nhs education for scotland future changes to medical act … changes to... · 2013-06-26 · 1 nhs...
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NHS Education for Scotland
Future Changes to Medical ACT Policy
Review of Consultation Responses and Next Steps
1 Introduction
The consultation document on future changes to Medical ACT policy was issued by NES on 30 May and responses were requested by the end of June. A copy is attached at Appendix 1.
A total of 14 responses were received many of which were composite responses from stakeholder groups, including a number of Regional ACT Groups and The Board for Academic Medicine. Individual responses were also received from a range of stakeholders including DMEs, Teaching Deans, ACT finance leads and PG Deans.
2 Overview
There was very strong support for the need to review ACT policy and the general direction of travel set out in the consultation document. The revised ACT principles shown below were also strongly supported (with some queries set out in paragraph 3);
• An open and transparent approach
• Support the requirements of the GMC
• The use of one national rate for all teaching
• Equity of approach across Scotland
• Equity of funding for teaching in hospital and Primary Care settings
• Use of total student numbers to drive the allocation model
• Robust performance management systems
All of the proposed changes outlined in the document received support from the majority of respondents although in some areas further clarity was requested.
Recognition of the need to address the changing GMC regulatory framework was recognised by all respondents, although some concerns were raised about whether some of the GMC requirements were realistic. There was strong general support for the need to develop ACT policies to underpin the future requirements of the GMC.
Proposed timescales were considered to be challenging, especially for the roll-out of the MoT project.
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3 Response to Consultation Questions
1 Do you support the revised key principles for Medical ACT?
Overview All respondents agreed with the revised principles although some questions were raised about what some of the principles would mean in practice. In addition,
Issue Response
One respondent was concerned that the performance management systems may deter clinicians from undertaking educational roles.
Noted – this issue will require to be kept under review especially as the GMC requirements on the recognition and approval of trainers are introduced. We will liaise with SDMEG and MDET as necessary.
It was suggested by a number of respondents that there would need to be clarity about at what level there should be equity of funding for hospital and primary care teaching.
Agreed – we will make it clear in future communications that equity of funding is applicable in the distribution of ACT funding to Boards - stage two of the allocation model. It does not impose any additional restrictions on how Boards spend ACT funding.
One respondent also suggested that there should be an exception to the use of one national rate for remote and rural placements.
Not supported. It was agreed to support remote and rural placements through the use of pump-priming funding (see paragraph 5) but we do not want to set a precedent of differing payment rates for differing types of teaching. Also, the ACT policy in respect of travel and subsistence remains in place.
There were a number of comments about the need for a measured approach to performance management to avoid unnecessary costs and increased bureaucracy.
Agreed.
2 Do you support the use of ACT funding to support future GMC requirements for the approval of trainers and to support faculty development?
Overview All respondents were in agreement with this proposal. In addition;
Issue Response
Some respondents went further and suggested a more explicit requirement for a proportion of ACT funding to be
Not supported as this could be too prescriptive. However, Regional Groups could agree to such an initiative locally if
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used for staff development. this was supported by the Boards in the region.
The Board for Academic Medicine looked for reassurances that ACT funds intended to support undergraduate teaching should not be diverted to support postgraduate teaching.
Noted. This will be made explicit in the revised ACT guidance notes issued with the allocation letters but recognising that many educators have dual roles across undergraduate and postgraduate education.
Some respondents considered this might be challenging where ACT funds are already being spent on other teaching activities.
Noted. It is understood that there is a need to manage existing ACT funded activity to avoid destabilising services.
3 Is it reasonable to ask Boards to incorporate the MoT data into job plans and directorate budgets within the next 2/3 years?
Overview All respondents supported the general principles around the need to identify teaching time in job plans although there were mixed views about the reasonableness of the associated timescales. In addition;
Issue Response
Most respondents supported the proposals and thought the 2/3 year timescale was reasonable.
Noted.
Some respondents thought there should be a longer timescale for incorporating the data into directorate budgets but there was broad support for adopting this principle.
Noted. Further guidance will be issued in due course but it is recognised that some aspects of the MoT project will take longer than others.
A number of respondents were concerned that the associated administrative costs should be kept down.
Agreed.
One Board did not think that incorporating MoT data into job plans was feasible for larger Boards and also did not agree that it would be possible to incorporate MoT data into directorate budgets.
Noted. We will work with all Boards in conjunction with ACT Officers on a 1/1 basis as all Boards are at different stages in this process.
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4 Depending on the outcome of the work to be carried out by SGHD in conjunction with the rest of the UK, is it appropriate to manage any ACT-type levy to support the NHS cost of overseas students through MoT and the ACT allocation model?
Overview All respondents agreed with this approach. In addition;
Issue Response
A number of respondents thought the detail would require careful consideration.
Agreed. The detail will be developed under the guidance of Scottish Government (SG).
One respondent suggested we should await the outcome of any UK level discussions.
Not supported. We will work with SG in conjunction with work underway in other parts of the UK. However, as timescales remain uncertain we will work with SG to implement local arrangements where appropriate.
The Board for Academic Medicine (BfAM) expressed willingness to discuss the introduction of an ACT-type levy on all international students.
Noted. This is very helpful and we will work with the BfAM in conjunction with SG.
5 Are there other ways we can enhance the quality of undergraduate teaching within the NHS through the management of medical ACT?
