Written evidence submitted by the General Medical Council (ELC0086)

1            We welcome the opportunity to provide evidence to the Health Committee Inquiry into end of life care.

2            Supporting improvements in end of life care has been high on our agenda since we published guidance for doctors working in this area in 2010. Most recently we have been a prominent member of the Leadership Alliance for the Care of Dying People (LACDP) which developed a collaborative system-wide response to the findings of the Neuberger Review of the Liverpool Care Pathway (LCP) and identified where improvements could be made to the care of dying people and their families.

3            In this submission we set out our statutory role, our involvement in the LACDP and the progress we have made against our commitments as part of this group.

Introduction

4            The GMC is an independent organisation that helps to protect patients and improve medical education and practice across the UK.

• We decide which doctors are qualified to work here and we oversee UK medical education and training.
• We set the standards that doctors need to follow, and make sure that they continue to meet these standards throughout their careers.
• We take action when we believe a doctor may be putting the safety of patients, or the public’s confidence in doctors, at risk.

5            Every patient should receive a high standard of care. Our role is to help achieve that by working closely with doctors, their employers and patients, to make sure that the trust patients have in their doctors is fully justified.

6            Of particular relevance to this inquiry is the guidance we provide for doctors on Treatment and care towards the end of life: good practice in decision making. This builds upon the core professional standards expected of all doctors in Good medical practice, which covers the fundamental aspects of a doctor’s role, including working in partnership with patients and treating them with respect.

7            Our statutory role for medical education and training means that we also have an interest in the competence, capacity, skills and training of the workforce – areas which the Inquiry is examining.

Our involvement with the national focus on end of life care

8            The LCP was in use for over a decade. Its aim was to bring the best of terminal care to all clinical settings. If followed correctly and by properly trained staff, the LCP is consistent with our guidance and would help ensure that patients receive good care as they reach the end of life, and are treated with dignity and respect.

9            Though the LCP was introduced to help doctors and nurses provide quality care to patients in their final hours and days of life, over the last few years there were media reports that some patients had been put on this regime when it had not been appropriate for them. There was considerable concern among some relatives who felt that this framework had been misused and that they have been excluded from decision making about the nature of the care and support their loved one had received.

10       The subsequent Neuberger Review found that in some places the LCP had come to be regarded as a generic protocol and hence engendered a tick box approach. Care for dying people should not be based on protocols or tick boxes. A new approach was therefore needed that was about providing individualised care, focussing on the needs and wishes of dying people and their families. 

11       In July 2013 we joined the Leadership Alliance for the Care of Dying People (LACDP) to develop a collaborative system-wide response to the findings of the Neuberger Review of the Liverpool Care Pathway and identify where improvements could be made to the care of dying people and their families.

12       The system-wide response, One chance to get it right, identified a more intuitive approach to the care of dying people. Central to this approach are the five Priorities for care. These emphasise the need for personalised care plans and describe the high level outcomes that will ensure doctors and other professionals deliver the best possible care.

13       In addition to care plans, the Priorities focus on the importance of clear and sensitive communication with and about the dying person, and ensuring that the needs and wishes of the dying person and those closest to them are known and respected.     

14       The Priorities are supported by advice on the Duties and Responsibilities of Health and Care Staff implementing the Priorities in the different settings where they care for dying people. The Priorities for care and supporting advice for staff align with our good practice guidance, Treatment and care towards the end of life: good practice in decision-making, and with the standards and codes of other regulators including the Nursing and Midwifery Council.

15       We also helped the LACDP build a picture of the existing coverage of end of life care in the education standards, curricula and guidance which regulators, professional bodies and other institutions in the health and care sector have set. There is a summary of the findings in One chance to get it right. This work also helped identify opportunities for further developments in education and training and continuing professional development to better support and equip health and care staff in the care of dying people.

Our commitments and progress to date

16       One chance to get it right was accompanied by Commitment Statements, which set out a number of pledges by members of the LACDP on the action they will take to improve aspects of service delivery, professional practice and education and training to help embed the Priorities across health and social care.

