Professionalism and Excellence in Scottish Medicine - A Progress Report

Executive Summary

Purpose

This report documents progress achieved since the publication of the Scottish Medical and Scientific Advisory Committee (SMASAC) Report: Promoting Professionalism and Excellence in Scottish Medicine, in 2009: www.scotland.gov.uk/Publications/2009/06/12150150/0. The original SMASAC Report was instigated during the 60^th anniversary year of the NHS and it is therefore timely to look 5 years on, at progress achieved by the 65^th anniversary year.

A number of encouraging strands of work have been taken forward in the last 5 years. There is however much work yet to do and a series of pressing recommendations are made in order to secure further progress.

Process

In 2009, SMASAC commissioned the Scottish Academy of Royal Colleges and Faculties to carry forward the principles and aspirations of the Promoting Professionalism and Excellence in Scottish Medicine report. The Scottish Academy established a Working Group on Professionalism and Excellence chaired by Dr John Colvin, in his capacity as present Chairman of the Academy. Members of the Group are listed at the end of this Executive Summary (p7), along with an Acknowledgements Section (p8) which recognises that many individual clinicians and support staff colleagues working in NHSScotland and Scottish Government have been engaged in, and committed to achieving the aims of the original SMASAC Report.

Content

In the introductory Chapter 1, the Scottish Government policy context is summarised, including the Quality Strategy (2010), which sets out the Quality Ambitions of safe, effective and patient centred care. More recently, the 20:20 Vision for Healthcare in Scotland (2011), 20:20 Vision Route Map (2013) and 20:20 Workforce Vision (2013) have been published to retain a focus on improving quality. The latter document, in particular sets out a commitment to the delivery of high quality healthcare that the people of Scotland expect and to valuing the workforce and treating people well. These values are echoed in the recently published Greenaway Review of the Shape of Training: Securing the Future of Excellent Patient Care (2013), which is predicated on patient needs driving how doctors must be trained in the future. In all of this, it will be essential to recognise the paramount importance of professionalism as a key driver in defining new ways of working.

In Chapter 2, practical responses to the professionalism 'challenge' in medical education and training are described for both undergraduate and postgraduate medicine in Scotland. The guiding principles and expectations of undergraduate training by Medical Schools are defined in the GMC document: Tomorrow's Doctors, with the doctor as professional, as one of 3 key outcomes. The emphasis given to professionalism by the GMC needs to be fully reflected in medical school curricula. In postgraduate training, the ability to communicate effectively, empathise, be diligent and to lead, are complementary to sound clinical skills. Recent developments in specialty curricula are described, with a move to a more standardised approach and an increasing emphasis on non-clinical elements, reflecting the guidance in the Medical Leadership Competency Framework and the Common Competences Framework. Explicit reference to professionalism in current postgraduate curricula is inconsistent and greater convergence will be fostered by the GMC and the Greenaway Review will also be key. In leadership development, the roles and contributions of the Scottish Academy, individual Colleges and Faculties, and NHS Education for Scotland (NES) are discussed, including Launchpad for Leadership (NES). The UK Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement are also active in this area. Relevant work of the NHSScotland Quality Improvement Hub (QI Hub) is described. A number of key issues for trainees are identified, including: intelligent rota design, continuity of the training team, meaningful clinical induction, specific mentoring, and explicit recognition of trainees as professionals. Specific barriers identified by the Scottish Academy Trainee Doctors Group are listed in Annex A. It is also clear that current contractual provisions for doctors in training are a significant obstacle to professionalism and Scottish Government are working with other UK nations and the BMA around a potential review of the Junior Doctors' Contract. All working patterns in Scotland are approved by the Scottish Government's Workforce adviser with best practice feedback on rota patterns and designs.

