MEDICAL EDUCATION: THE CURRENT STATE OF AFFAIRS
I. OVERVIEW
1. Introduction
The United Kingdom’s healthcare system is unusual for a developed country, in that it is dominantly publicly funded (around 85% from taxation) and publicly provided (through the National Health Service –NHS).· This has major implications for Continuing Medical Education (CME) because more than 90% of healthcare practitioners are employed by the NHS. This includes a majority of doctors who work in the private sector, because most only do so part time, with their dominant contract being with the NHS.Practitioners· As a result, public sector requirements determine the nature of medical education. Guidance from national bodies –professional, regulatory and governmental –sets the basis for CME, and individual practitioners are required to comply with these.· A formal focus on CME for doctors in the UK began almost 40 years ago, though continuing education already had been established well before then.o Since then incremental changes have been introduced and recently a a shift away from CME points towards peer-review of educational outcomes, through Appraisal, and most recently, a combined statutory and regulatory requirement for revalidation that includes CME.· Therefore, CME for healthcare practitioners is consistently well developed, and particularly so for doctors. Indeed, the medical profession in the UK is looked to as setting the pace and direction in CME for other healthcare professionals in the UK, and also for many physicians in other European countries.· In addition, the UK, for more than a decade, has worked towards a model of Continuing Professional Development (CPD) that addresses educational needs such as communication skills, team-working, the ethics of clinical practice, etc.o CPD incorporates CME, which is considered to be more narrowly focused on speciality-specific clinical knowledge and skills.· Similar requirements have been introduced, usually with a delay of around five years, for all healthcare professionals.Providers · The environment for Providers of CME is surprisingly deregulated, with there being an open market that permits the full range of Providers:o by locality –local, regional, national and international, and;o by institution –NHS, employer, academic, professional bodies, private.· The largest Providers of CME, in terms of volume of delivery, are the NHS bodies: the employing organisations for healthcare professionals.o In this context CME is locally delivered, frequently generic, and focused on local needs. However, for more specific CME, practitioners will seek more directed regional and national specialty conferences, or e-learning.· A full range of activities being accessible: local meetings, national conferences, e-learning, and blended learning. (and print?)· The UK has encouraged multi-professional learning and, while most speciality-specific conferences will be targeted at a specific professional audience, more generic CME events (e.g. ALS/ATLS training) frequently will be multi-professional.Funders· Because most healthcare professionals are employed by the NHS, and have contracts that support funded study, developments in CME have been funded predominantly through the public sector.o Individual practitioners, particularly doctors, can claim reimbursement from their employers for travel, subsistence and educational expenses;o Local CME is funded out of budgets held by local employers or by regional educational bodies;o National events receive most of their delegate income from practitioners who will claim these costs as permissible study leave expenses.· As a result, pharmaceutical companies have had considerably less opportunity for funding CME.o In addition, NHS employees are required to declare sponsored education, and are barred from related purchasing decisions.· However, the private sector does contribute to CME, predominantly by part-funding national and international conferences, and by presenting company-delivered CME, such as satellite symposia at major conferences.
2. ACCREDITATION SYSTEM
Given that most CME in the UK is delivered locally or regionally, the large majority is not accredited. However, for national and international conferences, accreditation is considered essential.· Accreditation frequently is provided by the speciality-specific Royal Colleges, all of which have well-developed CME departments.o They are also responsible for organizing national CME conferences. While efforts are made to separate organizing and accrediting, concerns have been expressed as to the potential for conflict of interest.· As a result, for conferences that are large enough to attract an international audience –frequently so, given that English is the international language of Medicine, and the proximity of many European countries –international accreditation usually is sought. For specialist doctors is provided by the European Accreditation Council for CME (EACCME) (www.eaccme.eu) that has mutual recognition agreements with 21 European countries, the USA and Canada.
II. CURRENT REQUIREMENTS FOR MEDICAL EDUCATION
1. DOCTORS
Mandatory
While CME has been a professional responsibility for around 40 years, in 2012, it become a statutory and regulatory requirement for all registered doctors. (should we site a link to this action?)
Regulatory Authority
The General Medical Council (GMC) (www.gmc-uk.or/) through national guidance sets the framework for CME/CPD. Doctors are expected to comply with this guidance, and fulfil these requirements in accordance with their speciality and local circumstances.
Methods of delivery
A full range of learning activities is permitted and encouraged, recognising that individual practitioners have different learning styles and preferences. Accordingly, all of the following are accepted: reading of print materials, online reading, attending audit and clinical review meetings, e-learning modules, workshops, conferences, lecturing, etc.
Increasingly, emphasis is being placed on the practitioner “reflecting”on what they have learned, and implementing into practice suitable learned points.
