Written evidence from The General Medical Council (IDF 15)
Public Administration and Constitutional Affairs Committee
Follow-up to the PHSO report ‘Ignoring the alarms: How NHS eating disorder services are failing patients’ inquiry
About the GMC
1 The General Medical Council (GMC) helps to protect patients and improve medical education and practice in the UK by setting standards for medical students and doctors, alongside the environments that they work and study in. We support them in achieving (and exceeding) those standards and take action when they are not met.
2 We are independent of government and the medical profession and directly accountable to Parliament. Our powers are derived from the Medical Act (1983) and associated legislation.
Overview
3 The GMC welcomes the opportunity to provide evidence to the committee’s inquiry. Tragic cases, such as that of Averil Hart covered in the Ignoring the alarms report published by the Parliamentary Health Service Ombudsman (PHSO), underline the highly complex nature of eating disorders and the related challenges for patients, families, the service and also medical education.
4 These complex issues are now receiving more attention, both publicly and through health service planning. Initiatives like the NHS Long Term Plan and the Scottish mental health strategic plan continue to bring them into sharp focus.
5 In its report, the PHSO recommended that the GMC ‘should conduct a review of training for all junior doctors on eating disorders to improve understanding of these complex mental health conditions’. The PHSO recommended that the GMC use the findings of the research undertaken by the Faculty of Eating Disorders at the Royal College of Psychiatrists, to inform a review.
6 We believe that all doctors should have a relevant understanding of a wide range of conditions, including mental health, nutrition and eating disorders. To this end, the outcome requirements we set for all stages of UK education and training require medical students/doctors to be able to identify potential vulnerable patients - including those with physical and mental health related conditions and where lifestyle and environmental issues are contributing to ill health or safety.
7 However, our ability to respond to the specific nature of this recommendation is limited by our regulatory role and legislative remit. We believe we have pursued all the options available to us in progressing its delivery. We are confident that the efforts that we have made are helping to ensure that greater priority is placed on eating disorders within UK medical education and training as part of a wider cross organisational response to the PHSO’s recommendations.
8 The remainder of this written evidence sets out the manner in which our current regulatory initiatives and powers have been utilised as part of delivering on the PHSO’s wider recommendations, alongside the constraints they present in doing so. We also note the actions we have taken to deliver on the fundamental view outlined in paragraph 6 above. Despite these limitations, we will continue to do everything we can to bring trainers and medical schools together to determine how to improve provision. Our efforts to do that are ongoing.
The GMC’s wider regulatory role in medical education
9 It is important to understand that the GMC’s role is purely one of oversight. We do not write curricula. We determine the outcomes, skills and professional knowledge that we expect undergraduate medical students to achieve, and approve the curricula for doctors undergoing their immediate postgraduate training[*], and for doctors seeking to become a specialist in one of the UK’s 65 recognised specialty areas.
10 It is for medical schools and other training establishments to determine exactly how those requirements should be met. Our expectation is that they will do so in accordance with the requirements that we outline in a number of documents that are published and updated on a regular basis:
a Promoting Excellence (2016) which sets the basic standards for the delivery of medical education.
b Generic professional capabilities framework (2017) – these form the professional knowledge and skills that all doctors in training need to demonstrate. These have been supplemented by Adapting for the Future (2018) which sets out how we postgraduate training should be made more flexible
c Excellence by design (2017) establishes a new set of standards for how the UK’s 25 medical royal colleagues should develop the curricula that doctors seeking to become specialists need to follow.
d Outcomes for Graduates (2018) These are the specific outcomes that we expect all undergraduate medical schools to enable students to meet. They incorporate the Generic professional capabilities noted above and are supplemented by specific guidance in our document Practical skills and procedures.
Oversight of medical education
Undergraduate
11 As part of our role in determining which doctors are qualified, we set the outcomes which UK graduates must meet as the threshold for entry to the medical register. These are documented in Outcomes for Graduates. Medical schools must integrate the outcomes by providing an education that allows students to achieve them by the time they graduate, including a number of practical procedures that we directly specify on the advice of a representative group of independent medical experts.
12 The outcomes that we set are, by definition, broad in nature. We do not believe it would be practical for us to include all possible presentations or conditions that a newly qualified doctor could expect to encounter. Our objective is to ensure that new doctors are able to determine the broad characteristics of a range of complex conditions and know which specialist to then refer that patient too to establish a formal diagnosis and/or course of treatment.
