§ Dr. Ian Gibson (Norwich, North)
In many professions new discoveries, new evidence, new technologies and new problems require a fresh examination of the skills and knowledge that are needed for training programmes, not only for those who are already in the profession but for those who are about to embark on a career within it.
That is particularly true for the practice of medicine, which has changed dramatically in the past 20 years. For example, the results of keyhole surgery and its effects on bed occupation have been dramatic. Indeed, the new organisational structures of the health service have meant that a re-examination of the roles of general practitioners and hospital doctors is vital.
The next 10 years promise to be equally turbulent, as the human genome project unfolds, information technology explodes, new diseases emerge and the public, whose scepticism has been fanned by media scares of incompetence, start to question the adage that the doctor knows best.
Demands for new approaches to medical education are being made. A modern doctor will, for example, need to understand the human genome project, its relevance to patients and its consequences for health programmes. He or she will have to understand predisposition genes for disease and how patients have an individual genetic profile, which will also be relevant to their offspring. I bet that each profile will, following genetic diagnosis, end up like a passport on a microchip.
The result will be—if indeed GPs survive—that advice will have to be given about life styles, risk analysis and on-going treatment. The effects will reverberate around our hospitals, as informed patients ask, "Why this treatment and not that one?" Demands will be made, based on public knowledge, for the best treatments available. Individual patients will need to receive advice on what happens if they smoke or eat this or that. The effects of global warming on disease patterns will also require local, national and international programmes of health management.
As yet, few GPs or consultants are aware of those likelihoods, and I doubt whether they are much considered in medical education in our universities. Past inadequacies—in, for example, occupational health training, toxicology and nutritional studies—will be mirrored in current medical training programmes.
The new considerations will, of course, involve resource spend—insurance companies are already considering, with eagle eyes, the premium consequences for life policies. Patients will need to be well informed before and after genetic tests are proposed. It is clear that doctors will need education in many new areas.
Some doctors will also want to go into research, as happens in the United States, where clinical knowledge and scientific research go hand in hand, Nobel prizes are won and new strategies for disease treatment are evolved. Such doctor training has given rise to new therapies and treatments, and it should be encouraged in this country. The fossilised, ghettoised methods and attitudes that persist in our medical training will need to be fundamentally altered.
847 Doctors will need to have other understandings and skills. They will need a knowledge of economics to understand the implications of cost analysis and to make decisions about resource allocation. All hon. Members have heard constituents complaining about how difficult it is to get time with the doctor and to understand what the doctor or consultant has said about the treatments that are available. New communication skills and methods of imparting knowledge should be learnt as part of medical training.
An essential part of training could be a project to follow a patient or family through the medical system, the social services and the benefits system. People who were ill when they went into that process can come out even iller as they try to understand the Child Support Agency, for example—benefit problems and unemployment can impart illnesses. Medics must understand the importance of the effect of social conditions on their patients.
The basic scientific programmes—the clinical, medical and surgical skills of conventional training—are still essential, as was recognised in the General Medical Council's 1993 report "Tomorrow's Doctors". Although a few medical schools have made changes to their curriculums as a result of that influential document, it can be argued that the changes required to equip doctors to function effectively in the 21st century must be radical rather than additions to the existing formula. There is serious resistance from the medical fraternity to changes in a well-established system.
I propose the establishment of a new medical structure—let us call it a school—in which we can design a new curriculum and educational process to meet the training needs of the new doctor. That process must be sufficiently flexible to incorporate future changes in training needs.
Such a training programme would ensure multi-disciplinary educational opportunities, which would enable medical students and other health professionals to share learning and experience. Clinical and theoretical aspects of learning should be integrated throughout the training period, so that reflection and debate are the order of the day. Primary and secondary care experience should be balanced to match the needs of medical employment opportunities.
Another essential area of training should be problem solving. That would facilitate the development of self-directed adult learning, so that individuals can take advantage of lifelong learning in the medical workplace. A curriculum should, at the outset of training, integrate such subjects as the economics of health care and resource allocation with basic science teaching. Current and future technology should be emphasised, as should the transmission of knowledge, management of systems of care and the direct assessment and treatment of health.
The global increase in information technology will aid progress and help to disseminate best practice, so that the best treatment and techniques are available to everyone. The new doctor will have science teaching integrated with behavioural sciences, health economics, ethics and public health and will be involved in wide-ranging discussions of disease and health care. He or she will experience clinical and social care settings with professional development built in.
