COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Supplement for Undergraduate Medical and Dental Education
25 June 2009
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey
Witnesses:
Ms Helena Brown )
Mr Peter Gregg ) Department of Health, Social Services and Public Safety
Dr Paddy Woods )
The Deputy Chairperson (Mrs O’Neill):
The next evidence session is with officials from the Department of Health, Social Services and Public Safety. The subject is the supplement for undergraduate medical and dental education (SUMDE) funding. I welcome Dr Paddy Woods, Peter Gregg and Helena Brown. You are all very welcome. I invite you to make your presentation, after which members may have some questions.
Mr Peter Gregg (Department of Health, Social Services and Public Safety):
I apologise if our presentation is repetitious. I was listening to Paddy and Norman’s earlier presentation. SUMDE is a difficult subject to get your head around, and perhaps we will give members a different slant on it.
I understand that the Committee has requested today’s briefing session as a result of the consultation paper that the Department issued in February 2009 on the review of SUMDE funding. We welcome the opportunity to address the Committee and to provide evidence and an update on the progress of that consultation and review. I also understand that the Committee visited Queen’s University Belfast (QUB) recently and has been briefed by Professor Paddy Johnston and Norman Bennett, with whom we work closely. Much of what they have said is relevant to the Department and trusts, both of which work in partnership with them. The Department cannot train future medical students on its own, and it relies on the trusts and the university being equal partners.
I will expand on the purpose of SUMDE, the consultation, current position and proposals for its future development, and how we propose to progress the recommendations. SUMDE is a mechanism to reimburse hospitals for the additional costs that they incur when medical and dental students are present in clinical settings. The supplement is based on a set of 10 strategic, operational and funding principles that originated in a 1996 report by Dr Graham Winyard. That report provided the basis for the supplement mechanism that operates today, in whole or in part, in Northern Ireland and, indeed, in other regions of the UK. Although those principles are mostly still intact, we need to improve their implementation and cost-effectiveness. It is important to focus on SUMDE’s two main purposes. The health and social care trusts must support undergraduate medical and dental education. It is for the trusts and the system to train our future doctors; it is not the exclusive responsibility of the universities. The purpose of the supplement is to ensure that service providers are not financially disadvantaged in carrying out that task.
A review by Cyril Chantler in 2004 led to the expansion of the School of Medicine at Queen’s and increased the annual student intake from 154 to 250 from September 2005. The full benefit of that will be seen at the end of the 2009-2010 academic year, when the first of those students complete their fifth year. The Chantler review also recommended that a management group be convened to oversee that expansion and other issues relating to undergraduate medical students. That group, which has now been established in the Department, is known as the medical student management group (MSMG) and includes representatives from QUB, such as Paddy Johnston, the five trusts and the Department. Although the Department owns the document, those partners were part of a joint effort to pull it together. That does not necessarily mean that they agreed with all its content, but they are signed up to what we are aiming towards.
The expansion at the School of Medicine provided an opportunity to examine the distribution methods of supplementary funding and to develop accountability, a principle that Chantler certainly recognised. A new funding stream model was developed for the additional students, and, for internal management purposes, we call that “new SUMDE”. Unfortunately, that has led to two different models currently being in place, “old SUMDE” and new SUMDE. It has been accepted that we need to move to a single system, because the existing system is somewhat cumbersome and difficult to administer. We have started that process through the consultation document, and that is built around the overriding principle, which Professor Johnston mentioned, that funding should follow the student. We must keep focused on that.
The Department and the other key players recognise that the review offers a fresh opportunity to strengthen accountability mechanisms, audit funding streams and assure value for money. The proposals are high level, and they describe one simpler and more easily understood allocation method to be developed. That is built around the concept of a teaching unit, which members have just heard about. The teaching unit will be an identifiable unit of staff time and costs, based around the salary levels of consultants. The teaching unit costs will then be used in a formula, which is contained in the document, to distribute the funding proportionate to the number of students to each hospital. That will provide a more equitable distribution of existing funds and allow for a transition period, or, as we call it, a “glide path”, so that any changes will have a minimum impact and any negative impact on a trust will be avoided. In this case, the Belfast Trust is the main nucleus for providing clinical placements.
