Undergraduate medical education: recommendations
A series of recommendations to increase undergraduate medical education in Scotland by enabling more general practice based teaching in primary care.
Chapter Six: Summary and Recommendations
Chapter two highlighted the range of barriers and facilitators to increasing undergraduate education in primary care. Chapters three to five outline the wide ranging systemic action that is required if we are to progress towards the goal of significantly increasing medical students' exposure to primary care placements and to GP educators. Individual initiatives, no matter how evidenced-based or innovative in nature, are unlikely to be sufficient. It is important to state that all curricula will have to ensure that students are prepared for the forthcoming GMC Medical Licensing Assessment (said to represent the minimum standard expected of a student graduating from a GMC approved programme). This will apply to teaching in general practice and other community settings as well as all other clinical contexts.
The breadth of membership of the working group indicates the complexity of the issues involved in increasing undergraduate education in primary care. The high attendance, joint working and engagement of group members has been impressive and has enabled clear recommendations. It is also very apparent that as we move forward to implementation, developing and sustaining improved working across and between many of these organisations will be necessary for an increase to be achieved and maintained. In particular, the output of this group offers an opportunity to strengthen existing links between undergraduate and postgraduate medical education, and between Universities and Health Boards. An example of this is given in the box on page 52.
RCGP Scotland has a significant role in many areas, but especially in supporting undergraduate GP societies, advocacy for strengthening education in primary care and providing independent feedback from GP educators in the profession. The recently published RCGP Scotland document 'From the Frontline' recognises the importance of increasing general practice based teaching for undergraduates (RCGP Scotland 2019). The role of SGPC in advocacy for resourcing of GP education is also important. The principle set out in Sir Lewis Ritchie's 2015 report on primary care OOH services, that of pulling together to achieve a common aim, also applies strongly to all partners involved in increasing undergraduate education in primary care. A consistent and demonstrable approach by medical schools, and the wider profession, to address tribalism and negativism about general practice will also be necessary.
Throughout the life of this group, it has become clear from many sources that many GPs are stimulated and even 'rejuvenated' by undergraduate teaching if the time, space and financial support can be found to address the tension that currently exists between service provision and teaching. That is the purpose of these recommendations.
Health Boards and Universities: moving from cooperation to collaboration
As part of a structured approach to supporting Medical Education Delivery in NHS Highland, across several universities and in particular to support the growth in delivery in primary care the board established two groups to bring partners together- the NHS Highland Medical Education Strategic Board. This Board provides an opportunity for partners (UofA, UofD, ScotGEM, NES, NHSH) to share openly on changes and challenges regarding local, regional and national development in medical education and service delivery, particularly if one will have an impact on the other, and to then provide advice and support to each other as necessary. This Board also has a remit to share at a strategic level how, where and by who medical education is being delivered, good practice and successes for the Local Education Provider, Educational Organiser, students, clinicians and patients.
This group is informed by the Undergraduate Medical Education Committee (UMEC) which has responsibility for the oversight of the operational delivery of undergraduate medical training across NHS Highland. UMEC has a remit to support an increase in the capacity for providing medical undergraduate education teaching in both primary and secondary care and to support the development of local medical staff to be effective teachers and role models by providing educational opportunities and relevant CPD that meet their needs. UMEC has an important communications role ensuring communication to the local medical education faculty regarding local, regional and national developments in undergraduate medical education across primary and secondary care.
Developing the GP educator workforce
It is clear that in developing the necessary workforce, a 'more of the same' approach will fail. There is a real opportunity here for medical schools to develop teaching faculty in innovative ways, such as the Generalist Clinical Mentor model initiated by ScotGEM, which offer a diversity of teaching opportunities to GPs who may be partners, salaried or sessional employees. Innovative ways of delivering 'near-peer' teaching by FY and GP trainees will also be important. The joint initiative between NES and University of Glasgow on utilising GP trainees in UG teaching sets out a model that could be applied with local adaptation across Scotland. (see Glasgow's year 3 teaching week on page 40) Recent evidence (Allsopp, 2019) also suggests that near peer teaching has a positive effect on GP trainees as well as on medical students. Among other positive findings they found 'increased resilience, increased desire to work as a GP, increased interest in medical education and an increased desire to stay and work locally.' These are potentially important findings for recruitment and retention in practices.