Overview A number of further suggestions were made as set out below. We would welcome further feed-back on any of these issues;
Issue Response
We should consider asking teachers their views, in the same way as the GMC does on the postgraduate side through the trainers’ survey, and ask for suggestions for improvement.
This will be considered further with the Scottish Deans Medical Education Group (SDMEG) and discussed with the GMC in terms of the national context.
We should consider promoting the principle of teaching consultants with up to 50% of their time in job plans for teaching and training.
We would be happy to support the piloting of this approach. Funding may be an issue.
One respondent suggested a percentage of the personal study leave budgets for consultants should be used for educator roles if relevant.
A mandated approach could be difficult to achieve but there is no reason why this cannot be agreed on an individual basis through the appraisal process.
We should adopt a more positive approach to clinicians to enhance
Agreed. In conjunction with stakeholder groups we will try to ensure a positive
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teaching quality as the current systems give a negative message which reduces engagement with teaching.
message is given to clinicians engaged in teaching where-ever possible.
We should do more to acknowledge the role of the non-consultant grade and other professional groups involved in teaching.
Agreed. We are also trying to pick this up through our MoT project.
We should consider the potential value of medical education fellowships in improving quality and driving innovation.
We could support the piloting of this proposal if supported by Regional Groups. Funding would require to be identified by Boards but this could be an initiative appropriate for any available in-year funding.
4 Other Issues
Supporting the development of the educational infrastructure
The proposal to update the Medical ACT Performance Management Framework to be more specific about the requirements of Local Education Providers (LEPs) to meet GMC requirements through the effective use of Medical ACT was welcomed.
One respondent noted that the focus on Tomorrow’s Doctors as an undergraduate set of standards to be delivered, where applicable through Medical ACT, was also welcomed.
Quality Management
The proposed changes to the performance management framework to support an integrated approach to quality management through the ACT allocation model was supported. The use of the year-on-year RAG data to identify trends was welcomed.
The use of the ACT allocation model to address persistent quality issues was broadly supported but one respondent noted that any impact on service delivery would always require to be considered.
Teaching Activity Data and MoT project
In addition to the comments on the feasibility of achieving the proposed timescales, there were also a number of additional issues raised;
Issue Response
A number of respondents suggested there needs to be further clarity on what we are trying to measure.
Agreed. This will be picked up in the further guidance on the MoT project to be issued later this year.
One respondent noted the need to recognise informal teaching.
Agreed. Again this will be covered in the guidance.
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One regional group suggested reporting to the GMC and NES on teaching delivery and time in job plans should be devolved to the medical schools.
Under GMC requirements on the recognition and approval of trainers this will be the responsibility of the Medical Schools. However, the MoT project is designed to help Schools deliver this requirement.
One respondent raised the issue of the imbalance of teaching provided between the University and NHS and the impact on ACT allocations.
This is an issue for local agreement between the Medical School and the Boards. However, the two stage allocation model ensures equity in the distribution of ACT funding.
The need to consider cost-effectiveness of teaching was also raised.
Agreed. There is a need to consider both the quality of teaching through the RAG reports alongside teaching activity data.
Economic Pressures
There were very few comments on the proposals to manage economic pressures other than;
Issue Response
One respondent said there should not be a minimum level of efficiency savings and any requirement to generate efficiency savings should be left to Boards to manage.
Not supported. We should maintain some pressure on Boards to deliver efficiency savings to ensure there is some investment funding available for priority developments.
A number of respondents requested further clarification on the current status of the glide-path.
Agreed. This will be issued with the 2013/14 allocation letters.
Multi-professional Education
This section was generally acceptable to respondents or they had no comments other than;
Issue Response
There was a suggestion from two respondents that to be acceptable the proposals for the use of ACT funds should require at least 80% of the benefits (rather than the proposed 50%) to be for medical students.
Not supported - while 80% may be a reasonable level for many initiatives it could be unnecessarily restrictive.
Primary Care Teaching
There was only one issue raised on this section;
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Issue Response
A number of queries were raised about the proposals to separately identify ACT funding relating to Primary Care and notify Primary Care Academic Departments accordingly. It was suggested that separating PC funding in this way could encourage further division between primary care and acute services.
Although this point should be noted and we need to manage expectations carefully, on balance the increased level of transparency could be useful. We will however, ensure this is carefully worded in the revised guidance notes for Medical ACT.
5 Summary of proposed changes to the ACT Allocation Model
Based on the responses received the following changes proposed to the allocation model will be adopted in due course;
Student Numbers
Total student numbers as opposed to SFC funded numbers are to be used within the first stage of the allocation model once the funding arrangements for overseas students are agreed with SG, taking into account UK-wide policy.
MoT Data
The second stage of the allocation model will continue to distribute the funding which is identified in Stage 1 of the model to NHS Boards based on historic levels of teaching activity undertaken for each Medical School. However, the model will be developed to run on historic MoT data collected by the Medical School. This data will be issued to the Boards for review in advance of being used in the ACT allocation model. This change will not be made until use of the MoT data has been fully tested and the results discussed with stakeholders.
Efficiency Savings
NES will continue to identify a minimum level of efficiency savings that Boards will be required to generate each year. These savings will be retained year-on-year by Boards to provide a development fund for re-investment in agreed priority developments. The level of efficiency savings required will generally mirror requirements for other NHS services.
