Professor Helen Stokes-Lampard PhD FRCGP HonFFPHM MD DSc
Chair, Academy of Medical Royal Colleges
As this is my first foreword to an Academy Review as your new Chair, I thought it prudent to look back at what my wonderful predecessor Carrie MacEwen wrote last year…. Back then, we were ‘pleased the Long Term Plan had finally been published’ and were privately speculating about a possible new Secretary of State. We didn’t refer to it at the time, but we were also acutely aware some people were warning about an issue that would have a potentially ‘catastrophic’ impact on the UK’s healthcare system, the tax arrangements for doctors’ pensions. Well, none of that has gone away and ongoing uncertainty is a constant…
Fast forward to now and I don’t think any of us can still quite grasp the magnitude of what has just happened or, for that matter, what may be to come as a consequence of the COVID-19 pandemic. Just to put this in context. I am writing just after the ‘safety six’ announcement, and I live just on the edge of the Birmingham conurbation, but who knows what further sloganised messages and directives are to be landed on an increasingly frustrated and sometimes rightly confused public in the months ahead.
It is, however, a great honour for me to have been elected as Chair of the Academy and at this extraordinary time, doubly so I think. Not just because of the strangeness of the times, but also because of the opportunities that we, as medical leaders have, when it comes to effecting long and lasting change for good. I believe we have a golden opportunity to leverage the trust and confidence that has been bestowed in medical royal colleges and faculties over the last seven months, to ensure the quality of care our patients receive is the best that it can be across all four nations. Even in a system so historically stretched.
Of course, some argue that with a potential second wave of the pandemic, Brexit deadlines and the perennial winter pressures, we are on the cusp of a perfect storm. My view is that our job is to do everything we can to ensure that the apocalyptic predictions do not happen. For me, there are three things we can and must prioritise if we are to stop the health and care system falling over. The first is to demonstrate clear unambiguous leadership. And while this is a well-worn phrase, for me it means owning the issues, speaking out clearly and leading by example. In my own specialism, we have shown we can work remotely and change that would by any measure have taken perhaps a decade to implement, came about almost overnight. I know you have all seen the same in your respective specialities – this quiet revolution has brought many benefits to both patients, doctors and all who work in health and care. But, some serious unintended consequences also need to be addressed and our job now is perhaps to adjust the balance – to fine tune the number of patients who are being seen remotely to ensure those that want or need face to face consultations can and do get them and to use what levers we can to ensure fairness in access to care.
The second priority will be to call out poor decisions, policies and practices. If something is wrong, if the quality of care is being put at risk for the sake of political expediency or dogma, we must say so. And we will speak very clearly and, if required very loudly. Sometimes this will be publicly. Sometimes not. I am so grateful to Alastair’s wise counsel on this point. I have already come to appreciate that the Academy is not a college. It can, and frequently does, act more subtly behind the scenes, as well as speaking out in public.
Finally, and perhaps the most exciting opportunity ahead, is to start to reset patients’ relationship with the healthcare system in the medium term. Carrying out tests, treatments and procedures just because we can does not always mean we should. Delivery of great care requires thinking about the whole patient, not one disease or system. For this reason, I believe we have a once in a generation opportunity to have an honest conversation about the care that doctors should and should not be delivering. Where that care should take place and what our patients should and should not reasonably expect – so we start the medical journey with the patient, not the institution. Some of this, such as access to first point of contact care, is already happening out of necessity to reduce the risk of the spread of disease, but it needs to be refined. Some changes will take longer and will take a large-scale behaviour change programme, directed at both doctors, other healthcare professionals and their patients. The Evidence-based Interventions programme, which the Academy is taking a leading role in, is for me just the start of a far broader approach based on the principles of seriously Rethinking Medicine.
I am not under any illusion – we are talking about huge challenges in the year ahead. But with an incredibly solid set of colleagues around me and the support a fantastic Executive team, I am confident we can make this happen. I think you for the wonderful support you have given me so far and know I can count on you all in the future.