In Chapter 3, specific developments in management and leadership training are described. These include:

• The Scottish Patient Safety Fellowship Programme (3.1) - a partnership between Healthcare Improvement Scotland (HIS), NES and territorial boards. Aims and objectives of the Fellowship are described, and Fellows (presently numbering more than 400) typically develop leadership roles in territorial or special NHS Boards or with the Scottish Government.
• Clinical leadership development for doctors (3.2) - the Medical Leadership Competency Framework (MLCF - see Figure 1 and the domains of MLCF at Annex B) has underpinned postgraduate curricular change and also is included in Tomorrow's Doctors. Further support for leadership developments in doctors throughout their careers is also essential and the National Leadership Unit (NLU) of NES is providing a number of programmes to deliver this aspiration (see Annex C).
• Leadership development for Scottish Medical Trainees (3.3) - NES has developed a flexible range of resources in this area, including the Leadership and Management Programme (LaMP) which offers leadership and management development to all Scottish Trainees in higher training, as part of a conceptual framework which also includes the Management Trainees Scheme, the Clinical Leadership Fellowship Scheme, and Launchpad for Leadership (see Figure 2). The establishment of the Faculty of Medical Leadership and Management (FMLM) of the UK Academy of Medical Royal Colleges, is also an important development with >40% of Scottish trainees joining the Faculty by end 2012.
• Scottish Clinical Leadership Fellows (3.4) - two inaugural fellows have been appointed in late 2013, aimed at doctors in training, with a view to increasing the cohort in future years, following evaluation. The Board for Academic Medicine is also seeking support for an enhanced Senior Clinical Fellowship Scheme with a view to recruit and retain the very best early-career clinical academics to harness their future leadership role in improving the health, healthcare and wealth of our nation.
• Developing Leadership in Primary Care (3.5) - a joint project initiated in 2012 by the Royal College of General Practitioners (RCGP Scotland) and NES, with the support of SGHSCD Primary Care Directorate. This project aims to enhance the professional role of primary care contractors, specifically general practitioners and pharmacists using an evidence based approach (see also Annex D).
• Delivering the Future (3.6) - NES established an ongoing high level leadership programme in 2005 which aims to identify senior clinical leaders from across the professions. Longitudinal evaluation indicates that over 87% move on to promoted or expanded roles.
• Development and Leadership of Quality Improvement (QI) (3.7) - This NES initiative adopts a tiered approach to education and training in QI methodology for training (see Figure 3). The target audience is specialty trainees in the last 18-24 months of training building on prior learning in the LaMP.
• Paired Learning (3.8) - A recurring theme in SMASAC Annual Reports, submitted by CMO Specialty Advisers, relates to the typically dysfunctional nature of the consultant/middle management interface throughout NHSScotland and a lack of a shared common understanding. Going forward, improved mutual understanding and more effective working between consultants and middle management colleagues are essential. Experience of a Paired Learning Programme at Imperial College NHS Trust (2010) found that co-development of doctors and managers, has had a powerful and positive impact on participants, resulting in improvements in patient care. The Leading Quality Network hosted by the National Leadership Unit within NES is taking forward this important work in Scotland. The importance of the key interface and reciprocal relationship between managers and doctors was flagged by the original SMASAC Report and this now needs to be promulgated as a reality in day to day working throughout NHSScotland.

In Chapter 4, Next Steps, a number of specific recommendations are made in the further pursuit of Professionalism and Excellence in Scottish Medicine. If these recommendations are to be realised, a concerted programme of activity will be required on a number of fronts. The recommendations, listed in detail in Chapter 4 of this report are therefore directed at the bodies with the power to effect further change in this area:

• Scottish Government
• Professionalism and Excellence Group
• Scottish Academy, through member Colleges and Faculties
• Medical Schools
• NHS Education for Scotland (NES)
• NHS Board Chairs
• NHS Board Chief Executives
• NHS Board Medical Directors
• Directors of Medical Education
• The GMC

The Professional and Excellence Group, supported by the Scottish Government, will exercise oversight on the implementation of these recommendations, going forward.