13 In the context of this approach, we already set a number of outcomes for graduates that are associated with identification and treatment of eating disorders such as wider mental health issues. Annex A provides more detail on the nature of these.
14 However, our powers under Section 5 of the Medical Act (1983) do not extend to the approval of the specific content of undergraduate medical school curricula. Instead, UK medical schools determine the content themselves. This means we do not (and cannot) specify how the outcomes should be achieved, such as the number of hours of teaching on a subject or the precise nature of that teaching. Our powers in this area are limited to quality assuring the medical schools against broader educational outcomes, as outlined below.
Foundation Programme
15 All graduate doctors are required to undertake two-year Foundation Programme. This provides training to develop doctors with a range of essential interpersonal and clinical skills for managing acute and long-term conditions. During Foundation year 1, doctors are provisionally registered with the GMC. Doctors entering Foundation year 2 will be fully registered. We refer to doctors in the Foundation programme as ‘doctors in training’.
16 The Academy of Medical Royal Colleges develops the Foundation programme curriculum which sets out the requirements to develop doctors with a range of essential interpersonal and clinical skills. The GMC’s regulatory role is to approve this curriculum.
17 We do not, in determining approval, make requirements relating to the specific content of the Foundation programme curricula. Instead, we set out a process that the AoMRC should follow to ensure that appropriate consultation is undertaken and appropriate medical expertise is brought to bear in its development.
18 In that context, we note that the AoMRC do require Foundation year 2 doctors to be able to ‘work with other healthcare professionals to address nutritional needs and communicate these during care planning, recognise eating disorders, seek senior input and refer to local specialist service, and formulate a plan for investigation and management of weight loss or weight gain’.
19 Effectively therefore, even though provision in individual medical school curricula may vary, doctors must still meet a common standard in terms of their knowledge and understanding of eating disorders once they graduate.
Specialty training
20 Once a doctor has completed the foundation programme, there are a number of career options open to them. A number will choose to become a specialist doctor and ultimately a consultant in a given field. There are currently 65 recognised medical specialties in the UK. Each of these have specific curricula, which are formulated by 25 separate medical royal colleges and faculties.
21 Under Sections 34H – 34M of the Medical Act (1983), the GMC has powers to approve these curricula as well as the assessment systems attached to them. As noted in paragraph 23, in determining approval we do not ask that specific provision is made for treatment and diagnosis of individual conditions. But these organisations must show how they have determined the content of their curricula, including external consultation that they have undertaken in doing so.
22 We have looked at whether these curricula do reflect the wider need there undoubtedly is for better understanding and knowledge of Eating disorders. They are specified in the curricula for a number of specialties in the forefront of identifying and treating patients with eating disorders. Annex B provides some examples of these.
23 The colleges and faculties must also incorporate the Generic professional capabilities framework (GPC) and contextualise it to the needs of their specialties. Like the outcomes for graduates, the GPC framework sets the high-level outcomes we expect all doctors in training to achieve. We are in the process of requiring all colleges and faculties to update and incorporate GPC within their curricula. Annex C provides examples of domains in GPC and themes which are often associated with eating disorders.
Quality assurance
24 Alongside setting the educational outcomes they should deliver, we decide which organisations can award UK primary medical qualifications and carry out quality assurance of bodies which want approval to issue a medical degree, or to start a new programme.
25 We use our quality assurance process to check medical schools are meeting our standards. We also can visit medical schools, deaneries and local offices and local education providers. Our visits are risk based, which means we look at our evidence and decide which areas of education are most likely to be of concern. We focus our visits on those areas. We also explore areas of good practice which can be shared with other organisations.
26 We receive regular reports from medical schools, deaneries and local offices, and royal colleges and faculties about the medical education and training that they provide and manage. We ask these organisations to tell us about anything which is of concern to them and anything which they think is particularly good or effective.
27 If we are concerned about something we ask the organisation for more information to assure us that any issues are being dealt with appropriately. In postgraduate training, if we are not satisfied with the response of the organisation we can intervene. We call this intervention enhanced monitoring.
28 Where possible we work with all organisations to address the concern and develop a sustainable solution. Sometimes we need to work with other regulators and organisations to make improvements.