Year-on-year allocation adjustments, arising from changes in relative teaching activity between Boards, will be capped. The rationale for this approach is to avoid the destabilisation of service delivery arising from major in-year ACT adjustments – this is akin to the guide-path approach introduced at the start of the new allocation model in 2005/06. We expect the maximum reduction in year to be capped at a level that we would not expect to exceed 5%.
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Primary Care Teaching
To mirror the objectives of the MoT project and increase transparency, details of funding allocated to each Board for Primary Care teaching by Medical School will be sent to the GP Academic Department so that priorities for the use of this funding can be discussed with Boards through the Regional ACT Groups. However, there will be no additional requirements on Boards on how they decide to use their overall ACT allocation.
Remote and Rural Placements
Pump-priming funding for new remote and rural placements will be made available through the allocation model, especially to support smaller Boards develop placements, and ensure all Schools have equal access to the required number of remote and rural placements.
Multi-professional Education
We will tighten the guidelines to ensure ACT funding delivers maximum value for money and meets its core purpose (i.e. the teaching of medical students within the NHS) as follows;
1. There will be a requirement to demonstrate the measurable enhancement for medical students and other professional groups from the investment.
2. All proposals will require to be predominantly for medical students. This will usually be defined as more than 50% of the benefits.
Medical ACT Allocation for Dental Students
This funding, along with the respective commitments it currently funds, will be transferred from Medical ACT to Dental ACT from 2013/14 with the agreement of the NHS Boards concerned.
6 Summary of proposed changes to the Medical ACT Performance Management Framework
Based on the responses received the following changes proposed to the performance management framework will be made in due course;
Development of the Educational Infrastructure
The next version of the performance management framework will be more specific about the requirements of LEPs to meet GMC requirements through the effective use of Medical ACT. In particular, there will be a greater emphasis on a transparent link between ACT funding and teaching activity. The focus will be to target ACT funding towards the development of an efficient and effective educational infrastructure, with a joined up approach to undergraduate and
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postgraduate medical education and greater transparency on the use of all funding available to support medical education.
There will be a clear requirement for Boards to meet the standards set out in Tomorrow’s Doctors, as well as future GMC requirements for undergraduate medical education, in order to be eligible to receive ACT funding through the allocation model.
The performance framework will also be used to underpin the requirement of Boards and the Medical Schools to meet GMC requirements for the recognition and approval of trainers through implementation of the Faculty Development Programme for Scotland. It will also support the use of ACT funds to meet these requirements.
Quality Management
The Performance Management Framework will aim to integrate the quality management data into the management of Medical ACT by promoting the use of the RAG results by the Medical Schools when considering future changes to NHS student placements.
Where appropriate, NES will adjust the allocation model to eliminate in advance the distribution of ACT funding to specialties or locations where there have been persistent quality issues identified which have not been addressed and where the School(s) have determined the need to withdraw future students from these placements. This will only be done as a last resort in consultation with the Board and the School(s) and the wider impact on teaching and service delivery taken into account.
Teaching Activity, MoT Data and Job Plans
Over the next 2/3 years Boards will be required to make a direct link between the annual ACT allocation received from NES and the level of teaching time within job plans which will sit alongside all other ACT expenditure including GP ACT and support costs. This information on teaching time within job plans will require to be provided to NES in the Accountability Reports and is also likely to be required by the GMC to support future monitoring visits.
From this exercise ACT expenditure on teaching activity should also be identifiable within directorate budgets.
Accountability Reports
The accountability report will be further enhanced to underpin the revised performance management framework. In particular;
• Timescales will be changed to make RAG report follow-up more timely and relevant (from 2012/13 reports).
• Focus will be on quality data and enhancement.
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• Financial information will be required to link MoT data via teaching time in job plans to overall ACT allocations and directorate budgets (from 2014/15 reports).
• Allocations for Medical ACT will only be issued where a satisfactory report has been received for the previous year.
Development of Regional ACT Groups
We will review the terms of reference, membership and reporting arrangements for Regional Groups as part of the revised performance management framework to ensure they remain appropriate and makes best use of stakeholders’ time.
It is also proposed to ensure the role of the Regional ACT Groups is aligned to the role of any local ACT groups that may operate.
We will undertake a review of the infrastructure required to support ACT at a local and regional level including the role of ACT Officers and other staff supporting ACT and to consider appropriate training and development.
7 Next Steps
1. All stakeholders will be given the chance to comment on these final proposals through the Regional ACT Groups. A dead-line of 31 January is proposed.
2. There are no changes proposed to the ACT allocation model for 2013/14 but further guidance on a number of these proposals will be issued with the allocation letters and supporting guidance notes.
3. Separate guidance will be issued before the end of this financial year on the roll-out of the MoT project with links to the Faculty Development Programme for Scotland and the GMC requirements for the recognition and approval of trainers.
4. A revised Performance Management Framework will be issued for consultation later in this financial year.
Jayne Scott Project Manager 19 November 2012
Appendix 1
ACT Consultation Document – final Page 1 of 14
NHS Education for Scotland (NES)
Future Changes to Medical ACT Policy
Consultation Document
1 Introduction
Medical ACT funding is provided by the Scottish Government Health and Social Care Directorates (SGHSCD), via NES to support the Additional Cost of Teaching (ACT) undergraduate medical students within the NHS. This funding is part of NES’ overall allocation.