Professor Carrie MacEwen
Chair, Academy of Medical Royal Colleges 2017-2020
A pandemic has long been expected. It was, according to many, overdue. There has been planning but, inevitably, when COVID-19 was declared a pandemic much had to be learned and delivered from scratch. Preventing the spread of the virus has affected everyone – all aspects of society have been changed.
This change has caused considerable challenges within healthcare. The desire by the population and medical professionals to keep patients away from the increased risks associated with healthcare facilities meant that virtual consultations, which had previously not been commonplace, rapidly became the norm – but patients and professionals showed they can adapt. Of course, this was not a suitable route for the seriously ill or those requiring diagnostic tests or therapeutic interventions, placing such patients at increased risk. But again, the medical profession responded – working hard from an early stage to maintain patient confidence so that they could be seen and treated safely in a healthcare setting – while at the same time creating adequate facilities to deal with the growing number of patients needing treatment for COVID-19.
‘Perfect did not get in the way of good’ and acceptable compromises were made in ways that would have been unimaginable pre-Covid as necessity accelerated changes that have been developing slowly for years in all aspects of the NHS. The NHS proved itself adaptable and finance, for once, was not seen as a barrier. Instead, clinical input and leadership became the highest rates of exchange and were allowed to flourish. Things were far from ideal and mistakes were made in an evolving situation where everyone was learning constantly. The lack of focus on the needs of care homes was disastrous – it was an error caused, at least in part, by trying to do the right thing (free up beds within the hospital system).
However, what has impressed me most, but not surprised meat all, has been the commitment and dedication of the healthcare professions. Undertaking training to quickly become a ‘covid-ready’ workforce, moving across their workplace and speciality boundaries in force to deal with this new need and increased staff sickness rates. Keeping infected patients separate from those who were not and effectively and quickly setting up areas with different infection risk profiles. Final year students in all healthcare professions stood up and were counted as they joined the workforce early, while retired staff and those in the private sector too re-joined. For those in training, ways to continue to learn and progress were identified and delivered – the training environment mirroring patient care with virtual experiences and changes in the physical environment to permit some form of continuity. All this despite the many serious challenges and safety concerns from a lack of adequate testing to a shortage of drugs and equipment, in particular PPE.
And now while we restore services – the backlog of those requiring treatment for on-going and new conditions is the major aftermath issue of COVID-19 – we must also embed other positive change such as continued use of the ‘virtual environment’ for consultations, while recognising those that were convenient at the time but are not long term solutions. We have shown our capacity and acceptability for positive change and it is warmly welcomed.
Teams and Zoom have transformed the way we and broadcasters work. A simple down-the-line interview, which could take hours to set up, can now be done in a few minutes
‘While the straightforward media work was intense at times, I can’t deny it wasn’t exhilarating too. Without doubt though, one huge benefit that will emerge from this year has been the strong new working relationships that have been built across colleges and faculties’ comms teams. Whatever the coming months bring, the trust we have in one another and the collaborative way we now work has brought huge benefits in terms of members’ brand equity and our relationship with key partners and the media.’
Dr Stania Kamara
Academy of Medical Royal Colleges, Clinical Fellow, 2019-2020
‘I had a great year at the Academy and I'm so grateful to Carrie and Alastair for the help and support they gave me, as well as the incredible access and many opportunities I had as the academy's Clinical Fellow. The team were fantastic and I'm especially proud of the report on maintaining professional identities and multi-professional working we produced as well as our work on shared decision making with the Choosing Wisely initiative and EBI. I will have fond memories of my time in Dallington Street and have no doubt the experience I gained will be useful as I return to clinical practice.’
The dedication and hard work of all NHS staff during the COVID-19 pandemic has been invaluable. While welcoming measures to support staff, we continue to call for solutions to the long-term workforce shortages, as set out in our response to the People Plan.