Topics required
Doctors are encouraged to develop and maintain their knowledge, skills and attitudes with certain “core”topics being mandatory for all doctors (maintaining knowledge base; resuscitation skills; communication skills) and “specialist”ones being more specific to their specialist area.
Hours or Credits needed, or other means of meeting requirements
Doctors are expected to fulfil the CPD requirements (where are these available. What about non accredited locally delivered CME –how are eligible hours determined and then does that go to the Royal College as evidence of compliance?) set by their relevant Royal College and to ensure a balance of CME and CPD. This should involve a minimum of 25 hours of “internal”(employer-based) learning and 25 hours of “external”learning.
Penalties and/or Rewards for engagement in CME
A multi-layered form of accountability now exists, with doctors accountable to their employer for delivering contractual objectives and the GMC for regulatory components. Both of these include CME/CPD.
While there are no rewards for compliance, potential penalties include withholding of pay progression (employers) and regulatory intervention (GMC). (is this happening to your knowledge? And does it affect revalidation and therefore relicensure –which is not mentioned?)
Evaluation
Initial evaluation of engagement in CME/CPD is performed as part of annual Job Plan Review (for NHS employees) and annual Appraisal (for all doctors).
In addition, national evaluation (not sure what this means?)can occur as part of Revalidation. While the GMC has the power to scrutinize the details of compliance, to date, in most cases, engagement in CME/CPD, as confirmed by Appraisal, has been considered sufficient.
Reciprocation of Credits
CME credits are specific to the UK only, except in the case of international CME credits accredited by the EACCME.(www.eaccme.eu)
State Bodies
While the NHS is gradually developing four different healthcare systems for the four countries of the UK (England, Northern Ireland, Scotland, Wales), as the GMC is a UK-wide Regulatory Authority, the regulations that apply to CME/CPD also are UK-wide.
Speciality Boards
The UK is unusual in an international context in having very highly developed speciality bodies, the Medical Royal Colleges. The oldest of these, the Royal College of Physicians of London was established almost 500 years ago and they now exist for almost all specialities and sub-specialities.
b. PHARMACISTS
Mandatory / Voluntary
Pharmacists in the UK currently are in transition between a voluntary system and a mandatory one. While they are required to fulfil a defined amount of CPD, the mechanisms for monitoring that have yet to be fully developed.
It is likely that the implementation of Revalidation will occur within the next seven years, and will enforce a mandatory system.
Regulatory Authority
The General Pharmaceutical Council (GPhC). (www.pharmacyregulation.org) sets national guidance that applies to all registered throughout the UK. This includes the requirements for CME.
Methods of delivery
The GPhC recognises a wide range of CPD activity, including print materials, online learning, attendance at conferences and courses, etc. A key element that it requires is reflection on the need for the CPD and on the outcome.
Many organisations are permitted to deliver CPD, including the education departments of local employers, Universities and national bodies.
The large majority of CPD for Pharmacists (more than 80%) is provided locally, with only a limited amount provided in the form of conferences and courses.
Unlike in the case of doctors –who usually are re-imbursed their expenses –Pharmacists usually are required to pay for their own external CPD. The Pharmaceutical industry –has limited involvement in the funding of CPD and, at most, is involved in providing satellite symposia at large conferences.
Topics required
There is an expectation that the subjects covered by CPD will differ within the year, and from year to year, thereby ensuring that all subjects are covered.
Hours or Credits needed, or other means of meeting requirements
The GPhC requires that Pharmacists complete at least nine modules per year of CPD activity. These can range from 4-5 hours (for reading and reflection), to a few days (for a conference).
Penalties and/or Rewards for engagement in CME
While it is possible that a Pharmacist could be removed from the Register (ie. no longer allowed to practice) if he/she has not fulfilled their CPD requirements, this is unlikely to occur in the absence of other impairment of performance. However, the GPhC is consulting on the implementation of Revalidation, which would give it greater powers to intervene in this area.
Evaluation
The GPhC largely relies on local (employer-based) scrutiny of CPD portfolios, but has the power to review the portfolio of any registered Pharmacist.
Reciprocation of Credits
As there is no formal credit system, there is no form of reciprocation.
However, the GPhC does provide accreditation for major conferences and courses, as a marker of the quality of the CPD to be expected.
Other Bodies
In addition to the GPhC, a key national body is The Royal Pharmaceutical Society (RPhS), (www.rpharms.com) which is the professional organisation for Pharmacists. It effectively acts as a national Speciality Board, providing CPD but also representing and supporting Pharmacists.
c. NURSES
Mandatory / Voluntary
Nurses in the UK currently are in transition between a voluntary system and a mandatory one. While the requirements for CPD are more clearly established, the mechanisms for monitoring that have yet to be so.
