The Francis Report on Mid Staffs (http://www.midstaffsinquiry.com/pressrelease.html)
makes a number of points germane to medical education. For those of you (slackers!) who haven’t read the full 4000 pages, I’ve cut and pasted some interesting sections below. Section numbers refer to the original.
One comment points at the value of direct observation (qualitative research!) as an essential supplement to quantitative data.
1.70 …. The investigation demonstrates how powerful the combination of direct observation of practice, contact with patients, families, frontline staff and examination of real cases is, as opposed to reliance on files of policies, committee minutes and overall figures. This is not to say that examination of systems is not important, but it is not and never will be sufficient”
The local medical education systems (Keele Medical School…) come under particular scrutiny, and bullying receives a particular mention. Relevant sections include:
1.84 The system of regulation and oversight of medical training and education in place between 2005 and 2009 failed to detect any concerns about the Trust other than matters regarded as of no exceptional significance. There were a number of factors contributing to this:
While patient safety was theoretically given primacy in the system, the domain to be monitored was unduly limited to the potential risk posed to patients by the trainee. Insufficient consideration was given to the relevance of good quality training of practice in a setting which complied with minimum patient safety and quality standards, and to the professional obligation to protect patients from harm.
The Postgraduate Medical Education and Training Board (PMETB)/GMC/deanery wide reviews focused on deanery systems of quality management, resulting in only superficial examination of the standards being observed. Such reviews did not consistently consider compliance with patient safety standards.
When concerns were raised about inappropriate pressure or bullying by staff towards trainees these were not followed up or investigated.
A reluctance to prejudice the provision of a service or the training of trainees has resulted in the implied threat of removal of approval for providing training places being largely theoretical.
This has particular implications for the education of trainees in reporting adverse events which they observe during the course of training, as below.
1.86 All doctors, whether fully qualified or in training, work in environments where they are under a duty to protect patients. Good practical training should only be given where there is good clinical care. Absence of care to that standard will mean that training is deficient. Therefore, there is an inextricable link between the two that no organisation responsible for the provision, supervision or regulation of education can properly ignore. Trainees are invaluable eyes and ears in a hospital setting.
Also significant are aspects of professional development which will have to be inculcated in students from the earliest stages of their training. As Francis cogently identifies, cultural aspects are particular important in delivery of safe practice.
1.116 The negative aspects of culture in the system were identified as including:
- A lack of openness to criticism;
- A lack of consideration for patients;
- Looking inwards not outwards;
- Misplaced assumptions about the judgements and actions of others;
- An acceptance of poor standards;
- A failure to put the patient first in everything that is done.
Patient safety and education are explicitly mentioned in a number of places, e.g..
1.172 Medical education and training systems provide an opportunity for enhancing patient safety. Students and trainees should not be placed in establishments which do not comply with the fundamental standards, and those charged with overseeing and regulating these activities should, like all other participants in the system, make the protection of patients their priority.
1.204 The GMC and the NMC should ensure that patients’ safety is the first priority of medical training and education.
The Recommendations reinforce the comments made in the main body of the Report, and provide clear action points. I’ve assembled all the relevant ones below. The use of Section Headings or numbers alone is inconsistent in the Report itself.
152 Medical training
Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, must be required to inform the relevant training regulator of those concerns.
153 The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between the deanery, commissioners, the General Medical Council, the Care Quality Commission and Monitor with regard to patient safety issues must be reviewed to ensure that each organisation is made aware of matters of concern relevant to their responsibilities.
154 The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight of medical training to coordinate their oversight of healthcare organisations which provide regulated training.
155 The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles:
- The Postgraduate Dean should be responsible for managing the process at the level of the Local Educational Training Board, as part of overall deanery functions.
- The Royal Colleges should be enlisted to support such visits and to provide the relevant specialist expertise where required.
- There should be lay or patient representation on visits to ensure that patient interests are maintained as the priority.
- Such visits should be informed by all other sources of information and, if relevant, coordinated with the work of the Care Quality Commission and other forms of review.
- The Department of Health should provide appropriate resources to ensure that an effective programme of monitoring training by visits can be carried out.
- All healthcare organisations must be required to release healthcare professionals to support the visits programme.
It should also be recognised that the benefits in professional development and dissemination of good practice are of significant value.
156 The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.
157 Matters to be reported to the General Medical Council
The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical Council either routinely or as they arise. Reports should include a description of all relevant activity and findings and not be limited to exceptional matters of perceived non-compliance with standards.
Without a compelling and recorded reason, no professional in a training organisation interviewed by a regulator in the course of an investigation should be bound by a requirement of confidentiality not to report the existence of an investigation, and the concerns raised by or to the investigation with his own organisation.