Prior to the pandemic, the Academy undertook a project on the development of professional identities in multi-professional teams, led by Clinical Fellow Stania Kamara and Workforce Policy Manager Alison Moulds.
The resulting report called for collaboration without protectionism or the perpetuation of silos. Effective team-working across professional groups has proven particularly important during the pandemic.
Over the last year the Academy has also worked with the Medical Workforce Race Equality Standard team, led by Professor Mala Rao, on indicators that relate to ethnicity and diversity among the Royal Colleges.
We also welcomed the Government’s recognition of the problems pensions tax arrangements were causing for NHS doctors, after we highlighted how this was leading to many retiring early or reducing clinical sessions, which directly impacted service provision and patient care. A temporary fix was found, but a longer-term solution is still awaited.
Having successfully worked with NHS England on Wave one of the EBI programme, the Academy hosted the Expert Advisory Committee which developed a list of a further 31 tests, treatments and procedures which have little or limited clinical value or should only be used in certain circumstances when specific criteria are met. The committee, which is co-chaired by Professor Martin Marshall and Professor Sir Terence Stephenson, is currently undertaking an engagement process to ensure doctors and patients can make their views known about the proposals. This work is due to be completed in October. A further wave is planned for 2021.
The Academy has produced the first iteration of the National Patient Safety Syllabus. It forms a vital foundation for the NHSE/I National Patient Safety Strategy. Further iterations of the syllabus will be produced on a six-monthly basis following stakeholder engagement. Work is ongoing, funded by HEE, to determine relevant levels of training that will be provided for all NHS, social care, and voluntary sector members. The pandemic has influenced the speed with which this work has been able to progress, but the first two levels of training will be ready for use in April 2021.
Following, Sir Norman Williams’ review of Gross Negligence Manslaughter in Healthcare, we published guidance for professionals when acting as an expert or professional witness. The work was led by Carrie MacEwen and has been well-received by both the medical and legal professions.
The Academy continues to work with DHSC, GMC, the Independent Healthcare Providers Network, CQC, NHSEI and charity groups representing patients to agree proposals for implementing the recommendations from the Paterson inquiry. A draft response will be produced in October ensuring that there is complementarity with responses to the more recent Cumberlege report.
In 2020 The Academy was approached by the Professional Records Standards Body to conduct an online audit to assess what doctors really thought about the digital transformation in healthcare. It is fair to say that this work was rather overtaken by events! Funded by HEE and conducted by the opinion research company Clever Together the final report gives details of the somewhat mixed views on the extent to which technology is improving the quality of patient care and making doctors’ working lives easier.
The Academy and members were approached by NHS England to support a review of clinical standards on areas such as cancer wait times, mental health and perhaps most controversially, removing the four hour wait-time target for A&E. The object of this latter move being to improve patient flow and enhance the quality of care. Of course, this work, like so much else was put on hold during the first wave of the pandemic, but at the time of writing the DHSC has announced that it will put the proposed changes to A&E waiting times out to consultation before the end of the year. The less contentious changes are already being adopted.
There has been some hiatus in our work with NHS England on implementing genomics within education and training and across the wider NHS due to the coronavirus pandemic, but we have been fortunate to recruit Professor Kate Tatton-Brown as our HEE-funded genomics clinical education lead. Kate is working with colleges to ensure that genomics is incorporated into postgraduate medical education and training, ensuring alignment with education provided from medical school to CPD, and with NHS England’s newly-created Genomics Medicine Service Alliances and the associated Genomic Laboratory Hubs.
The Academy has continued to contribute across a wide spectrum of postgraduate education and training activities. The pandemic has given us a very challenging year, but we have positively engaged with HEE, the GMC and others in education to ensure trainees have still been able to progress through training. There is no doubt that this engagement will continue to build going forward as challenges and opportunities continue to present themselves.
