Are the General Medical Council's Tests of Competence fair to long standing doctors? A retrospective cohort study.

The General Medical Council's Fitness to Practise investigations may involve a test of competence for doctors with performance concerns. Concern has been raised about the suitability of the test format for doctors who qualified before the introduction of Single Best Answer and Objective Structured Clinical Examination assessments, both of which form the test of competence. This study explored whether the examination formats used in the tests of competence are fair to long standing doctors who have undergone fitness to practise investigation

The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England

The Health and Social Care Committee commissioned a review of evidence for the effective implementation of the Government’s policy commitments relating to maternity services. Our report has been produced independently of the Committee’s own inquiry into the safety of maternity services in England. 3 Our report has been reviewed by the Committee and supports the Committee’s inquiry. A panel of experts has been established consisting of members with recognised expertise in quantitative and qualitative research methods, and policy evaluation. This core group was complimented by four clinicians with a working knowledge and experiences of maternity services delivery.4 Evaluations and judgements in this report are summarised in a CQC-style rating of particular Government policy commitments for maternity services. While these are in the style of ratings used by national bodies such as the CQC, the ratings in this report have been determined by us and do not reflect the opinion of the CQC. The commitments under review are interconnected allowing an overall rating to be given relating to a combined assessment against all four commitments. Separate ratings have also been given to each commitment and its main questions. All ratings are informed by a review process using robust research and evaluation methods. Published data and other sources of evidence, including written submissions from stakeholders, focus groups and round table discussions have been used to provide evidence for review by the Expert Panel. The Department of Health and Social Care have been invited to contribute to the process at each stage of evaluation. 3 Health and Social Care Committee, Safety of Maternity Services in England 4 First Special Report of Session 2019–21: Process for independent evaluation of progress on Government commitments [21 July 2020] 4 Selected Commitments On 14 December 2020, the Department of Health and Social Care provided the Panel with its main policy commitments for maternity services. Using this information and wider policy documentation, we selected the four commitments we identified as the most important and appropriate sample for review and agreed to evaluate the Government’s progress against these commitments. The commitments are: 1. Maternity Safety: By 2025, halve the rate of stillbirths; neonatal deaths; maternal deaths; brain injuries that occur during or soon after birth. Achieve a 20% reduction in these rates by 2020. To reduce the pre-term birth rate from 8% to 6% by 2025. 2. Continuity of Carer: The majority of women will benefit from the ‘continuity of carer’ model by 2021, starting with 20% of women by March 2019. By 2024, 75% of women from BAME communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period. 3. Personalised Care: All women to have a Personalised Care and Support Plan (PCSP) by 2021. 4. Safe Staffing: Ensuring NHS providers are staffed with the appropriate number and mix of clinical professionals is vital to the delivery of quality care and in keeping patients safe from avoidable harm. For each commitment under review, The Health and Social Care Committee set out main questions to guide the Expert Panel’s evaluation. We then developed a set of sub-questions relating to specific areas of the commitment. These main questions and sub-questions were incorporated into a final framework referred to as the Expert Panel’s planning grid. 5 The planning grid was shared with the Department and formed the basis of the Department’s formal written response.6 We used the key questions in the planning grid, as well as our own thematic analysis of written submissions, transcripts from focus groups and roundtable events, as the basis for this evaluation. The main questions set out in the planning grid are: A. Was the commitment met overall? Or is the commitment on track to be met? B. Was the commitment effectively funded (or resourced)? C. Did the commitment achieve a positive impact for women? D. Was it an appropriate commitment?7 The ratings for all commitments and main questions are summarised in Table 1. An analysis of each sub-question, as described in the planning grid, can be found in annexes A-D. We invited the Department of Health and Social Care to respond to all main questions and subquestions in its written response.8 5 Letter from Rt Hon Jeremy Hunt, Chair, Health and Social Care Select Committee, and Professor Dame Jane Dacre, Chair, Health and Social Care Committee’s Expert Panel, to Rt Hon Matt Hancock MP, Secretary of State, regarding Government commitments in the area of maternity services [16 March 2021] 6 Department of Health and Social Care (EPE0026) 7 First Special Report of Session 2019–21: Process for independent evaluation o

Mend the Gap: The Independent Review into Gender Pay Gaps in Medicine in England

The Independent Review into Gender Pay Gaps in Medicine in England was commissioned by the Department of Health and Social Care in 2017. It is the largest and most comprehensive review of its kind ever completed in the public sector. Chaired by Professor Dame Jane Dacre and led by Professor Carol Woodhams, the review takes a comprehensive approach to understanding the structural and cultural barriers affecting the female medical workforce

Doctors who pilot the GMC's Tests of Competence: who volunteers and why?