29 Beyond quality assurance of the education students receive, we have also taken steps to ensure that the mental health of students themselves is supported. In July 2013 we also produced Supporting medical students with mental health conditions jointly with Medical Schools Council, (this was updated in 2015). This gives advice to medical schools on how they can provide the best possible support to students who have mental health conditions themselves. It covers some of the most common conditions that medical schools will encounter, including eating disorders, depression, anxiety disorders and substance misuse (including alcohol).
30 We also have a parallel quality assurance process for those training establishments that employ doctors in training. These are often large hospitals. We grant and can remove approval from organisation to have Doctors in Training in post, and as interim step we can place them on an ‘enhanced monitoring’ list.
31 We can also set specific conditions on these establishments for them to maintain their approval by us. Again, it is unclear whether it would be proportionate to do so on the basis of whether those establishments were making effective provision for delivery of specific elements of the curriculum.
Beyond our regulatory remit: working with others
32 The GMC does not have the ability to determine the specific nature of undergraduate and postgraduate curricula. Therefore, as noted in paragraph 7, it is difficult for us to undertake a review of eating disorders in the manner envisaged in the PHSO report, or indeed for any other specific condition. We do not have the statutory powers to undertake such reviews in a meaningful way.
33 However, we do recognise the role we have in terms of convening and incentivising medical schools and royal colleges to respond to the clear need for improved provision around eating disorders - through consistency of training, consideration of whether their current provision is sufficient and to share best practice.
34 As the following information shows, since the PHSO report was published, we have taken a number of actions to progress this agenda. We have looked not only at training for junior doctors on eating disorders, which was the focus of PHSO’s original recommendation to the GMC, but are also exploring coverage at undergraduate level.
35 In June 2018, the GMC presented to the NHSE PHSO delivery group chaired by Professor Tim Kendall, National Clinical Director for Mental Health. We are pleased Professor Kendall has confirmed that the GMC will be invited to future meetings of the group and we look forward to working with them as this progresses.
36 We have worked closely with leading parliamentary advocates to support their efforts to raise the profile of training provision for eating disorders. This culminated in our working with Baroness Parminter to convening a Parliamentary roundtable on Tuesday 12 March 2019.
37 The roundtable provided an important forum that brought together a range of Parliamentarians, organisations and individuals: including NHS England, Health Education England, the Academy of Medical Royal Colleges, the Medical Schools Council, several individual medical schools and students and doctors with personal experience of the condition.
38 The discussion was a helpful and productive one, identifying a range of priorities on which the group agreed to work together and how all parties can work together in response to the PHSO’s report. This includes not just the NHS England delivery group but also driving values throughout the NHS on integrating mental and physical health, coordinating between specialities on sharing resources and best practice, and ensuring learning environments are providing the best opportunities possible. In order to understand in greater detail how eating disorders are taught in practice, we have since met with individual participants who spoke at the event in order to gain the first-hand insight of their experience of the undergraduate teaching they received.
39 We have also invited a number of other stakeholders to meet with us. This includes several Parliamentarians, with whom we will discuss the actions we are taking and listen to their views and any issues constituents have raised with them. Following the roundtable, we have committed to and delivered a number of specific actions:
Seeking information from medical schools
40 To gain a wider picture, and building on the research undertaken by the Dr Agnes Ayton, Oxford Health NHS Foundation Trust in 2017, we have written to every medical school in the UK seeking specific information about:
how eating disorders are currently taught and covered in curricula
the relationship between teaching on eating disorders and teaching in mental health, nutrition and physical health
the exposure medical students get to eating disorders as part of their clinical attachments
41 We will use this to develop a clearer view of the coverage of eating disorders at undergraduate level and how the complex themes are socialised among students at the earlier stages of education.
Shared curricula and resources across postgraduate training
42 It’s important that medical education and training keeps pace with developments in medicine, and that the sector shares knowledge and expertise. We have therefore been asking royal colleges and faculties to identify where there are overlaps between specialities and where curricula content could be shared. The Academy of Medical Royal Colleges is also coordinating a discussion between relevant specialities and colleges on sharing resources and best practice.
Annex A - Outcomes for graduates
In the section on Safeguarding vulnerable patients, we say that newly qualified doctors must recognise and identify factors that suggest patient vulnerability and take action in response. Specifically, they must be able to:
assess the needs of, and support required, for people with mental health conditions…
recognise where addiction (to drugs, alcohol, smoking or other substances), poor nutrition, self-neglect, environmental exposure, or financial or social deprivation are contributing to ill health. And take action by seeking advice from colleagues and making appropriate referrals
In the section on Leadership and team working, we say that newly qualified doctors must:
learn and work effectively within a multi-professional and multi-disciplinary team and across multiple care settings. This includes working face to face and through written and electronic means, and in a range of settings where patients receive care, including community, primary, secondary, mental health, specialist tertiary and social care settings and in patients’ homes.