158 Training and training establishments as a source of safety information
The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, and should generally place the highest priority on the safety of patients.
159 Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing the survey and routinely share information obtained with healthcare regulators.
160 Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.
161 Training visits should make an important contribution to the protection of patients:
- Obtaining information directly from trainees should remain a valuable source of information – but it should not be the only method used.
- Visits to, and observation of, the actual training environment would enable visitors to detect poor practice from which both patients and trainees should be sheltered.
- The opportunity can be taken to share and disseminate good practice with trainers and management.
Visits of this nature will encourage the transparency that is so vital to the preservation of minimum standards.
162 The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of medical training and education maintains as its first priority the safety of patients. It should also ensure that providers of clinical placements are unable to take on students or trainees in areas which do not comply with fundamental patient safety and quality standards. Regulators and deaneries should exercise their own independent judgement as to whether such standards have been achieved and if at any stage concerns relating to patient safety are raised to the, must take appropriate action to ensure these concerns are properly addressed.
163 Safe staff numbers and skills
The General Medical Council’s system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure patient safety in the course of training.
164 Approved Practice Settings
The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision of the same. Consideration should be given to empowering the General Medical Council to charge organisations a fee for approval.
165 The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.
166 The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view in particular to provision for active exchange of relevant information with the healthcare systems regulator, coordination of monitoring processes with others required for medical education and training, and receipt of relevant information from registered practitioners of their current experience in approved practice settings approved establishments.
167 The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments with a view to ensuring that the General Medical Council (or if considered to be more appropriate, the healthcare systems regulator) has the power to inspect establishments, either itself or by an appointed entity on its behalf, and to require the production of relevant information.
168 The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for post graduate training.
169 Role of the Department of Health and the National Quality Board
The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation between them and healthcare systems regulators.
170 Health Education England
Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.
All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education.
172 Proficiency in the English language
The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required for a registered medical practitioner to assume professional responsibility for medical treatment of an English-speaking patient.
Of particular interest (and possibly concern) are the recommendations on the duty of disclosure.
181 Enforcement of the duty
Statutory duties of candour in relation to harm to patients
A statutory obligation should be imposed to observe a duty of candour:
On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to provide such information and explanation as the patient reasonably may request;
On registered medical practitioners and registered nurses and other registered professionals who believe or suspect that treatment or care provided to a patient by or on behalf of any healthcare provider by which they are employed has caused death or serious injury to the patient to report their belief or suspicion to their employer as soon as is reasonably practicable.
The provision of information in compliance with this requirement should not of itself be evidence or an admission of any civil or criminal liability, but non-compliance with the statutory duty should entitle the patient to a remedy.
Of interest to those of us with a particular focus on selection is this Recommendation, which indicates a requirement for a personal aptitude test of some kind, although this rather seems to underestimate the difficulty of achieving this task in a valid, reliable and defensible way.
188 Aptitude test for compassion and caring
The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in particular, candidates’ attitudes towards caring, compassion and other necessary professional values.
The Report also makes clear that the University senior authorities bear responsibility for medical issues arising from training. The PVC and Faculty Dean came in for particular comment, in ways which may not always sound comfortable.
The Pro-Vice-Chancellor of Keele University and Dean of its Faculty of Health, Professor Garner, assured the Inquiry that there had been extensive mechanisms in place to monitor the training offered to students at the Trust.43 Unfortunately, as he had not been personally involved in this function, he was unable to assist with specifics. He explained that he was not head of the medical school but had overarching responsibility for four schools and two research institutes; he suggested that the Inquiry could approach medical school staff.44
However, the extent to which he had not informed himself of such details given the concerns uncovered about the Trust was surprising in light of his overall role at the faculty. For example, he was unable to assist the Inquiry with whether there had been any review of the systems in place following the Healthcare Commission (HCC) report or to explain why the GMC was given the impression in a letter of 24 March 2009 that the problems at Stafford were now in the past and had been resolved.
18.118 Professor Garner explained to the Inquiry112 that a review had been undertaken of the information the University had received from students over the relevant period, and none of the concerns uncovered by the HCC had been communicated. He accepted that the University would have wanted to know about them at the time. He could offer no explanation why the University had not become alert to any of them. This review was not in fact undertaken by the University until June 2011 in preparation for his giving evidence to the Inquiry. The 2011 review did not seek out the reasons why the Medical School had been unaware of issues surrounding the quality of care, or why students had not raised them or whether those reasons were relevant to the suitability of the Trust as a location for students.
So, in general, much to reflect upon. Comments very welcome.