Background: Doctors who are investigated by the General Medical Council (GMC) for performance concerns may be required to take a Test of Competence (ToC). The tests are piloted on volunteer doctors before they are used in Fitness to Practise (FtP) investigations. Objectives: To find out who volunteers to take a pilot ToC and why. Methods: This was a retrospective cohort study. Between February 2011 and October 2012 we asked doctors who volunteered for a test to complete a questionnaire about their reasons for volunteering and recruitment. We analysed the data using descriptive statistics and Pearson’s chi-square test. Results: 301 doctors completed the questionnaire. Doctors who took a ToC voluntarily were mostly women, of white ethnicity, of junior grades, working in general practice and who held a Primary Medical Qualification from the UK. This was a different population to doctors under investigation and all registered doctors in the UK. Most volunteers heard about the GMC’s pilot events through email from a colleague and used the experience to gain exam practice for forthcoming postgraduate exams. Conclusions: The reference group of volunteers are not representative of doctors under FtP investigation. Our findings will be used to inform future recruitment strategies with the aim to encourage better matching of groups who voluntarily pilot a ToC with those under FtP investigation

Performance in the MRCP(UK) Examination 2003-4: analysis of pass rates of UK graduates in relation to self-declared ethnicity and gender

Background: Male students and students from ethnic minorities have been reported to underperform in undergraduate medical examinations. We examined the effects of ethnicity and gender on pass rates in UK medical graduates sitting the Membership of the Royal Colleges of Physicians in the United Kingdom [MRCP( UK)] Examination in 2003-4. Methods: Pass rates for each part of the examination were analysed for differences between graduate groupings based on self- declared ethnicity and gender.Results: All candidates declared their gender, and 84 - 90% declared their ethnicity. In all three parts of the examination, white candidates performed better than other ethnic groups (P < 0.001). In the MRCP(UK) Part 1 and Part 2 Written Examinations, there was no significant difference in pass rate between male and female graduates, nor was there any interaction between gender and ethnicity. In the Part 2 Clinical Examination (Practical Assessment of Clinical Examination Skills, PACES), women performed better than did men (P < 0.001). Non-white men performed more poorly than expected, relative to white men or non-white women. Analysis of individual station marks showed significant interaction between candidate and examiner ethnicity for performance on communication skills (P = 0.011), but not on clinical skills (P = 0.176). Analysis of overall average marks showed no interaction between candidate gender and the number of assessments made by female examiners (P = 0.151).Conclusion: The cause of these differences is most likely to be multifactorial, but cannot be readily explained in terms of previous educational experience or differential performance on particular parts of the examination. Potential examiner prejudice, significant only in the cases where there were two non- white examiners and the candidate was non- white, might indicate different cultural interpretations of the judgements being made

Expert Panel: Evaluation of the Government's Progress against its policy commitments in the area of mental health services in England