The current Medical ACT Allocation Model was introduced at the start of 2005/06. It is based on a two-stage process which allocates total ACT funds firstly by University based on the number of Scottish Funding Council (SFC) funded students and secondly by the level of teaching carried out by Health Boards for each University. All teaching is treated equitably for the purposes of distributing ACT funds.
The original ACT policy was clearly documented and was developed following extensive consultation with stakeholders. These core principles have served us well. ACT policy has also been supplemented in the intervening years with the Medical ACT Performance Management Framework, funding guidelines and other operational policies. ACT funding to support multi-professional educational initiatives is encouraged in the guidelines, as is a joined-up approach to undergraduate and postgraduate medical education.
The regulatory framework determined by the General Medical Council (GMC) that underpins undergraduate medical education has been developed and implemented since the allocation model was introduced with;
• The updating of Tomorrow’s Doctors in 20091,
• Moves towards the Approval of Trainers as set out in the GMC’s recent consultation document2,
• The piloting of a national (UK) student placement evaluation system based on the Scottish model and
• A move towards a single system of regulation with joint undergraduate and postgraduate monitoring visits3.
In financial terms changes are also underway as we have nearly reached the end of the glide path, which was introduced to smooth the transition from the old system to the new allocation model. In addition, Scottish Government funded student numbers are reducing and significant economic constraints are a reality for all parts of the system.
1 http://www.gmc-uk.org/TomorrowsDoctors_2009.pdf_39260971.pdf 2 http://www.gmc-uk.org/Trainers_consultation_document_Jan_12.pdf_46886901.pdf 3 http://www.gmc-uk.org/Education_Strategy_2011_2013.pdf_36672939.pdf
Appendix 1
ACT Consultation Document – final Page 2 of 14
All of these changes may impact on our ACT policy and funding guidelines. This paper sets out proposals for changes to be made to the allocation model, performance management framework and the funding guidelines, which we expect to implement during 2013/14.
2 Outline of Consultation Process
The issues set out in this consultation document are for consideration by stakeholders. In particular, written comments are requested by the end of June and it would be helpful if the responses could consider the questions at the end of this document. However, stakeholders are encouraged to raise any other relevant issues.
The consultation document has been sent to members of the following stakeholder groups, although colleagues are encouraged to distribute the document more widely if that would be helpful:
• Scottish Deans Medical Education Group (SDMEG)
• Directors of Medical Education (DME) Group
• Regional ACT Groups
• Medical ACT Finance Leads
• Scottish Association of Medical Directors (SAMD)
• ACT Officers Group
• SGHD
• NES Medical Directorate Executive Team (MDET)
• Board for Academic Medicine (BfAM)
• BMA Scotland
Each of the groups identified above have been contacted to offer the opportunity to discuss the proposals set out in this document directly with the NES Medical ACT team.
Final proposals will be issued to stakeholder groups for further comment over the summer and revised policy documents prepared thereafter.
3 History of Medical ACT and Key Principles
In 2005 The Scottish Executive Health Department (as it then was) announced the outcome of a review of ACT funding to ensure the key objectives of using ACT to support undergraduate medical and dental education within the NHS. As a result funding for direct ACT costs was transferred to NES. The new allocation model for Medical ACT was then introduced following extensive consultation with stakeholders, based on the key principles of equity and transparency. This moved the distribution of ACT funds away from only the main “Teaching “ Boards to all Health Boards.
Through consultation on the development of the new Medical ACT allocation model a number of key principles were established as follows;
• An open and transparent approach.
Appendix 1
ACT Consultation Document – final Page 3 of 14
• The use of one national rate for all teaching.
• Equity of approach across Scotland.
• Equity of funding for teaching in hospital and Primary Care settings.
• Use of SFC student numbers to drive the allocation model.
• Robust performance management systems.
These principles are considered to remain as relevant today as they were when the model was first introduced, with the possible exception of the use of SFC funded student numbers - this is dealt with in section 8. In addition, the development of the regulatory framework for undergraduate medical education by the GMC has led to the proposed addition of the new principle;
• To support the requirements of the GMC.
The consultation questions at the end of this document ask stakeholders to comment on these revised principles to underpin Medical ACT.
4 Supporting the Development of the Educational Infrastructure
As the GMC moves to adopt a single system approach to regulation across undergraduate and postgraduate medical education, and their requirements relating to the teaching of medical students within the NHS become more explicit, there is a need to ensure the ACT allocation model and performance framework supports these requirements.
Since the allocation model was introduced in 2006 we have made significant progress in a number of areas including;
1. The introduction of the quality management system of student placement evaluation,
2. Progress in counting teaching activity through the Measurement of Teaching (MoT) project and
3. Work towards a Faculty Development Plan for Scotland.
For some time we have recognised that the above three projects require to be considered as part of a holistic approach to ensuring high quality student teaching within the NHS.
As these projects have progressed the GMC has also been developing its approach to the regulation of undergraduate medical education. This is coming together through;
• GMC plans to introduce the requirement for the approval of trainers for both undergraduate and postgraduate medical education4,
• Likely requirement for the identification of dedicated teaching time within job plans for approved trainers,
4 http://www.gmc-uk.org/education/10264.asp
Appendix 1
ACT Consultation Document – final Page 4 of 14
• Development of a national (UK) system of student evaluation and
• Piloting of joint undergraduate and postgraduate monitoring visits to Local Education Providers (LEPs).