In the section on Applying psychological principles, we say that:
Newly qualified doctors must explain and illustrate by professional experience the principles for the identification, safe management and referral of patients with mental health conditions e.g. describing how patients adapt to major life changes, such as bereavement, and the adjustments that might occur in these situations.
May 2019
Annex B - Speciality curricula examples
The Joint Royal Colleges of Physicians Training Board (JRCPTB)’s specialty training curriculum for Gastroenterology states that that by the end of Specialty training, trainees must be able to identify, explain and manage patients with significant weight loss and/or anorexia.
The Level 1 General Paediatrics syllabus 2018 states that by Level 1 (Specialty training years 1-3), trainees must be able to recognise and initiate the acute management of young people with severe eating disorders.
The Level 2 General Paediatrics syllabus 2018 states that by Level 2 (Specialty training years 4-5), trainees must be able to assess and manage the acute presentation of eating disorders, and liaise with an MDT where appropriate.
The Paediatrics sub-specialty Child Mental Health syllabus 2018 states that by Level 3 (Specialty training years 6-8), trainees must demonstrate the ability to recognise and manage competently a range of mental health difficulties and disorders, such as eating disorders.
The sub-specialty Paediatric gastroenterology, hepatology and nutrition syllabus 2018 states that by Level 3 (Specialty training years 6-8), trainees should be able to identify any patients with faltering growth, significant weight loss and/or anorexia, or those who require complex nutritional support, and know local referral pathways to professionals with specific expertise.
The Royal College of General Practitioners (RCGP) Curriculum: Professional & Clinical Modules includes eating disorders in the following two modules:
Care of Children and Young People:
GPs should manage and appropriately treat common and rare but important paediatric conditions encountered in primary care, such as eating disorders.
Women’s Health:
GPs should recognise common signs and symptoms of, and be the first port of call for eating disorders and other conditions more common in women, involving other members of the healthcare team as appropriate
GPs should demonstrate knowledge of women’s health problems, conditions and diseases, and recognise that some non-gender specific issues present differently in women, such as eating disorders.
The Royal College of Psychiatrist (RCP)’s curriculum for Specialists in General Psychiatry states that by the end of Specialty training year 5, the trainee must be able to meet the following requirements for patients presenting with eating disorders:
demonstrate an understanding of the need for safe and positive decision-making with respect to risk management in specialist services (e.g. eating disorders) for working age adult patients and will demonstrate skills in providing clinical supervision
conduct a risk assessment, instigate a treatment plan and supervise the progress of patients
will be familiar with the range of psychotherapies available to patients and be able to incorporate the principles of these techniques into their own clinical practice
be able to concisely summarise the previous case records of patients with severe and enduring mental illness presenting and use this information to inform the assessment, treatment plan and subsequent monitoring of these patients.
Annex C Generic professional capabilities
Domain 2 – Professional skills: Dealing with complexity and uncertainty
Doctors in training must recognise patients with common mental health conditions (eg depression, dementia or delirium), manage them and, if appropriate, refer them to colleagues with relevant expertise.
Domain 3 – Professional knowledge: National legislative requirements
Doctors in training must be aware of their legal responsibilities and be able to apply in practice any legislative requirements relevant to their jurisdiction of practice, for example:…… mental health.
Domain 4: Capabilities in health promotion and illness prevention
Doctors in training must be aware of and demonstrate:
basic principles of public health, including population health, promoting health and wellbeing, work, nutrition, exercise, vaccination and illness prevention
applying the principles of promoting:
public health interventions such as targeting smoking cessation,…. the harm caused by alcohol abuse
mental health and wellbeing
how to assess mental health and wellbeing
Domain 7: Capabilities in safeguarding vulnerable groups
Doctors in training must demonstrate that they can:
apply mental capacity legislation in clinical practice, to protect the safety of individuals and society
identify, assess and manage suicide risk
understand positive behavioural support and determine when and how to safely restrain and safeguard vulnerable adults in distress.
Interprofessional team working
The importance of effective multidisciplinary and interprofessional team working is also highlighted throughout the framework.