The Health and Social Care Committee commissioned a review of the evidence for the effective implementation and appropriateness of the Government’s policy commitments relating to mental health services in England. This report has been produced independently of the Committee’s inquiry into children and young people’s mental health and examines a broader remit than the Committee’s inquiry. Our findings and ratings in relation to commitments made to improve services for children and young people do, however, contribute to the Committee’s inquiry on this topic. The Expert Panel consists of members with recognised expertise in quantitative and qualitative research methods, and policy evaluation. This core group was complemented by experts with a working knowledge and experience of frontline delivery of NHS mental services, clinical research and policy development and implementation. Evaluations and judgements in this report are summarised by ratings which chart the Government’s progress against specific mental health commitments. While these ratings are in the style used by national bodies such as the Care Quality Commission (CQC), the ratings in this report have been determined by us and do not reflect the opinion of the CQC or any other external agency. The commitments under review are inter-connected allowing an overall rating to be made which forms a combined assessment against all the commitments we evaluated. Separate ratings have also been given to each commitment and its main questions. All ratings are informed by a review process using a combination of established research methods, expert consensus, and consultation with communities (see Annex A for key evidence). Published data and other sources of evidence, including written submissions from stakeholders, and round table discussions have been used to provide evidence for review by the Expert Panel, which are referenced in footnotes throughout the report. The Department of Health and Social Care and relevant non-departmental public bodies were invited to contribute to the evaluation. Selected Commitments The Department of Health and Social Care provided the Panel with its main policy commitments in the area of Mental Health Services in England. Using this information and wider policy documentation, we identified nine commitments across four broad policy areas. These included important and measurable ambitions for improvements in health services, reflecting wider NHS and social care systems. The Panel considers these commitments to provide reasonable generalisable evidence of progress against policy aspirations in the broader area of mental health. The Expert Panel evaluated the Government’s progress against these commitments. The commitments we have chosen to examine are: 10 Second Special Report of Session 2021–22 Policy Area Government Commitment Workforce • we are committed to growing the mental health workforce Children and Young People’s (CYP) Mental Health • at least 70,000 additional children and young people each year will receive evidence-based treatment … • achieve 2020/21 target of 95% of children and young people with eating conditions accessing treatment within 1 week for urgent cases and 4 weeks for routine cases • ensure there is a CYP crisis response that meets the needs of under 18-year-olds Adult Common Mental Illness • All areas commission IAPT-Long term condition services Adult Severe Mental Illness • 280,000 people with SMI will receive a full annual health check • new integrated community models for adults with a severe mental illness [delivery date of 2023/24] • the therapeutic offer from inpatient mental health services will be improved by increased investment in interventions and activities, resulting in better patient outcomes and experience in hospital. • all areas will provide crisis resolution and home treatment (CRHT) functions that are resourced to operate in line with recognised best practice, delivering a 24/7 community-based crisis response and intensive home treatment as an alternative to acute inpatient admission For each commitment under review, the Health and Social Care Committee approved the main questions to guide the Expert Panel’s evaluation. The Panel then developed a set of sub-questions relating to specific areas of the commitment. These main questions and sub-questions were incorporated into a final framework referred to as the Panel’s planning grid. The planning grid was shared with the Department for Health and Social Care and formed the basis of the Government’s formal written response. The Expert Panel used the key questions in the planning grid, as well as its own thematic analysis of 25 written submissions, publicly available data, and transcripts from roundtable events with 24 mental health practitioners as the basis for this evaluation. We invited The Department of Health and Social Care to respond to all main questions and sub-questions in its written response. The main questions set out in the planning grid are:2 • Was the commitment met overall? Or is the commitment on track to be met? • Was the commitment effectively funded (or resourced)? • Did the commitment achieve a positive impact for service users? • Was it an appropriate commitment? 2 First Special Report of Session 2019–21: Process for independent evaluation of progress on Government commitments (July 2020), p. 3 Second Special Report of Session 2021–22 11 The ratings for the nine commitments within the four policy areas and main questions were used to inform the Panel’s overall rating for the area of mental health. The ratings for each of the nine commitments in the four policy areas are summarised in the following table. Overall rating across all commitments Requires Improvement Workforce Commitment A. Commitment Met B. Funding and Resource C. Impact D. Appropriate Overall Grow the workforce Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Children and Young People’s Mental Health Additional treatment Good Good Good Inadequate Requires Improvement 95% CYP accessing treatment for eating conditions Requires Improvement Good Requires Improvement Outstanding Good Crisis response Requires Improvement Requires Improvement Requires Improvement Outstanding Requires Improvement Adult Common Mental Illness All areas commission IAPT-Long term condition services Requires Improvement Requires Improvement Good Requires Improvement Requires Improvement Adult Severe Mental Illness Physical health check Inadequate Requires Improvement Requires Improvement Requires Improvement Requires Improvement Integrated community models Requires Improvement Inadequate Requires Improvement Requires Improvement Requires Improvement Improved therapeutic offer Requires Improvement Requires Improvement Requires Improvement Inadequate Requires Improvement 12 Second Special Report of Session 2021–22 Commitment A. Commitment Met B. Funding and Resource C. Impact D. Appropriate Overall Crisis resolution and home treatment Requires Improvement Good Requires Improvement Good Requires Improvement The overall rating for the nine commitments across the four policy areas evaluated is: Requires Improvement This rating relates to how the government have progressed overall against nine commitments across the four policy areas based on guidance outlined in the anchor statements (Annex B) set out by the Health and Social Care Committee. While an overall rating of progress against all nine specific commitments is challenging to determine and the ratings of individual commitments are standalone, the evidence we assessed shows that the Government’s progress against its commitments to improve mental health services in England requires improvement. Because of this concern, each of the nine commitments have been rated separately. Although significant efforts have been made across the four main policy areas evaluated (with some notable