As a result the next version of the Medical ACT Performance Management Framework will require to be more specific about the requirements of LEPs to meet GMC requirements through the effective use of Medical ACT. In particular, there will be a greater emphasis on a transparent link between ACT funding and teaching activity. The focus will be to target ACT funding towards the development of an efficient and effective educational infrastructure, with a joined up approach to undergraduate and postgraduate medical education and greater transparency on the use of all funding available to support medical education.
At the centre of the performance framework there will be a requirement for Boards to meet the relevant requirements currently set out in Tomorrow’s Doctors as well as future requirements for undergraduate medical education in order to be eligible to receive ACT funding through the allocation model.
This will be monitored by the Medical Schools through their GMC returns and by NES through the ACT accountability reports. Specific performance criteria will be developed in conjunction with SDMEG to support this approach.
5 Quality Management
In collaboration with SDMEG we have developed a robust national student evaluation system in Scotland the essence of which has since been piloted by the GMC and Medical Schools’ Council to consider whether a system based largely on the Scottish model can be introduced across the UK.
This national evaluation system is now into its 4th year of operation and data from the system is incorporated into Quality Management reports produced annually by NES for Health Boards setting out undergraduate placement feed-back along-side the GMC trainees’ survey results5.
Recent work has focused on ensuring robust review and follow-up arrangements. Revised proposals were agreed with DMEs for reporting on the 2010/11 results and incorporated into the accountability report template. The revised approach includes;
• The use of trend analysis to identify areas of significant concern for more detailed consideration
• A more robust approach to the documentation of follow-up action agreed with the relevant parties
• Subsequent evaluation of the effectiveness of follow up action.
• The sharing of best practice from the identification and review of persistently good results.
5 http://www.nes.scot.nhs.uk/education-and-training/by-discipline/medicine/about-medical-training/quality-management/general-medical-council-%28gmc%29-regulation/gmc-reports-surveys-and-visits.aspx
Appendix 1
ACT Consultation Document – final Page 5 of 14
This approach follows existing best practice and will be subject to scrutiny through Regional Groups and the NES Quality Management Group. We will continue to enhance these requirements over time as the system matures.
The review of any clinical service should bring together the quality data as well as the MoT data and information on job plans - this is covered in paragraph 6. This approach should put Scotland in a strong position to meet future GMC requirements if a national student evaluation system were introduced and joint undergraduate and postgraduate monitoring visits undertaken.
The Performance Management Framework will aim to integrate the quality management data into the management of Medical ACT. This will be achieved by promoting the use of these results by the Medical Schools when considering future changes to NHS student placements.
In addition, as a last resort, NES will adjust the allocation model to eliminate in advance the distribution of ACT funding to specialties or locations where there have been persistent quality issues identified which have not been addressed and where the School(s) have determined the need to withdraw future students from these placements.
6 Teaching Activity Data and Measurement of Teaching Project (MoT)
A major work programme lead by NES and the Medical Schools has developed a comprehensive data set of hospital based teaching activity that is delivered by the NHS and funded through Medical ACT. This has been called the Measurement of Teaching (MoT) data. There has not been a comparable study of Primary Care teaching as this is already explicitly identified and funded through GP ACT.
Further work is underway to support Boards to review the MoT data available from the Schools alongside any local data held on teaching delivered during clinical placements. These data can then be reviewed specialty by specialty by DMEs in conjunction with Clinical Directors to review existing teaching within SPA time and help to determine future requirements for teaching time in job plans, probably on a departmental basis. This approach is already being developed in a number of Boards and NES will support this work where possible.
The Medical Schools should outline what teaching and educational support they require for their students whilst on placement. For example, are there essential areas of the curriculum to be covered, should there be a minimum number of clinic sessions, lectures, tutorials, ward based teaching sessions etc. built into a timetable, and how much assessment, feedback and mentoring is to be provided? At present there are significant variations between the Schools in respect of the level of guidance given to Boards and this creates difficulties especially where students from a number of schools are being taught within a department. When the MoT data are being reviewed on a specialty by specialty basis this work should be undertaken in conjunction with the school(s) to ensure these teaching requirements are understood by both parties and remain relevant.
Appendix 1
ACT Consultation Document – final Page 6 of 14
At the heart of the GMC’s consultation document on the future Approval of Trainers6 there is a requirement for approved trainers to have dedicated teaching time within job plans. NES will support NHS Boards to deliver the anticipated GMC requirements through the rollout of the MoT project and activity data. Whilst this exercise will not identify additional funding to support new teaching time it should provide a lever to ensure the requirement for teaching SPA time is identified and protected as far as possible.
This work will be developed in conjunction with PG Deans to support an integrated approach to the identification of all undergraduate and postgraduate teaching time in job plans. This is a pragmatic response to avoid additional unnecessary bureaucracy for the service in splitting out postgraduate and undergraduate teaching time and also aligns to the emerging approach to support a single system approach to regulation being adopted by the GMC.
The use of MoT data will be incorporated into the Performance Management Framework by working with NHS Boards to link this data over time to consultant job plans at a directorate level and then to directorate budgets through identifiable SPA time for teaching as well as other relevant ACT costs.
