5with the rapidly ageing population, mean that in future doctors will need to focus more of their time

     i Based on data extracted from the GMC database on 31 December 2010.


    6on supporting patients with long-term conditions, many with comorbidities. More doctors will work in

    the community, and GPs and other practice staff will deliver a much wider range of procedures, as 7many already are.

    8Medical practice is also becoming inherently more complex than in previous years. The greater the

    knowledge we gain, the more factors doctors have to understand and weigh in the balance when deciding the best course of action for their patients, often under intense time pressures. Ultimately, doctors must take responsibility for their actions.

    Patients too have a greater knowledge of health and increasing expectations of their doctors. So the doctor-patient relationship is also shifting and, for many health professionals, including doctors, the emphasis may be „less on trying to know all the answers and more on knowing how to help the patient

    9find them out‟. Never before have good communication skills been so vital, or involving patients in 10their own care and treatment so important.

    Implementation of the Working Time Regulations (WTR), which has recently reduced working hours from 56 to 48 hours a week, has been a further cause of considerable change to the way that doctors

    11, 12work. The WTR have been a positive development in terms of doctors‟ working conditions and

    patient safety because fatigue can have a detrimental effect on doctors‟ performance (discussed further

    13, 14, 15in chapter 2). However, in the UK, the reduction in hours has put increased pressure on service rotas, particularly in acute care settings and in some specialties, with possible consequences for how

    16medical training is delivered.

    The way doctors work has also been transformed by the introduction of multiprofessional teams. This longstanding shift from independent practice to team working demands that all doctors possess and foster team based skills, including working effectively with colleagues and the ability to judge individual performance within a team setting. In many cases, doctors also need to take on more complex leadership roles. Thus, more than ever, doctors are working within systems and their professionalism 17and ability to adapt to new responsibilities is central to how well those systems perform.

    At the same time, although health systems across the UK are better funded in real terms than they have ever been, they are also facing demands for unprecedented efficiency savings ?20 billion over

    18the next four years in the NHS in England alone. In Scotland, public services‟ efficiency savings of 3% ii, 19(equivalent to around ?330m for health) are required this year (2011-12). The position for Northern

    iiiIreland is similar, with a projected shortfall of about ?300 million in health and social care funding in 202011/12, potentially rising to ?800 million in 2014-15. Healthcare costs in Wales have grown by 5% a

    21year for the last five years, and Wales is projected to face a gap of ?1.3-?1.9 billion by 2014-15.

    The four UK countries are likely to address the need for efficiencies in different ways. This may very well increase the speed at which the healthcare systems across the UK diverge. These differences present challenges for professionals working across these boundaries but also opportunities to deliver care tailored to the needs of the local population.

     ii Scotland‟s next spending review is expected to cover three years. iii Health and social care in Northern Ireland are integrated, and consequently the estimated funding gap covers both health and social care. It is not possible to disaggregate the shortfall specifically in health funding from this total figure.


    Issues for the medical profession also need to be considered in the context of our role in Europe, which similarly poses both challenges and opportunities. The European Recognition of Professional Qualifications Directive has made it easier for doctors to move both into and out of the UK. The UK has benefited from this. However, concerns have been raised about whether migration affects the quality of care for both sending and receiving countries given the differences that will exist in the culture, language and health systems between countries (discussed further in chapter 1). This, coupled with expected cuts in public budgets available for healthcare and training in some countries, may further

    22affect the composition of the medical profession in the UK.

    The role of professional standards in reducing variation A host of studies and reports have shown that there are significant differences in the quality of care

    23, 24provided by different healthcare systems across the world. We also know that the UK is no 25, 26, 27exception both in the context in which medical practice takes place and the outcomes of care.

    The medical profession is at the heart of the debate about quality and safety and doctors have a key role in improving and maintaining standards of care. The rapid expansion of data about quality, and improvements in measuring the impact of healthcare interventions provide a real opportunity to focus 28both on patients‟ experiences and the outcomes of care. This information should also enable

    individual doctors, teams, departments and institutions to monitor their performance more effectively and benchmark themselves against others.

    As most practitioners and organisations strive to improve, there are still too many reminders that in some places standards of care and treatment are unacceptably low. High profile examples such as the 29neglect of older people in England revealed by the Health Service Ombudsman, the blatant abuse in

    30care homes such as Winterbourne View, and the shocking failures at the Mid Staffordshire NHS 31Foundation Trust all raise questions for doctors and other healthcare professionals about their role in ensuring that every patient has a good standard of care and is treated with respect and dignity. Such cases raise profound questions for regulators such as the GMC. Our fitness to practise data also provide information on trends in variations in practice. The standards we set for the profession must have a part to play in preventing unwarranted and inappropriate variation in the quality of care and, of course, if they were adhered to appalling practice would either not occur or would be identified and tackled at a much earlier stage.

    32Our core guidance Good Medical Practice sets out the ethical and legal considerations doctors must

    take into account in their practice and when making decisions.

    We know that virtually every doctor in the UK is aware of the guidance. However, we also know that Good Medical Practice is not always playing the part it should both in medical education and clinical practice. In a recent survey, for example, one in 20 doctors reported that they had not referred to the

    33guidance during their medical careers.

    If we are to help raise standards generally and play a part in addressing serious, system level failings, we need to understand why doctors are not consistently complying with the standards in Good Medical

    , or what may make the standards difficult to put into practice. We also need to know who the Practice


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