There are also other ways in which GP faculty could be developed and strengthened. GP teaching fellows (see SCOTGEM proposal on page 41) have considerable potential for expanding undergraduate education while also helping to develop and train the future GP educator workforce. Another potential development is on the basis of the post CCT positions being developed following the Shape of Training Review (Greenaway D. Shape of Training, 2013). These currently under development offer a blend of clinical experience in general practice for 4 to 6 sessions per week with the remainder of time spent in other clinical activities of relevance to general practice. However, the model also easily lends itself to post CCT educational models combining clinical work in a practice with delivery of UG education on a 'near-peer' basis such as is seen in the OOH Development Fellowship. They could also be developed rapidly, and may help to address the current workforce crisis in general practice in Scotland. Such a development also offers the opportunity for further collaborative working between NES, Health Boards and medical schools.
Looking forward, the contribution of academic general practice to the support and visibility of GP education and to providing role models for medical undergraduates is vital, as recognised in the RCGP Scotland 'Securing the Future' report, chaired by Sir Lewis Ritchie (RCGP Scotland 2009.) The short life working group on the Academic Training Pathway for General Practice in Scotland established under the chairmanship of Professor Frank Sullivan (Scottish School of Primary Care 2019) should provide much needed momentum for GP academic careers to counteract the current concerning decline in academic GP numbers in Scotland. It will provide an initial report to the Board for Academic Medicine in September 2019.
GP tutors are the core resource in all undergraduate GP education, yet it is clear that the role does not have the same profile and status as that of GP educational supervisor for postgraduate trainees. A Scottish Tutor of the Year award by Universities and/or RCGP Scotland may help to raise the profile. Support for postgraduate education certificates and diplomas could help to grow the educational workforce of the future. Forging links between undergraduate tutors and GP postgraduate educational supervisors could benefit both. A specific targeted recruitment drive for GP tutors, possibly organised collaboratively by all medical schools and relevant territorial health boards with RCGP Scotland support should be considered. Recent evidence from four medical schools in England (Barber et al 2019) suggested that a perceived lack of support from medical schools was a barrier to GP teaching. While Scottish medical schools engage effectively with GP tutors, some comments in the capacity survey suggest this is an area worth further examination.
Ensuring a variety of placements
By Choice not by Chance (HEE/MSC 2016) suggests that a variety of placements is important so that students are exposed to a wide range of general practices and understand the adaptive nature of generalist practice to local settings.
Out of Hours (OOH) services
GP OOH services across Scotland are generally not funded through NES ACT to provide undergraduate teaching but most provide postgraduate training for GP trainees. The most frequently seen age groups are the under 5s and the over 80s, which suggests that OOH services are a relatively untapped resource for good clinical GP experience and a great breadth of presentations. They potentially provide an excellent training environment for medical students seeing urgent primary care problems in a clinical setting led by GPs. The OOH setting requires staff to be confident working in isolation, deal with complexity and uncertainty and to be able to manage a wide variety of conditions. There is now a range of practitioners involved within Out of Hours services; this would allow students to experience how different practitioners work and how the team works together for the benefit of patients.
Current OOH staffing pressures are considerable and may limit expansion of teaching in the short term. However, due to the substantial clinical teaching potential and wide geographical spread, as staffing improves, OOH services should be included in plans for expansion of undergraduate education. OOH services could also contribute to some of the digitally supported tutorial methods as described in the report, e.g. supplying video consultations for the shared library that could be part of teaching in day time hours.
Remote and rural Scotland
Using Scotland's unique remote and rural geography and population for teaching is vital as they provide different clinical and organisational challenges to urban populations. Despite provision for transport and accommodation within NES GP ACT, some students and practices (see Biggar practice vignette and findings from capacity survey) report that these support arrangements do not work sufficiently well and that some practices have to subsidise accommodation costs and students' travel costs in some Health Boards. This situation represents a disincentive for both students and practices and limits practice engagement. As part of the development of general practice teaching, this issue should be addressed over the next 12 months through a collaborative approach between NES ACT, medical schools and relevant health boards.
There is also strong evidence (see, for example. Jones et al., 2014; WHO, 2010) that establishing a 'rural pipeline' which runs from encouraging rural school students into medicine, exposing undergraduates to rural general practice, and ensuring good quality rural postgraduate training and CPD will increase the supply of remote and rural GPs. As people in remote and rural Scotland suffer disproportionately from GP shortages at the moment, it is especially important that Universities and territorial Health Boards covering remote and rural parts of Scotland use these recommendations to increase remote and rural placements for students. An example of the breadth and depth of undergraduate teaching possible in remote areas is given below.
Welcoming Undergraduates to Benbecula Medical Practice: A Remote and Rural Experience
Our practice provides placements for undergraduate electives, with preference given to students who have a clear idea of what they want to learn while they are here. We pride ourselves on the support we give to students, who often say coming to us has been a high point in their undergraduate experience. All of our teaching is 1:1 and we try to give students as much patient contact as possible to help them develop their consulting skills. This is usually the highlight of their time with us.