The Academy has worked collaboratively with the GMC on the future delivery of exams. Many Colleges have moved parts of their exams to be delivered and proctored online during the pandemic, allowing trainees to progress where possible. As part of this move the Academy developed a repository of exam delivery changes to help inform the GMC of approval and self-approval requirements. We have provided a monthly forum for College exam leads and the GMC to meet and share good practice and experiences – exploring issues such as how Colleges manage intra-exam connectivity problems and social distance/infection control arrangements for exams which will still run face to face. The aim is to develop consistent policy across the specialties in both these areas where appropriate and possible.
There has been full engagement with HEE and the GMC on the new ARCP codes and curriculum derogations which were put in place in May. Derogations are now being reviewed and work has been ongoing to consider the continuing impact of the pandemic on training experience and progression across the Colleges. The Academy now hopes to influence consistency in format of both ARCP decision aids and temporary curriculum derogations from Colleges, as well as working with the GMC on proposed changes to person specifications.
The Academy is working with the GMC to produce a document on differential attainment which outlines best practice interventions and actions Colleges can take to ensure curricula and assessments are fair for all, working to address the attainment gap.
The Academy Assessment Committee has been working with stakeholders over the past year to develop a proposal for a joint assessor to consider more complex requests received by Colleges for reasonable adjustments to be granted for candidates sitting postgraduate exams. The Academy is currently looking to explore this issue further with the GMC, HEE and postgraduate deans to see whether a more joined up holistic approach can be taken from the point of view of learning, assessments and feedback. In the meantime, we have provided a secure online forum for Colleges to share challenging requests and gain experience from other exam departments.
The Assessment Committee also continued current workstreams such as known and unknown bias and lay input into assessment in early 2020 and plans to resume these workstreams once the pandemic settles.
In late 2019 the Assessment Committee published guidance on Academic Dishonesty which was well received by Colleges and other stakeholders. This guidance looks to help Colleges detect and deter dishonesty in summative exams, although it is now recognised that with some summative exams moving to an online platform this may need reviewing.
We have completed the first phase of the work with the GMC publishing Guidance for flexibility in postgraduate training and changing specialties, which has been very well received. It explores how doctors can receive recognition of capabilities gained in one specialty if they change specialty or take time out of training so that they do not have to repeat elements of training. We are grateful to Mr William Allum and the working group for their work on the Guidance.
This two-year training programme provides opportunities for doctors from other countries to come to the UK on a Tier 5 visa to develop their skills and then take them back to their home countries for the benefit of their healthcare systems. The pandemic has had a significant impact on these doctors and we were very pleased to secure a one-year visa extension for all MTI doctors from the Home Office.
A major review of the programme is now being undertaken with our funders HEE and the other devolved nations in order to ensure that the scheme maximises its philanthropic aims and objectives and achieves the greatest benefit for the individual doctors, the health system in their countries of origin and the NHS. We are grateful to Sophie Slavin and Philippa Byrom for their excellent work on this scheme and are delighted to welcome Sharon Merchant to the team on her recent return from maternity leave.
The Academy contributed to DEMEC in December 2019, where several successful interactive workshops were held including reasonable adjustments for candidates sitting postgraduate exams, flexibility and the patient safety syllabus.
The Academy Foundation Programme Committee, chaired by Dr Tony Choules, has been working to revise the foundation programme curriculum, which was submitted to the GMC for approval this Summer, with a decision expected in the Autumn. If approved, the curriculum would be implemented for summer 2021. The Academy is also working on recommendations from the HEE Foundation Programme Review, looking at ways it can provide support and representation for foundation doctors, including proposals to devise a scheme whereby senior trainees mentor foundation doctors.
Many thanks to Mr Derek Alderson who led for the Academy on the education agenda until July 2020. The Academy now welcomes Dr Jeanette Dickson, Academy Vice-Chair, who took over as Education lead. The Assessment Committee also welcomes Mr Bob Taylor as incoming Chair from 1 October, and the Academy extends its thanks to Mr Gareth Griffiths who will be demitting office and has very efficiently led a busy assessment agenda through the pandemic.