17       The action that we are taking and the progress made to date is summarised as follows:

How we are promoting the importance of end of life care at local and national level

• We have continued to promote our guidance on end of life care, at the local and national level, focusing on the key themes we know doctors find challenging and which were highlighted in the LCP Review. Our regional teams in England regularly engage with doctors, medical students and patients, Clinical Commissioning Groups and other organisations involved in local healthcare services. End of life care remains one of the themes on which we are most frequently asked to present and we have this year received nearly one hundred requests for such sessions.

• Following an initial meeting with the National Council for Palliative Care to discuss opportunities for partnership working, we’re planning to collaborate on the production of case studies, opinion pieces and some ‘mythbusters’ aimed at encouraging patients to engage with issues around end of life care planning. We expect this work to begin in January 2015.

• We are redeveloping our end of life care decision making flowchart as an interactive tool to help doctors to assess a patient’s capacity to make decisions about their care and work more effectively in partnership with patients and those close to them. It will be launched in early 2015. We are also refreshing the presentation of our end of life care guidance and supporting resources on our website, to make them more prominent, easy to use and accessible. And we are exploring with E-Learning for Healthcare the scope for updating GMC content available through their website. We will run a campaign during 2015 to raise awareness of all of these online resources, and how they can support doctors to deliver the Priorities for care.

• We have been exploring a range of possibilities for collaborating with other organisations to deliver training opportunities for practising doctors. For example, we are working with the Royal College of General Practitioners (RCGP) to run a series of pilot workshops for GPs. The first of these was held in September in Sheffield and received positive feedback. We are assessing their value as a longer term means of engaging with groups of GPs, in addition to the ongoing work of our regional teams. We are discussing with NHS Education for Scotland the scope for running a series of workshops for doctors across the Scottish health board areas. We are also exploring opportunities to work with Marie Curie on its ‘Transforming your palliative and end of life care’ programme in Northern Ireland.

• We are contributing funding and content for the production of a DVD for GPs, in partnership with RCGP Wales. The DVD will be sent to all GP practices in Wales and hosted on our website, and will look at the issues and challenges of end of life care from a range of perspectives. The DVD will be launched in early 2015.

Our focus on education and training and continuing professional development

• A joint letter from the GMC and Medical Schools Council was sent to all Deans of medical schools (July 2014) reminding them of the need to ensure that the curricula they set equip students effectively to support the care of dying people. We also included a question about end of life care in the annual return we require medical schools to complete as part of the quality assurance process. Responses are due in December and these should enable us to build a picture of current coverage of end of life care in undergraduate education and monitor future compliance against our expected standards and outcomes. We are also considering the possibility of funding further evaluation of undergraduate and postgraduate education and training in end of life care.

• We are working with the Academy of Medical Royal Colleges to develop a framework for ‘generic professional capabilities’ which focuses on areas such as shared decision-making, effective communication and team working - areas which are integral to all clinical care, but particularly important to end of life care. The framework will describe the knowledge and skills that are common across all specialties and that we expect doctors to be able to demonstrate by the time they are ready for unsupervised practice. Work is now well underway to develop the categories and themes which will form the framework. We will be engaging and consulting with the medical royal colleges, faculties, Health Education England,  Local Education and Training Boards, the NHS Leadership Academy, patient organisations and others in 2015.

• We are developing advice to help doctors to access guidance and learning opportunities on end of life care, that support doctors’ continuing professional development (CPD). We are also developing a CPD electronic application (‘app’) for all doctors to help them plan, carry out and evaluate their CPD. It will emphasise the importance of relevant and reflective CPD as part of appraisal processes. The ‘app’ will be launched in 2015 and will include content related to end of life care. 

Monitoring progress

18       We hope the Committee find this summary helpful. We would of course be happy to provide further details of the action we are taking and the progress being made. 

19       We will continue to work closely with the Department of Health (England) and key interest organisations, both to monitor progress and explore opportunities that could strengthen education and preparedness of doctors in this important area of medicine.

18 December 2014