success), the Panel’s evaluation shows that more progress is required to achieve success in all nine commitments. We recognise that many, if not all, of the commitment areas have been impacted by the COVID-19 pandemic, which services could not have reasonably prepared for in advance. We have considered factors related to the COVID-19 pandemic throughout our evaluation, acknowledging where commitments were on track to be met prior to the pandemic. As the pandemic has been associated with a rise in mental health conditions,3 demand for services is greater than when these commitments were made, which could not have been anticipated by services. Therefore, continued and expanded resources for mental health services will be required to ensure the capacity for services increases with the need for mental health support. We recognise the effort by mental health services and frontline workers to support the health of the nation during the COVID-19 pandemic, which have been conducted under unprecedented circumstances. The rationale to support the ratings and our findings is summarised below. Workforce Commitment: Grow the mental health workforce (Requires Improvement) • Overall, the mental health workforce has increased by 17,778 FTE staff since 2016, meeting the targets set for 2021. 3 Fancourt, D., Steptoe, A., & Bu, F. (2021). Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. The Lancet Psychiatry, 8(2), 141–149; Saunders, R., Buckman, J. E. J., Fonagy, P., & Fancourt, D. (2021). Understanding different trajectories of mental health across the general population during the COVID-19 pandemic. Psychological Medicine, 1–9. doi: 10.1017/ S0033291721000957 Second Special Report of Session 2021–22 13 • However, key staffing groups such as mental health nurses and consultant psychiatrists (and specific sub-specialities relevant to priority policy areas) have not increased in line with targets set in the Stepping forward to 2020/21 and Mental Health Implementation Plans.4 • Funding has been allocated to train new staff; however, this funding was designated for overall mental health staff and has not been used to increase staff in specific professional groups. The increase in numbers is only meaningful if they represent appropriately trained and professionally governed individuals. Funding is also insufficient to retain and upskill existing staff. • Workforce shortages represent the single biggest threat to national ambitions to improve mental healthcare, impacting delivery across all mental health services. Children and Young people Commitment 1: Access to treatment (Requires Improvement) • The number of children and young people accessing treatment has increased greatly since this commitment was made, though this has also coincided with a probable increase in the need for services. • Children and young people who access services have reported significant improvements to their mental health. • However, the target that only 35% of children and young people should have access to treatment is inadequate and leaves the majority of children and young people who require support for a mental health diagnosis without access to services. Commitment 2: Eating conditions (Good) • The target to ensure 95% of children and young people receive treatment for eating conditions within one week for urgent cases and four weeks for routine cases has not been met. • Progress on this target has been significantly impacted by the COVID-19 pandemic, which has led to a dramatic increase in the prevalence of eating conditions. • Given the association between eating conditions and high mortality rates, the ambitious target outlined in this commitment was highly appropriate. The specificity of this commitment meant that services had a clear target to aim towards. Commitment 3: CYP Crisis Services (Requires Improvement) • The provision of 24/7 crisis support lines to provide support, advice and triage has been achieved; a target that has been met in advance of the deadline. 4 Health Education England, Stepping forward to 2020/21: The mental health workforce plan for England (July 2017) 14 Second Special Report of Session 2021–22 • However, in most regions less progress has been made with other functions of a crisis response service, meaning these services cannot provide treatment for the range of mental health symptoms children and young people present with at these services. • The absence of functioning crisis response services has led to children and young people being inappropriately placed on adult wards. Adult Common Mental Illness Commitment: All areas commission adult Increasing Access to Psychological Therapies-Long-term condition services (Requires Improvement) • Significant work is required before the commitment to establish Increasing Access to Psychological Therapies (IAPT) services for adults with long term conditions across all areas can be met by the 2023/24 deadline. • The provision of specialist services for adults with a long-term condition has the potential to have positive impact on service users’ ability to manage their physical conditions. • In treating long term conditions through IAPT, savings could be made across the NHS and reduce the burden on these services, but this has not yet been achieved. Adult Severe mental Illness Commitment 1: Annual Physical Health Checks (Requires Improvement) • Progress on this commitment has been inadequate, as only approximately half of the target numbers have been achieved as of Q1 2021/22. This commitment was not on track to be achieved prior to the COVID-19 pandemic. • Recent investment has been made to accelerate progress on this commitment, but we are unable to evaluate the impact of these additional funds as this is reliant on the capacity of general practice to deliver the health checks. • This is an important commitment as the average lifespan of an individual with a severe mental illness is 15–20 years shorter than the general population. Commitment 2: Community Models (Requires Improvement) • Progress on the commitment to deliver new integrated community models for adults with a severe mental illness requires improvement, as some services continue to rely on inpatient, residential models of care. • Early implementer sites report positive outcomes from community models, demonstrating the positive potential of this form of care. Second Special Report of Session 2021–22 15 • This commitment is not specific enough and requires improvement, as it is unclear which services comprise a community model, or which metrics can be used to evaluate community services. Commitment 3: Improved therapeutic offer (Requires Improvement) • Measures of length of stay in acute services suggest that progress on this commitment has been made, but the quality and scope of activities is not sufficient to provide an improved therapeutic offer. Although it is possible to measure length of stay this does not necessarily reflect improvements in outcomes. • There is a disparity between the measures used by services and the views of service users, who report the inpatient therapeutic offer to be insufficient. • The physical estate for mental health services is poor and presents a barrier to achieving this commitment, as service users report a lack of a therapeutic environment. • The insufficient mix of workforce skills and disciplines within inpatient facilities also constrains progress on this commitment. Commitment 4: Crisis resolution and home treatment (Requires Improvement) • Despite all services providing phone lines, the services are not operational 24/7, limiting their effectiveness. • Staffing issues, exacerbated by COVID-19, have contributed to difficulties establishing coherent and high-quality crisis services. • However, commendably, the specification of ideal services is clear, which will support their implementation in services across the country in fut