The Academy continues to play an active role in the Brexit Health Alliance and the Cavendish Coalition. By any measure what happens after the 31 December 2020 is going to present significant challenges to both patients and staff, coming at a time when the NHS is likely to be under extreme pressure from both Covid and winter pressures. We are grateful to Professor Alan Boyd for the brilliant work he has done and continues to do on this front on behalf of the Academy. We will continue to have regular briefings from Professor Keith Willett at NHSE and also continue to hope that a deal can done to mitigate some of the worst impacts.
Dr Anna Olsson-Brown, Chair, ATDG
The Academy Trainee Doctors’ Group has continued its work to represent trainees from Colleges and Faculties on cross-specialty issues. Dr Anna Olsson-Brown took over chairing the group last Autumn, taking the reins from Dr Alice Wort. The group has been particularly active during the pandemic, publishing a statement on trainee redeployment and principles for the re-establishment of medical training. They have been involved in national discussions about changes to examinations and recruitment amid the COVID-19 pandemic.
Ros Levenson, Chair, APLC
The APLC continues to go from strength to strength under the leadership of Ros Levenson. Along with the RCPCH it held a successful patient seminar in October which was also supported by the RCGP and the RCOG. Delegates had a chance to comment and reflect on the clinical review of standards, quality improvement and how patient engagement can be improved in medical royal colleges. A further conference is planned for later this year.
Dr Waleed Arshad, Chair, SASC
The Academy SAS Committee welcomed Dr Waleed Arshad as chair last Summer. Over the last year, the committee has published widely on issues affecting the SAS workforce, including retirement and later careers, the role of SAS doctors in education, leadership development, access to College and Faculty e-portfolios; and opportunities and support for SAS clinicians across the Colleges and Faculties. The Committee also issued a statement of support for the BMA’s template guidance on autonomous practice.
By any measure, this last year will surely go down as perhaps one of the most extraordinary of all our lifetimes. There is certainly great sadness for those that lost their lives to COVID-19, huge admiration for health and care staff who risked their own lives to save others and frankly amazement at the way the healthcare systems across all four nations reconfigured themselves to deal with the pandemic. As Chair of the Academy’s trustees, I must pay tribute to the Academy team who I know worked tirelessly to help bring about the changes that were needed to ensure the NHS could function effectively. In particular, Alastair Henderson and Carrie MacEwen who, I know, worked long into the night, day after day, to shepherd through changes to guidance on everything from the appropriate use of PPE to the morale and wellbeing of trainees. A quick glance at the Academy’s Covid pages on its website show the breadth and speed with which this work was done. And the professional nature of the output can only be applauded given the extraordinary constraints the team were working under.
As trustees, it’s our job to ensure the Academy is well run and adheres to best principles on matters of governance and financial probity. I am pleased to report that despite the extraordinary pressures the leadership team have been under the Academy has met the high standards that must rightly be applied. I am also pleased that now, perhaps like never before, the Academy and its members are able to leverage their new relationships with all the key policy makers to improve the quality of care for patients. I know, Alastair and our new Chair of Council, Helen Stokes-Lampard, will be focused on driving this agenda and building on the recent successes.
I am, of course, greatly helped in my work on the Board, by excellent colleagues. In the last year, Professor Carol Seymour and Doctor Suzy Lishman both stepped down, we are very grateful for their insight and acumen. They in turn, were replaced by Professor Ravi Mahajan and Professor Alan Boyd, who both bring additional talents to the team. I should also take this opportunity to thank Professor Carrie MacEwen, who demitted in July, but steered the Academy through some challenging times with great wisdom and clarity of purpose. It seems as if the Academy grows in stature with every new Council Chair. Carrie’s term of office was no exception and we are all very appreciative of the work she did.
Chair, Academy of Medical Royal Colleges Board of Trustees