From 2104/15 it is expected that details of actual teaching time identified in job plans which is supported by Medical ACT funding will require to be provided to NES to support the accountability framework and is likely to be required by the GMC to support future monitoring visits.
MoT data will also be used to drive the Medical ACT Allocation model after its use in the model has been tested over the next two years, and the results of the pilot programme evaluated. This is covered in more detail in paragraph 10.
MoT Project Success Criteria In summary, when the MoT project is fully implemented through the performance management framework we will aim for the following success criteria;
1. Schools will be able to provide a detailed breakdown of teaching activity required of the NHS. This will be documented in the SLA between the Board and the School.
2. Boards will have been able to undertake a programme of reviews by unit or specialty to explore the MoT activity in detail, ensure it remains relevant, linked to curriculum and learning outcomes set by the School(s) and agreed with the School(s). The service will be satisfied that teaching activity remains relevant,
3. Directorate SLAs and service plans will take account of the teaching requirements arising from student placements to ensure sufficient teaching time is allocated.
4. Job plans for consultants (and time available for other staff) will have dedicated SPA time available to undertake agreed formal teaching requirements.
5. The Schools will be able to review the delivery of actual teaching activity and the level of time available in job plans and be able to demonstrate compliance with GMC
6 http://www.gmc-uk.org/education/10264.asp
Appendix 1
ACT Consultation Document – final Page 7 of 14
requirements and report accordingly to NES through the annual accountability reports.
6. Directorate budgets will be linked to MoT activity to ensure transparency of ACT funding.
7. The ACT allocation model can be refined to use MoT activity that is transparent to the service.
Costing of ACT Activity The MoT data gathered over the last 2 to 3 years by the Medical Schools has allowed NES to undertake an initial costing exercise of all teaching activity in comparison to the overall level of ACT funding available. Although this exercise is on-going, initial conclusions suggest that in general terms the overall cost of teaching activity being generated within the NHS is higher than the overall funding currently available. This in itself may represent a risk to teaching time and there is already anecdotal evidence that there is less willingness to undertake teaching that is not explicitly recognised.
In addition, during 2011/12 all Boards have undertaken a review of their baseline ACT budgets to ensure existing expenditure on ACT initiatives is identified, remains relevant and has been agreed by Regional Groups.
It is also proposed that by 2014/15 Boards will be required to make a direct link between the annual ACT allocation received from NES and the level of teaching time within job plans. This will sit alongside all other ACT expenditure including GP ACT and support costs.
From this exercise it is anticipated that ACT expenditure should be identifiable within directorate budgets. This will represent a significant improvement in transparency and overcome the historic perception which has been prevalent in some parts of the service that undergraduate teaching activity is unfunded within the secondary care setting.
7 GMC Approval of Trainers and Faculty Development
The Performance Management framework will focus on meeting the needs of the GMC as set out in Tomorrow’s Doctors and in respect of their emerging requirements for the Approval of Trainers and the identification of dedicated teaching time within approved trainers’ job plans.
For the last two years a major project has been underway across Scotland to prepare a Faculty Development Plan for Scotland that aims to join together the requirements of undergraduate and postgraduate medical education supported by detailed programmes that meet the needs of the Medical Schools, PG Deaneries and the service. A detailed implementation plan to support the proposals is to be agreed with key stakeholders. Arrangements will require to be put in place to ensure educational activity is included in appraisal and revalidation where appropriate. More detailed project objectives and timescales have also been agreed with stakeholders to ensure the project remains aligned to the emerging requirements of the GMC in this area.
Appendix 1
ACT Consultation Document – final Page 8 of 14
Four working groups have been set up with representation from all stakeholder groups. The work of the first group, set up to develop a prioritised competency framework, is almost complete. This follows an extensive consultation exercise and the preparation of a draft report prioritising the competencies based on the survey results.
Working Group 2 has been reviewing existing programmes available to support the draft competency framework. A gap analysis has also been developed to link the content of existing programmes to the draft competency framework.
Working Group 3 is developing an implementation plan using the seven domains employed by the London Deanery that are likely to be adopted by the GMC. This will also identify the sources of evidence available to meet the required competencies as part of the appraisal and revalidation process. The aim is to produce a framework for Health Boards to allow them to identify the most effective mix of teaching roles, identify the funding available to support teaching and allow a more targeted, effective approach to faculty development which will be flexible to local needs.
Working Group 4 is to ensure a national electronic, recording system, is available to capture the relevant data on faculty development activity undertaken with access available to all relevant stakeholders. This work is at an early stage but will require considering all other systems in place to support appraisal and revalidation.
The performance framework will be used to underpin the requirement of Boards and the Medical Schools to meet the GMC requirements for approved trainers through implementation of the Faculty Development Plan for Scotland. It will also support the use of ACT funds to meet these requirements. However, free text comments from a large number of respondents to the Working Group 1 survey highlights the level of concern on the ground that will have to be addressed.
8 Medical ACT and Overseas Students
There is to be a reduction in the number of Medical Students funded by SGHD through the SFC with effect from August 2012. Some of the Medical Schools have expressed an interest in offsetting reductions in SFC funded numbers by increasing the number of overseas students.