It is likely that the implementation of Revalidation will occur within the next seven years, and will enforce a mandatory system.
Regulatory Authority
The Nursing and Midwifery Council (NMC) (www.nmc-uk.org/) sets national guidance that applies to all registered throughout the UK. These are set out in its post-registration and education practice (prep) standards, the defined requirements for CME. The cycle for CME/CPD achievement is three years.
Methods of delivery
The NMC accepts a wide range of CPD activity, with most emphasis being on CPD delivered locally within the nurse’s employing NHS organisation and is funded through the hospital budget.
Local Practice Facilitators and Practice Educators provide a network that ensures the delivery of CPD for employed Nurses.
In addition to CPD provision by the education departments of local employers, regional educational bodies, and national bodies are involved.
Universities provide graduate and post-graduate diploma and degree courses, for which funding sometime is available.
The largest national body involved in the delivery of CPD for Nurses is the Royal College of Nursing (RCN). (www.rcn.org.uk/) which acts as the professional organisation for Nurses in the UK.
Pharmaceutical industry involvement is very limited, with funding occasionally being provided to support local Practice Educators.
Topics required
Nurses are required to keep a portfolio of CPD activities that documents the range and extent of CPD that they have completed.
Hours or Credits needed, or other means of meeting requirements· In order to fulfil the prep requirements, Nurses are required to confirm that they have performed:o 450 hours of registered practice in the previous three years, and o 35 hours of learning activity (CPD) in the previous three years.Penalties and/or Rewards for engagement in CME
As Nurses have to re-register every year, it is possible that, in the absence of documented CPD and fulfilment of the prep standards, the NMC could refuse registration. In the absence of other performance problems, this is unlikely to occur. It is probable that, with the planned implementation of Revalidation for Nurses, enforcement will become stricter.
Evaluation
Most evaluation occurs locally, by peer-review, but it is possible for the NMC to perform a random sample of portfolios. In reality, this happens rarely.
Reciprocation of Credits
As there is no formal credit system, there is no reciprocation.
State Bodies
The Nursing and Midwifery Council is the only national body equivalent to a “state body”.
Speciality Boards
The Royal College of Nursing (www.rcn.org.uk/) is the only national body equivalent to a“speciality board”.
III. FUNDING OF MEDICAL EDUCATION POLICIES, REQUIREMENTS & REGULATIONS
Accrediting Bodies
In most cases accreditation is provided by the relevant Medical Royal College (for Doctors), the General Pharmaceutical Council (for Pharmacists), and the Royal College of Nursing (for Nurses).
In the case of Doctors, the criteria being applied increasingly are being aligned with the international criteria set by the European Accreditation Council for CME (EACCME –www.eaccme.eu)
Government Regulations for Sponsors
The UK currently has a remarkably deregulated system of support for CPD by pharmaceutical companies, with self-regulation by industry being the accepted model.
Recent legislative developments in the USA have meant that the European subsidiaries of global companies registered in the USA have to comply with the requirements of the Sunshine Act, but legislative changes in other European countries (e.g. The Netherlands) have prompted moves towards full disclosure of all payments to Doctors and Medical Organisations.
Pharmaceutical Association codes
The code of practice of the Association of the British Pharmaceutical Industry (ABPI – www.abpi.org.uk) is well-established, and largely is effective in determining the compliance of those companies that agree to abide by its requirements.
In addition, the new code of the European Federation of Pharmaceutical Industries and Associations (EFPIA - www.efpia.eu) is likely to have a major impact. (any key elements to mention with either of these codes ie limits on what can cover (meals, travel etc)?)
IV.MEDICAL EDUCATION RESOURCES – List of Suggested Vendors.
The following do not represent an endorsement from the developers of this section. They are just some of the better known vendors developing accredited CME in the UK at present.
BMJ Learning
Regarded as the market leader in online learning.
Claims to have more than 2000 modules available to doctors.http://n3.learning.bmj.com/learning/home.htmlDoctors.net.uk
Provides online learning for a claimed membership of more than 200.000 doctors.http://www.doctors.net.uk/
Liberum
Celeste Kolanko, Managing Director
Celeste.Kolanko@liberumime.com
4th Floor Holborn Gate | 26 Southampton Buildings | London, UK | WC2A 1PQ Mobile: +44 (0)7472 657999 Office: +44 (0)7552 289269
The Medical Royal Colleges
Details as above, their dominant mode of delivery of CPD is through live educational events. However, some are now developing e-learning modules in their speciality area(s).
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