We used to provide formal undergraduate placements for Dundee, but when the designated tutor retired, we were not able to sustain this. We still keep in touch with many of the students who came here; one has even come back to train us as part of a Scottish Core Obstetrics Teaching and Training in Emergencies Course (SCOTTIE) team.
As an example, our next undergraduate is coming for two weeks. She has already indicated that she is interested in palliative care, and wants to see how we can deliver this in a rural setting. Our practice covers the community hospital, which has a palliative care room, so she will spend some time there. We have organised a trip to Barra on the ferry with the MacMillan team, a VC with a hospice on another island, and a session with medical researcher with an interest in palliative care.
SCOTTIE: Scottish Obstetric teaching and training in emergencies course: https://www.scottishmaternity.org/scottie.htm
Areas of socio-economic deprivation
Scotland has also been a pioneer in exploring the needs of general practices and patients in the most deprived parts of Scotland - "GPs at the Deep End". Placements in these practices offer undergraduates exposure to and an understanding of the importance of social determinants of health and adverse childhood experiences (ACE), as well as what is now called 'deprivation medicine'. If we are to understand and address these challenges for the future, it is essential that many of our undergraduate students gain an understanding of the complex issues involved. In North Dublin, exposure to GP training specifically aims at training GPs with the capacity and desire to work in areas of social deprivation (Health Equity 2019). It is possible that undergraduate SSCs such as taught in Glasgow (see below) can have similar positive effects through role modelling and demonstration of authentic, quality general practice. Medical schools should aim to ensure that as GP placements increase, there is at least a proportionate increase in placements in areas of deprivation.
Special Study Component (SSC) in social determinants of health at the University of Glasgow
The SSC in Social determinants of health and health inequalities has been offered to Year 2 medical students at the University of Glasgow since 2014. The aim of the SSC is to develop understanding of the concepts of health inequalities and the social determinants of health within Scotland and their impact on health and health care provision.
Students spend time in a range of health and community settings, meeting patients, service users, volunteers and professionals. Placements include: Addictions team, Personality Disorder Team, Deep End GPs and Freedom from Torture. This is complemented by weekly academic learning on a range of health inequalities topics, including: adverse childhood experiences (ACEs), multiple exclusion homelessness, the inverse care law, LGBTQ+ health inequalities, and the social model of disability. There is an ongoing evaluation of the SSC aiming to assess if students have gained the intended learning as set out in the SSC ILOs and if so how this is achieved.
Student feedback on a community placement:
"When I become a doctor, I don't want prescriptions and medications to be the only solution I provide to my patients. [This placement] has really inspired me to want to use social prescribing in my own practice and provide my patients with sources of support from the community to improve their health and wellbeing." (Student from 2019 class)
Recommendations one to six, on physical space, digital access and educational tariffs follow directly from the findings of the capacity survey and collated evidence in this report.
Recommendations seven and eight cover growing the necessary GP educator workforce.
Recommendations nine and ten address monitoring and evaluation of the changes as they are implemented.
It was the view of the group that to achieve a well-managed increase in undergraduate education in primary care, these recommendations required to be implemented as a package rather than singly, recognising that timescales for implementation will be much longer for some than for others. Failure to address each of the areas covered by the recommendations is likely to prove a rate limiting step for many of the others.
Physical space for teaching
As shown by the general practice capacity survey and through discussions with stakeholders, it is clear that physical space is currently a major factor in limiting expansion of undergraduate education. This is likely to become more acute given existing Scottish Government commitments to increase the GP and wider MDT workforce.
Recommendation 1 (Scottish Government and Health Boards)
Capital investment in primary care by Health Boards must include provision of fit for purpose space that can be used for educating the primary care workforce of the future.
Recommendation 2 (Scottish Government)
The new NHS Scotland Capital Investment Strategy is due to be published shortly. It is recommended that this should make the case for investment in primary and community care facilities recognising specifically the need to include facilities to train the workforce of the future.
Access to high quality broadband throughout the NHS in Scotland, and easy access to educational e-portfolios and educational material in all primary care premises are absolutely essential to maintaining and developing high quality undergraduate education in primary care and for assessment of students by Faculty.
It is significant that in its National Training Survey for postgraduate trainees in 2019, the GMC specifically asks about access to Wi-Fi on the basis that poor Wi-Fi 'can really affect the ability of trainees to learn and trainers to teach.' This is also true for undergraduates.
Recommendation 3 (Scottish Government)
The SWAN programme should develop direct ties and representation with the R100 delivery team in Scottish Government both better to understand the timeframes for the remaining very hard to reach locations and to influence decisions on how the R100 priorities are decided about which locations should be prioritised i.e. those where GP surgeries are without connectivity and could therefore have access accelerated.