Such developments will not emerge in current medical schools, so an alternative structure—or school—needs to be established in an environment where there are true 848 partnerships between GPs, local trusts and health authorities. An environment is needed in which hospitals and educational research establishments can demonstrate excellence in programmes of science, public health, community health and clinical practice, both in teaching and research, so that clinicians prefer research to private patients.
Such an environment exists in the Yare valley in Norfolk, where a research science park nestles alongside a new hospital with the school of health at the university nearby—they all interact with one another. Medical students and other professional health service workers should be trained in such an environment. The new staff are young and enthusiastic—they provide us with a great opportunity to develop a new medical school with a new concept of teaching. Indeed, I am arguing for a new concept in medical schools, with a new medicine, new training and true interdisciplinarity—I wonder whether the Government are bold enough to allow it.
§ The Under-Secretary of State for Health (Mr. John Hutton)
I express my gratitude to my hon. Friend the Member for Norwich, North (Dr. Gibson) for choosing to debate this important subject, and I congratulate him on his constructive and thoughtful speech.
Medical education is a significant in-service activity for doctors and virtually all national health service employers. It is also a major investment. Centrally, about £1.1 billion of NHS funding has been allocated this year in England to support undergraduate and postgraduate medical education, of which £478 million is spent on undergraduate and £621 million on postgraduate education.
Further significant resources support continuing professional development. It is right to describe that as an investment: medical education is an investment in the health and care of our population. That is why it is so important, and why it should be valued so highly.
Let us be clear about the purposes of medical education. They are: to produce doctors who can communicate effectively; make a diagnosis; assess prognosis; recommend or carry out treatment; and work as part of a team. The Government want doctors to continue to learn and develop professionally throughout their careers.
I would like to explain how the Department of Health, the universities, the professional and regulatory bodies, and of course the NHS itself, can achieve that. This debate is about looking forward to the future training of doctors, so I want to focus on the current developments and initiatives that are aimed at improving the training experience of doctors and that reinforce the need for lifelong learning.
Medical education is a continuum, from medical student at one end to experienced hospital consultant or general practitioner at the other. Significant reforms to the undergraduate curriculum are being introduced by medical schools as they implement the recommendations in the General Medical Council's report, "Tomorrow's Doctors".
Those important changes encourage flexibility in curricular design and are intended to ensure that future doctors have an improved capacity to respond to changing patterns of disease and to take advantage of modern 849 patterns of health care delivery, taking account of the whole individual and his or her place in the family and in society. They give greater emphasis to the amount of teaching in a general practice or community setting, to communication and problem solving skills, and to disease prevention and health promotion.
"Tomorrow's Doctors" also drew attention to the need for medical students to develop an understanding of all aspects of human disorder, including the impact of social factors on patterns of disease and disability, and the psychological effect of suffering and disability on patients and their families. As my hon. Friend said, doctors clearly need to understand the roles, responsibilities and skills of the other caring professions. The Government believe that it is important that an understanding of the value of professional partnerships and a capacity for teamwork should be developed during the undergraduate years and beyond.
All medical schools in the United Kingdom are now in the process of implementing the changes. I would like to reassure my hon. Friend that their progress is being closely monitored by the General Medical Council, which has a statutory responsibility to determine the extent of knowledge and skills required for the granting of primary medical qualifications in the United Kingdom.
The Government are determined that the NHS will have the doctors needed to meet the health requirements of the new century. That is why, on 22 July, my right hon. Friend the Secretary of State announced an increase of approximately 1,000 in the intake of medical students in the United Kingdom. The Government plan to admit approximately 6,000 medical students each year by 2005: an increase of almost 1,000 over 1997. My hon. Friend might also be interested to know that there are now more doctors in training in the NHS than ever before.
Ensuring that we have the doctors we need is not only about the numbers trained. The Government want the creation of new student places to act as a driver to ensure that doctors receive the skills that they need to meet the challenges of the 21st century.
Following graduation from medical school, all doctors spend a year in general clinical training as pre-registration house officers. If that is completed successfully, the doctor is then eligible for full registration with the General Medical Council, which has stimulated an important debate about the nature of general clinical training by publishing its report, "The New Doctor". The report contains important recommendations, which the NHS is working to implement, aimed at improving the educational experience of house officers.
The Government recently introduced legislative changes to allow house officers to spend part of their pre-registration year in general practice. Allowing young doctors to get a proper feel for general practice early in their careers is an important development, and I am pleased to be able to tell my hon. Friend that the first placements have now begun on a pilot basis.