The NHS teaching costs of existing overseas students are funded through ACT but not taken into account in the allocation model. Originally, this was to ensure there was no financial incentive arising from ACT for Medical Schools to increase student numbers beyond the cap set by SFC. However, we now recognise this approach creates an inequity between Boards if the relative number of overseas students in each Medical School is not the same as the number of SFC funded students and recent work has established that the cap on the number of overseas students is not being applied consistently.
Further work is to be carried out by SGHD in conjunction with the other parts of the UK to explore options to fund the costs of teaching overseas students within the NHS. It is anticipated that any increase in overseas students would include an ACT-type levy that would be managed by NES as part of the overall ACT Allocation model.
Appendix 1
ACT Consultation Document – final Page 9 of 14
It is proposed to move towards a system where total student numbers are used within the first stage of the allocation model once the following conditions are met;
• The funding arrangements for overseas students is agreed by SGHD on behalf of Health Boards with the Universities through the Board for Academic Medicine taking account of future policy across the UK.
• Arrangements for the management of any ACT-type levy for overseas students are agreed between SGHD, NES and the Medical Schools.
• The total numbers of overseas students are monitored by an appropriate, independent body.
9 Economic Pressures
The economic downturn and pressure on public sector finance is likely to put downward pressure on the overall level of ACT funding available. There is also a risk that further reductions in the number of SFC funded students will reduce the overall level of ACT funding available unless this is offset by an increase in overseas students. While any reduction in student numbers should reduce the cost to the NHS there may be a disconnect between the two.
In 2011/12 there was already some evidence that Boards were unwilling to commit newly allocated ACT funds for recurring investment projects as a precaution in case ACT allocations reduce in future years.
The ACT Allocation model and funding guidelines have been reviewed and the following proposals are set out to encourage sustainable investment, provide future funding streams for key ACT developments and to limit the exposure of NHS Boards in-year if allocations are reduced.
NES will continue to identify a minimum level of efficiency savings that Boards will be required to generate each year. These savings will be retained year-on-year by Boards to provide a development fund for re-investment in agreed priority developments. The level of efficiency savings required will generally mirror requirements for other NHS services.
Year-on-year allocation adjustments, arising from changes in relative teaching activity between Boards, will be capped. The rationale for this approach is to avoid the destabilisation of service delivery arising from major in-year ACT adjustments – this is akin to the guide-path approach introduced at the start of the new allocation model in 2005/06. We expect the maximum reduction in year to be capped at a level that we would not expect to exceed 5%.
However, these proposals will not change the need to make an overall reduction in base-line ACT allocations should the overall level of funding available to support Medical ACT is reduced – either due to a reduction in student numbers or a reduction in the overall allocation available to NES.
Appendix 1
ACT Consultation Document – final Page 10 of 14
The use of MoT data requires a review of all teaching activity undertaken within a clinical specialty or department to be carried out in conjunction with the Medical School(s) to ensure it remains fit-for-purpose and continues to be a priority. This could be a very useful exercise should there be future reductions in the overall level of ACT funding.
All proposals for use of any additional ACT allocations or the reinvestment of efficiency savings will continue to require to be agreed with the Regional ACT Group in line with the existing ACT funding guidelines.
10 Proposed Changes to the Medical ACT Allocation Model
The current allocation model is based on a two-stage process which allocates total ACT funds firstly by University based on the number of SFC funded students and secondly by the level of teaching carried out by Health Boards for each University.
Medical Schools will continue to be responsible for determining the number of student placements and other NHS teaching activity required from Boards. They will also be responsible for agreeing these requirements directly with the Boards. The allocation model will continue to distribute ACT funds, in arrears, based on the teaching activity undertaken for each school.
We will continue to operate a two stage allocation model as the original policy objectives remain relevant, in particular, that each student should attract an equal amount of ACT funding which is allocated to Boards based on the number of students within each Medical School and the level of teaching activity being delivered by Boards for each School.
However, changes are proposed to the two stages of the model as follows;
• Total student numbers are to be used within the first stage of the allocation model if the conditions set out in paragraph 7 are met.
• The second stage of the allocation model will continue to distribute the funding which is identified in Stage 1 of the model to NHS Boards based on historic levels of teaching activity undertaken for each Medical School. However, the model will be developed to run on historic MoT data collected by the Medical School. This data will be issued to the Boards for review in advance of being used in the ACT allocation model.
The main benefit of changing from the existing student week data to MoT data is to significantly increase transparency. In addition, the MoT data are being collected on a consistent basis by all five Medical Schools to allow comparability across Scotland.
A pilot exercise will be undertaken in 2012/13 and 2013/14 to compare the use of the student week data with the MoT data in the allocation model, although during these two years the actual distribution of ACT will continue to be based on the existing student week data. The aim of this pilot will be to identify the extent of differences arising between the two sets of data and review the reasons for the differences. The results will be shared with stakeholders before a final decision is made on whether to use the MoT data in the allocation model from 2014/15.
Appendix 1
ACT Consultation Document – final Page 11 of 14
11 Accountability Reporting
Since the introduction of the new allocation model NES has required all Boards in receipt of Medical ACT funding to report to NES on the use made of this funding.
In recent years this requirement has been developed by the requirement for Boards also to report on the results of the student evaluation survey and agreed follow-up action.
The accountability report will be further enhanced to underpin the revised performance management framework. In particular;
• Timescales will be tightened to make reports more timely and relevant.
• Focus will be on quality data and enhancement.