Cross-comparison of MRCGP & MRCP(UK) in a database linkage study of 2,284 candidates taking both examinations: assessment of validity and differential performance by ethnicity.

MRCGP and MRCP(UK) are the main entry qualifications for UK doctors entering general [family] practice or hospital [internal] medicine. The performance of MRCP(UK) candidates who subsequently take MRCGP allows validation of each assessment. In the UK, underperformance of ethnic minority doctors taking MRCGP has had a high political profile, with a Judicial Review in the High Court in April 2014 for alleged racial discrimination. Although the legal challenge was dismissed, substantial performance differences between white and BME (Black and Minority Ethnic) doctors undoubtedly exist. Understanding ethnic differences can be helped by comparing the performance of doctors who take both MRCGP and MRCP(UK)

Characterising the atmospheric conditions leading to large error growth in volcanic ash cloud forecasts

Volcanic ash poses an ongoing risk to the safety of airspace worldwide. The accuracy to which we can forecast volcanic ash dispersion depends on the conditions of the atmosphere into which it is emitted. In this paper we use meteorological ensemble forecasts to drive a volcanic ash transport and dispersion model for the 2010 Eyjafjallajokull eruption. From analysis of these simulations we determine why the skill of deterministic-meteorological forecasts decrease with increasing ash residence time, and identify the atmospheric conditions in which this drop in skill occurs most rapidly. Large forecast errors are more likely when ash particles encounter regions of large horizontal flow separation in the atmosphere. Nearby ash particle trajectories can rapidly diverge leading to a reduction in the forecast accuracy of deterministic forecasts which do not represent variability in wind fields at the synoptic-scale. The flow separation diagnostic identifies where and why large ensemble spread may occur. This diagnostic can be used to alert forecasters to situations in which the ensemble mean is not representative of the individual ensemble member volcanic ash distributions. Knowledge of potential ensemble outliers can be used to assess confidence in the forecast and to avoid potentially dangerous situations in which forecasts fail to predict harmful levels of volcanic ash

The transition to consultant: Identifying gaps in higher specialist training

Background New consultants consistently feel better prepared for the clinical rather than non-clinical aspects of their role. However, deficiencies in generic competencies have been linked to burnout and patient complaints. This study explored how higher specialty training prepares doctors for the transition to consultant in genitourinary medicine. Results New consultants felt less prepared for non-clinical aspects of their role. Prior practical experience was the greatest influencing factor in levels of preparedness, with increased responsibility and leadership driving deeper learning. Observation of others helped individuals develop a professional identity but also learn about the wider processes within their service. The learning environment positively influenced preparedness but highlighted a need for dedicated time to learn non-clinical aspects. Conclusion To ensure future trainees feel prepared for the non-clinical aspects of the consultant role, practical experience of non-clinical areas with high levels of leadership and responsibility within a supportive learning environment is essential