Once they hold full registration, doctors can begin their postgraduate or specialist training by spending two to three years in the senior house officer grade. The beginning of specialist training is a key stage in the continuum that will determine the future direction of a doctor's career.
850 It is widely recognised that the educational experience of doctors in the senior house officer grade could be improved. The Government's main advisory group on medical education is currently preparing an implementation plan for introducing a series of changes aimed at doing just that.
The changes will improve the supervisory arrangements for senior house officers; set targets for increasing the number of posts in educationally approved programmes and rotations; and ensure that the junior doctors receive the careers guidance that they need to assist them in making important career choices. The General Medical Council will shortly publish its own recommendations for improving the training arrangements for senior house officers.
Following their period in the senior house officer grade, doctors usually complete vocational training for general practice or enter a specialty-specific higher specialist training programme. We all expect a great deal from our GP. Vocational training for general practice is intended to produce doctors who are caring and understanding of patients and their families and committed to keeping up to date with developments in practice and to improving the quality of their professional performance.
As well as being knowledgeable about clinical general practice, the Government also want general practitioners to build on their undergraduate training to ensure that they have an appropriate understanding of the impact of psychological factors on illness and of illness on patients and their families, as well as the social, cultural and environmental factors that contribute to health and illness.
We also want GPs who are skilled in communication and have the ability to listen carefully; to explain matters effectively to patients; and to involve patients in decisions about their health. New summative assessment procedures were introduced earlier this year and must be passed by all doctors training for a career in general practice. The procedures test whether a doctor has the required knowledge and skills.
Significant progress has been made in the past two years in implementing the Caiman reforms of higher specialist training. As a result of those important reforms, for the first time, about 12,000 junior doctors in higher specialist training are now following structured training programmes encompassing flexibility, choice, competition and regular assessments of progress.
The end point of training is now marked by the award of a certificate of completion of specialist training, which, like the certificates of prescribed and equivalent experience for general practitioners, shows that a doctor has completed a training programme to the required standards. In this case, it means that the doctor is now eligible for appointment as an NHS consultant.
The next stage in the process of implementing the Caiman reforms is to deliver the full educational benefits of the changes, which will involve ensuring that, in addition to developing effective clinical skills, higher specialist trainees are able to respond to service changes and to develop further a wide range of competencies, including team working, communication skills, and the ability to identify health needs and understand the opportunities for health promotion.
851 The pace at which new treatments and clinical techniques are developed, combined with the need to ensure public safety, means that a doctor's education and professional development cannot end with the completion of specialist or vocational training. Independent, fully trained practitioners such as NHS consultants or general practitioners have a duty to maintain and continue to develop their clinical practice. The Government, in turn, have a responsibility, shared with the medical profession and employers, to ensure that appropriate training is available.
My hon. Friend is right to highlight the importance of research in enabling doctors to respond to new discoveries, new challenges and new problems. The national need for trained doctors who are able to apply rapidly expanding knowledge in the biological and social sciences to clinical problems remains paramount. Advances in human genetics will, as my hon. Friend suggests, bring a revolution in health care in the next century. The Government recognise the need to strengthen medical education in genetics at all stages of the continuum of training to ensure that tests are used and interpreted appropriately and efficiently. My hon. Friend may also be interested to learn that the Sanger centre at Hinxton in Cambridge is jointly funded by the Medical Research Council and the Wellcome Trust and is the most prolific public domain institution in the world dedicated to reading the sequences of the bases that make up the genomes of living species.
In publishing their White Paper, "The new NHS", and the recent consultation document, "A First Class Service—Quality in the new NHS", the Government have 852 set out a new integrated, locally based approach to continuing professional development, which matches the needs of individual health professionals with local service objectives and patient expectations. It has set a target for the majority of health professionals to have personal development plans by April 2000.
"The new NHS" White Paper also introduced a new concept of clinical governance which embraces a range of quality assurance processes, such as clinical audit, and acknowledges the importance of continuing professional development and lifelong learning to the delivery of quality patient care in the NHS. Ensuring that the principles of clinical governance are properly reflected in medical education across the continuum provides a challenging agenda for everyone involved in the future training of doctors.
Patients are entitled to expect safe and effective care and treatment by staff who are expert in what they do. I have described a range of important and exciting developments taking place across the continuum of medical education that will ensure that the health service has the medical work force that it needs to respond both to changes in clinical practice and to increasing public expectation. That represents a substantial investment and provides clear further evidence of the Government's commitment to the long-term future of the national health service.
§ It being before Two o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Sitting suspended, pursuant to Standing Order No. 10 (Wednesday sittings), till half-past Two o 'clock.