Recommendation 4 (Universities and Health Boards)
Universities currently have information on problems with broadband and Wi-Fi access for their students. To provide a national picture, Universities and Health Boards should survey digital access for undergraduate teaching practices and premises across Scotland and plan to address access difficulties where this is possible, over the next 12 months.
Funding for undergraduate medical education
The level of ACT funding was repeatedly identified as being too low currently. It was clear that many practices consider that they are effectively subsidising undergraduate education. Falling numbers of practices engaging in undergraduate education supports that view. Tariffs at their current levels are leading to a substantial reduction in availability of GPs for teaching and hence a negative feedback loop resulting in fewer GPs in future. The extensive work of the NES Primary ACT group and the NES validation of the HEE work on actual costs of teaching has suggested that the tariff for a student in practice in years three to six (category A) should be £85 per session. However, GPs are also required for category B educational activity (lectures, campus based teaching and assessment, admissions procedures etc.). It will be important that any increase does not destabilise a system which currently has limited capacity, but instead contributes to increasing capacity across the system. A variety of different tariffs and rates are used across medical schools for category B activities. While flexibility will be needed to address differing conditions across Scotland, there is a need to reduce the complexity that arises from this.
As discussed in chapter three, there would be merit in considering whether the current ACT model across both primary care and secondary care requires a more fundamental review. It could be further argued that such a review should not be limited to ACT but rather consider the overall approach to the funding of undergraduate medical education. Consideration should be given to alternative models of distributing monies to support undergraduate clinical teaching, particularly against a background of innovative models of delivering undergraduate education, different career pathways in general practice and constrained public finances.
Recommendation 5 (Universities/ NES ACT)
The tariff for clinical teaching in primary care (category A) should rise from £40 per student per session to £85. A ceiling value of £255 for three or more students should apply. Current falls in practice teaching capacity across Scotland suggest that this should be implemented as quickly as possible.
Recommendation 6 (Universities/ NES ACT)
Further work needs to be done by NES together with relevant stakeholders to streamline the current range of category B tariffs in Primary Care ACT. This should produce a simplified range of tariffs applicable to all medical schools within 12 months.
Developing the GP educator workforce
Increasing undergraduate education in primary care over the next few years will challenge current capacity, not just for teaching but for educational management and administrative support for delivery. The GP Heads of Teaching group has, during the period of the working group and in this report, demonstrated the value of sharing ideas around innovation in undergraduate education but has no formal recognition. There are also variations across medical schools in roles and status of GP educators.
Recommendation 7 (Universities/ BfAM/ Universities Scotland/ Scottish Funding Council)
As part of progressing UG education in primary care, each medical school should develop over the next 12 months the outline implementation plans that they have submitted (chapter 5) for increasing teaching in primary care, as well as a strategy to develop and grow the GP educator workforce to increase teaching capacity. This should ensure that GP educators have a strong and effective voice within school decision making structures
Recommendation 8 (Universities/ BfAM/ Universities Scotland/ Scottish Funding Council)
A national level group for GP Heads of Teaching or equivalent in Scotland reporting to the Scottish Deans Medical Education Group should be formally established. The aims of this should be to strengthen educational leadership, build on the implementation plans referred to in recommendation 7, and share innovations to increase capacity and further curricular development.
Monitoring and evaluation
Monitoring and evaluation of the wider reform of primary care, of which this work is part, is vital to understand progress being made and to indicate where additional action may be required. The Scottish Government has recently published a 10-year National Monitoring and Evaluation Strategy for Primary Care in Scotland (Scottish Government, 2019).
Significant work has already been done by members of the group on proposed measurement of progress on increasing undergraduate education in primary care. This is complex, as there are six different curricula and no existing standard method for measuring and recording GP involvement, some of which is informal and not easily quantifiable. Further work is needed to agree a standard data set for use by all medical schools. This should be mapped onto 'By Choice not by chance'. The current GP HoTs Measures and Indicators paper is included as Appendix E.
Recommendation 9 (Universities/ Health Boards/ BfAM/ Universities Scotland/ SFC)
Monitoring of these recommendations, supported by the GP Heads of Teaching group, should be undertaken with reports six monthly to the Scottish Deans' Medical Educator Group for review by the Board for Academic Medicine and Scottish Government. There should be an independent review of progress after 12 months.
Recommendation 10 (Universities/ Scottish Government)
The investment involved in increasing undergraduate education in primary care requires rigorous evaluation from the outset. This should include (i) the indexing of all medical students at Scottish Universities at matriculation with a view to linking this data with existing data available through UKMed (ii) further educational research into attitudes of students and graduates in relation to careers in GP, all with a view better to understand the career choices of graduates. A programme of funded educational research will be required.
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