Clinical placements in undergraduate medicine in London: A review of the current placement programme OCTOBER 2016 Produced on behalf of London Medicine, this report outlines the current position regarding undergraduate medical clinical placements in London, and suggests ways in which the system could adapt to best meet the needs of the various stakeholders. The paper has been informed by colleagues from across the five London medical schools, as well as colleagues from commissioners, employers and stakeholders in London (listed in Annex 4). This report forms part of a series of work within the Vital Signs programme. Vital Signs addresses a range of challenges pertaining to both higher education and health policy which are likely to impact the provision of health education and training over the next five years. Theme 1: Clinical Placements in Undergraduate Medicine aims to maximize the potential of clinical placements in London whilst gaining a better understanding students’ perspectives of their clinical placement. London Medicine is the group bringing together the five schools of medicine, three schools of dentistry and schools of clinical academic disciplines in London. London Medicine is a division of London Higher, the body representing nearly 50 universities and higher education colleges in London, working to identify the opportunities and address the challenges of working in London. 1 | P a g e Contents Section 1: Background Setting the scene Page 3 Specific challenges for clinical placements Page 4 Section 2: The Current System Funding Pages 5-7 Placement quality and educational outcomes Pages 8-9 Primary care and care in the community Pages 9-10 Capacity Pages 10-11 Establishment of private medical schools Page 11 The role of private health providers Page 12 Section 3: Discussion and Questions for the Future New developments and the current system Pages 13-15 Systems Pages 15-16 Annex 1: Clinical Placements – Background Pages 17-18 Annex 2: Tariff Guidance Pages 19-20 Annex 3: Medical and Dental Target Intakes 2015-16 Page 21 Annex 4: Partners Page 22 References Pages 23-24 2 | P a g e Section 1: Background Setting the scene London’s diverse population is witnessed in its health outcomes. Its workforce, and its medical students, benefit from being exposed to a diverse population and range of health conditions that may not be seen so frequently in other areas of the country. In addition to the wide variety of health conditions, London is tackling an ageing population, which is placing an increasing demand on the healthcare system. These characteristics of the capital mean that there is a strong need for multi-professional education and training that thoroughly prepares medical students for the integrated healthcare system that they will work in as doctors. As such the requirements from the health service are changing with a need to be adaptable in order to cope with the increase in demand and the type of services being offered. Additionally, the Five Year Forward View1 and new Sustainability and Transformation Plans2 (STPs) propose a new way of working for the NHS. With the ongoing finance constraints on the NHS and the introduction of a new higher education bill, health education and training in London is entering a dynamic new phase. NHS England has a goal to achieve a net increase of 5,000 new GPs in the next 5 years3. The Department for Education is introducing legislation to more closely monitor the quality of teaching provision. These imperatives are being driven by the ultimate goal to shift a greater delivery of healthcare into community settings, an aspiration that must become a reality if England is to meet the chronic health challenges of its ageing population. In October 2016, the Government announced proposals to expand the student medical training cap to 7,500, an increase of 1,500 students per year. It will be 2024 before any benefits of this increase are seen in real terms. A core element of the current education and training curriculum, both in terms of budget and learning outcomes, is the well-established placement system. This paper looks at a number of challenges inherent in the current system of the management of placements, in particular as they pertain to the shift towards more community care, and also to changes to the quality agenda. 3 | P a g e Specific challenges for clinical placements - recent and ongoing policy developments include: Funding pressures on the NHS, in particular the increasing deficits run by most NHS Trusts, and the public drive for improvements in performance and efficiencies may impact on the quality and quantity of placements. The demands of an integrated healthcare system, and the move towards greater provision of community care, require re-thinking the learning and teaching framework, career pathways and placement contexts. Linked to this, the Shape of Training4 report argues for broader medical training at the start of a medic's career. There is a UK-wide recruitment problem in General Practice. There is going to be increased demand for GP services, so it is essential that more students are encouraged to pursue this career route. The introduction of a Teaching Excellence Framework5 (TEF), and how the metrics used can fairly recognise and/or evaluate the time spent on student placements. The development of new medical schools, and increased competition for placements, in an already close to saturated market. The expansion of the private providers of healthcare, and whether they provide placements to medical students. 4 | P a g e Section 2: The Current System Funding The commissioners for London are Health Education England’s London and South East Local Education and Training Board (LETB). They manage the funds to commission medical clinical placements from NHS Trusts for undergraduate students. The LETB acts as the intermediary between the Trusts and the universities regarding undergraduate clinical placements. Undergraduate clinical placements for medical students attract a national tariff from the commissioners. The Service Increment for Teaching (SIFT) was historically provided to fund the additional cost to the NHS that is incurred as a result of provision of teaching for medical undergraduates. SIFT has been transitioning to the Tariff payment since April 2013, a process which is nearly complete and has seen a significant reduction in overall funding, particularly to Teaching Hospitals. The Tariff is not a payment for teaching services but is designed to meet the extra costs incurred, compensating for the loss of service incurred through teaching; SIFT is paid directly to the institution to cover these costs. The current value (2016/17) of the Tariff is £33,286 + MFF (Market Forces Factor) for undergraduate medicine6. The Tariff covers funding for all direct costs involved in delivering education and training by the provider. The value of the Tariff was frozen for 2016/17 and its status for 2017/18 and beyond is unknown at present. The Tariff does not as yet cover medical placements in primary care (further detail outlined in Annex 2). Currently, although universities act as the broker for the funding, they do not receive any of the funding themselves. Through our preliminary discussions with medical schools it appears that there are current processes within this system which are not ideal. The universities hold all of the responsibility for their students’ clinical placements, whilst not being accountable as they are not the commissioner. Typically the Trusts are working under two contracts. The LDA (Learning Development Agreement) with the commissioner - the contract in which the funds are attached, and a separate contract between the university and the Trust. There is variation in these two contracts and some have discussed a lack of clear deliverables, quality assurance and accountability lines. 5 | P a g e Some medical schools have developed a ‘minimum standards’ document which they use as a shared document between Trusts and the university to address some of these issues and prevent disparity between the two contracts. Typically SIFT/Tariff funding is absorbed into the Trust’s finances. Trusts use the money differently; our discussions have shown that in newer Foundation Trusts more of the money is seen to be spent on the educational activities, whereas in older Trusts the money lines are not so transparent. There is wide disparity between Trusts regarding the transparency of funding. There can also be variation between Trusts regarding the value they place on the teaching component; the time and ability of the clinician in charge; plus other factors in the service setting. Medical schools do carry out an annual inspection/quality visit of placements, however if problems are found it can be a long process to get things improved. Also, in some cases even if a university may prefer to discontinue with a placement that they are unhappy with, it may not be possible for the placement to be moved elsewhere if there is not the capacity in the system to do this. Additionally universities may be reluctant to disrupt the system in this way. Ultimately the funding follows the student, so if there is capacity and need, placements can be altered if necessary. On the whole there are generally good relationships between commissioners, providers and universities in London. In order to improve and make better use of the current system, better liaison with all parties regarding the health professional workforce requirements are desirable. Clearer expectations and set boundaries, for example between medical schools and commissioners, may improve working practices and encourage closer working. In particular this may help strengthen multi-professional working as opposed to the current uni-professional approach. 6 | P a g e Case Study: Allocating funding to clinical service lines At the Royal Free London NHS Foundation Trust Paul Dilworth, UCL Medical School Sub Dean, has helped set up and implement a new process of tracking monies in clinical departments, devolving to service lines.