Written evidence from the General Medical Council (BRE0102)

1. During our oral evidence to the Committee on 28 February we agreed to provide further information about the legislation which impacts on flexibility in postgraduate training.

2. This is an issue that we have been considering in detail as part of a report that we have conducted for the four UK health ministers, Adapting for the future: A plan for improving the flexibility of UK postgraduate medical training[*].  This review has now been published and is available on our website.

3. In this submission we highlight some of the key points which address the questions raised by Dr Phillippa Whitford on 28 February. We also set out how we plan to address these barriers to flexible training arrangements.

4. Since our oral evidence we have also published a report which may be of interest to the Committee in terms of understanding the current make up of the EEA medical workforce. We include details about this work at the end of this submission.

History of recognition of professional qualifications (RPQ) Directive

5. There is a long history to the impact of EU legislation on medical education and training. In 1975, the so-called ‘Doctors Directive’ established minimum training requirements for primary medical and specialist qualifications. Doctors whose qualification met these minimum requirements were entitled to have them recognised in all EEA countries.

6. The provisions of this Directive have continued to change and evolve over time. They were updated throughout the 1980s before being finally consolidated into the recognition of professional qualifications directive (‘the [RPQ] directive’), which applies to a number of different professions, including doctors.  The directive was adopted in 2005 and then revised again in 2013.

7. Each time the directive is updated or amended, the amendments are incorporated in to UK law. The requirements of the directive concerning postgraduate medical education and training are embedded in UK law through the Medical Act 1983 and the Postgraduate Medical Education and Training Order of Council 2010 (‘PMET Order’).

Transfer between specialties

8. In the UK there are 66 specialties and 32 sub-specialties of medicine. Of the 66 specialties, over two-thirds are listed in an Annex to the directive[†] that governs the recognition of professional qualifications across the European Economic Area (EEA). These are referred to as ‘Annex V’ specialties.
9. The Annex was created to facilitate the mobility of specialist doctors across Europe. It allows doctors with a specialty qualification listed in the Annex to have that qualification automatically recognised in another EEA state that also lists that specialty in the Annex. In order to ensure minimum standards of training for these specialties that benefit from automatic recognition, the directive stipulates minimum training durations.
10. To maintain these minimum training periods set out in the Annex, the directive places some restrictions[‡] on doctors wishing to train in another specialty from the one they chose originally to train in. These were introduced in November 2013 and implemented in the UK via the PMET Order in November 2016.
11. This means that a doctor with a specialist qualification can have their training time in a second specialty reduced below the minimum duration set by the GMC. However there are restrictions around this:

• The doctor must have already obtained a qualification in an Annex V specialty.[§]
• The second specialty must be another Annex V specialty.
• And the training duration can be reduced by no more than 50%.

12. For the remaining 19 UK specialties not covered in the directive but covered in UK legislation, the above restrictions on exemptions from minimum training periods do not apply. Doctors can, with the support of medical royal colleges and postgraduate deans, move between specialties. They still need to secure a post through recruitment and selection processes.
13. Following the publication of our review into flexibility in postgraduate training, we will be engaging with the UK Government to seek clarity on the restrictions for doctors transferring from one Annex V specialty to another. The UK Government, in consultation with the devolved administrations of the UK, may wish to seek advice from the European Commission on this matter.
14. We will also explore with the UK Government, in the context of the UK’s departure from the EU, whether there is scope to adopt a different legislative framework in the future – one that provides more flexibility and consistency for trainees.

Transfer into general practice

15. For doctors who transfer into General Practice training, we were concerned about the apparent inflexibility which could be stopping doctors training in one specialty from transferring to general practice. Since the Health Select Committee session on 28 February, we have clarified the legal position in respect of GP training. We can confirm that the directive does provide discretion for exemption to the duration of GP training. However, this flexibility is not currently fully reflected in the requirements for GP training under the Medical Act 1983. Currently, the Act requires that GP training must be three years in duration; therefore we approve the GP curriculum on this basis.

16. We will now seek amendments to the Medical Act to reflect the flexibility offered under EU law for general practice training.

Prospective approval

17. In our oral evidence, we mentioned that prospective approval of training may cause barriers to flexibility. By ‘prospective approval’ we mean that the training programme that a doctor is undertaking must be approved by the GMC before they commence it if the training is to lead to the award of a CCT. We have now clarified the legal position which has confirmed that neither the directive nor the Act require that all elements of training must be approved prospectively by the GMC. However, training must still be approved by the GMC before a doctor can be awarded a CCT for completing their training.
18. We will now explore how we can amend our processes to ensure that this legal flexibility is reflected in practice.

GMC data on doctors from Europe

19. We want to make our data as useful as possible to those who want to understand more about the composition of the medical workforce.
20. Since the referendum vote to leave the EU we have received a large number of requests for data about the nationalities of the doctors practising in the UK. We therefore produced a paper ‘Our data about doctors with a European primary medical qualification’ [**]. This describes in detail the characteristics of doctors who are licensed to practise in the UK and have a primary medical qualification (PMQ) from the European Economic Area (EEA).  We have shared this report with the Committee.
21. In case it is helpful, we wanted to highlight that we have since our evidence session published a second working paper ‘The relationship between primary medical qualification region and nationality at the time of registration’ [††]. This covers the results of an analysis of how the regions in which doctors gained their PMQs relate to their nationalities at the time that they joined the register.
22. The relationship between PMQ region - where we have precise information for each and every licensed doctor - and nationality at time of registration - where significant amounts of missing data have to be imputed or estimated - is not a simple one.
23. Our report concludes that EEA region PMQ is not a reliable indicator for counting doctors who were of EEA nationality at the time of their registration - therefore in considering the workforce implications of Brexit, it will be important to have regard to the fact that EEA region PMQ data under-estimates the number of EEA nationals.