• Financial information will be required to link MoT data via teaching time in job plans to overall ACT allocations and directorate budgets.
• Allocations for Medical ACT will only be issued where a satisfactory report has been received for the previous year.
12 Development of Regional ACT Groups
Regional ACT Groups were established in all areas during the second year of the new ACT allocation model to provide a forum to bring together all stakeholders involved in the teaching of medical students within each Medical School area.
Over time the role of these groups has evolved to take on additional responsibilities on behalf of NES to support the performance management of Medical ACT including;
• Review of regional priorities for the development of teaching activity,
• Approval of proposals for the use of additional ACT allocations and
• Review of the annual accountability reports to be submitted to NES.
It is proposed to review the terms of reference, membership and reporting arrangements for Regional Groups as part of the revised performance management framework to ensure they remain appropriate and makes best use of stakeholders’ time.
It is also proposed to ensure the role of the Regional ACT Groups is aligned to the role of any local ACT groups that may operate.
The role of the ACT Officers who support the Regional Groups has developed significantly over the last few years. Other ACT support posts, including ACT quality managers, have also been introduced in some areas and have been very successful.
It is proposed to undertake a review of the infrastructure required to support ACT at a local and regional level including the role of ACT Officers and other staff supporting ACT and to consider appropriate training and development.
Appendix 1
ACT Consultation Document – final Page 12 of 14
13 Primary Care Teaching
Teaching activity undertaken in Primary Care will continue to attract ACT funding at the same level as teaching within the secondary care sector. This was a key policy decision agreed with stakeholders when the new allocation model was first introduced. Primary Care funding will continue to be paid directly to NHS Boards who will continue to manage payments to GPs.
However, to mirror the objectives of the MoT project and increase transparency, details of funding allocated to each Board for Primary Care teaching by Medical School will be sent to the GP academic department so that priorities for the use of this funding can be discussed with Boards through the Regional ACT Groups.
Detailed activity and costing information is already available in respect of Primary Care teaching and the student evaluation system is also being introduced in academic year 2011/12 in respect of Primary Care placements.
14 Policy Developments
NES will continue to align the Medical ACT allocation model with relevant policy initiatives agreed by SGHD and the NHS.
One example is to use the model to support remote and rural placements to underpin the future sustainability of supply of workforce for remote and rural services.
This will be done by pump-priming funding for new remote and rural placements through the allocation model, especially to support smaller Boards develop placements and ensuring all Schools have equal access to the required number of remote and rural placements.
15 Multi-professional Education
NES continues to support the use of Medical ACT to promote multi-professional education including an integrated approach to undergraduate and postgraduate medical education that allows flexibility for Health Boards to determine the most appropriate local solutions. This is also in line with policy guidance issued by SGHD and is covered within the existing ACT policy funding guidelines.
We intend to tighten the guidelines to clarify the necessary checks and balances required to ensure ACT funding delivers maximum value for money and meets its core purpose (i.e. the teaching of medical students within the NHS). This tightening of the guidelines reflects the lower level of investment funding expected to be available in future years.
1. There will be a requirement to demonstrate the measurable enhancement for medical students and other professional groups from the investment.
2. All proposals will require to be predominantly for medical students. This will usually be defined as more than 50% of the benefits.
Appendix 1
ACT Consultation Document – final Page 13 of 14
16 Medical ACT Allocation for Dental Students
Historically we allocate a small amount of Medical ACT for the teaching of medical subjects to dental students. This funding can be identified for specific projects and amounts to £1.1m.
It is proposed to transfer this funding, along with the respective commitments it currently funds, from Medical ACT to Dental ACT from 2013/14. This will simplify arrangements and allow the dental schools and NHS Boards more control over priorities for this expenditure in future.
17 Dental ACT
The allocation of Dental ACT, which is also managed by NES, is not covered in this consultation document. Dental ACT has a different allocation model primarily because patient activity delivered by dentists in training can be measured. As a result a different approach has been developed to performance management based on activity measurement.
18 Conclusion
The proposals set out in this document are intended to recognise the strengths of the existing allocation model and performance management framework to strengthen the existing system and to reflect the work done to support the performance management framework in recent years.
19 Consultation Questions
Stakeholders are asked to consider all aspects of the proposals set out in this consultation paper but it would be particularly helpful in the following questions could be considered;
1. Do you support the proposed revised key principles for Medical ACT as follows; • An open and transparent approach
• Support the requirements of the GMC
• The use of one national rate for all teaching
• Equity of approach across Scotland
• Equity of funding for teaching in hospital and Primary Care settings
• Use of total student numbers to drive the allocation model
• Robust performance management systems.
2. Do you support the use of ACT funding to support future GMC requirements for the approval of trainers and to support faculty development?
3. Is it reasonable to ask NHS Boards to incorporate the MoT data into job plans and directorate budgets within the next 2/3 years?
Appendix 1
ACT Consultation Document – final Page 14 of 14
4. Depending on the outcome of the work to be carried out by SGHD in conjunction with the rest of the UK, is it appropriate to manage any ACT-type levy to support the NHS cost of overseas students through MOT and the ACT allocation model?
5. Are there other ways we can enhance the quality of undergraduate teaching within the NHS through the management of Medical ACT?
Responses should be submitted to NES by the end of June to [email protected]
Jayne Scott Stewart Irvine Project Manager Medical Director 30 May 2012