SUMDE has a large resource of approximately £35 million, around £5 million to £6 million of which goes towards dental SUMDE, which is not included in the review. The MSMG is carrying out ongoing work to develop an audit pro forma of financial statements and performance management systems. We are actively working on those and trying to put systems in place that are built around new SUMDE. The medical budget, which was distributed in 2008-09, includes £4 million for joint appointments, £19·2 million for infrastructure and £6·4 million for clinical placements.
The formal consultation ended on 20 May 2009, and eight comprehensive responses have been received. The consensus in those responses is that any redistribution should take place as soon as possible. However, that points towards changes taking place from the start of the 2010-11 financial year. We are mindful of the fact that the system, as it stands, has been in place for a number of years, and we need time to ensure that it is implemented steadily and competently.
It is important to point out that the situation that the Department faces with SUMDE is similar to that being faced in the other UK regions. The benchmarking exercise in the report demonstrated that, although methods for allocating funding for undergraduate education vary, all regions need to tackle the issues of accountability, transparency and distribution.
It is critical to maintain a mutual understanding and agreement among the trusts, Queen’s University and the Department. That relationship is critical in moving forward. There is only one medical school in Northern Ireland. Traditionally, we have relied heavily on the Belfast Trust as a main medical teaching centre, although that is changing. The Department’s aim is to ensure that newly qualified medical doctors ensure the delivery of healthcare to the population of Northern Ireland. That is the business that we are in.
The Deputy Chairperson:
When the Committee visited Queen’s University, members were startled to hear how the money was distributed and the disparity across the trust areas, with most of the money being centred on the Belfast area. Therefore, we welcome any move towards the establishment of a more level playing field, transparency and openness. We accept that that is the direction in which we are heading.
You may have heard joint appointments being discussed in the previous evidence session. I know that the Department is establishing a group to examine that issue and that the SUMDE recommendations will feed into it. Concerns have been raised about us not opening the door to internationally qualified professionals. Is the Department doing anything about that? We do not want to close the door to anybody, and we want to attract the best. If we are to become internationally recognised as the place to be, we need to work on that.
Mr Gregg:
As the funding holder for SUMDE, we will consider the issue of joint appointments. A subgroup of the main management group has been established, and our first meeting is scheduled for 22 July 2009.
We are aware of the points made in Professor Johnston’s paper. We are also aware that there are a substantial number of vacancies for clinical academics. However, the funding has been available for the recruitment of clinical academics, so that is not the problem. The existence of vacancies is more because of the attractiveness of what is on offer and the complications in making that attractive between what Queen’s University delivers and what the service needs.
The Deputy Chairperson:
I accept that there is a combination of reasons, including merit awards and other issues that have been raised. I accept that the subgroup will meet soon, but time is passing, and we are missing out on opportunities. When will that subgroup finalise its report, make recommendations or implement changes?
Mr Gregg:
To be honest, it has been quite a difficult group to get together. The Department has been keen to separate the financial aspect, which is a concern for the Belfast Trust. The Department wants to take that out of the equation so that the discussions focus on training and education. We need to see how we can get that right and find out what needs to be done to attract the right clinical academics. I understand that the Belfast Trust has some serious concerns about the endgame and the impact that that will have on its service delivery. The Committee may wish to talk to the Belfast Trust. Is that a fair summary?
Dr Paddy Woods (Department of Health, Social Services and Public Safety):
It is fair to say that the SUMDE system, of which the joint appointment system is one element, is quite rigid, and there is the possibility that that reflects the state of affairs when it was established some 20 years ago in a very different world. As well as transparency, clear accountability and fitness for purpose, we must ensure that we are in a position locally to attract the best talent from wherever in order to secure the objectives of the university and the service locally, as they are interdependent. We have already made changes to the clinical excellence awards to try to address some of the issues on that front, but some other issues are more complex, and there is more than one perspective. There is great interplay between the needs of the academic community and the service community. The difficulty is trying to balance those needs so that neither is disadvantaged to any great extent. Part of the difficulty in getting the group together is the fact that it must reflect all those needs, both the needs of the university and the five healthcare organisations that contribute to the teaching of medical and, possibly, dental students across Northern Ireland. It is important that all those perspectives are brought to bear on the issue so that the end result is beneficial for both parties and, ultimately, for local people and our medical school.
The Deputy Chairperson:
Can the Committee be kept up to date as that develops?
Mr Gregg:
I did not answer your question about when we hope to see the results, because I do not know. It is an achievement to have that first meeting, and we will see how we move on from there. We have some problems in the system, and if budgets have been set aside for clinical/academic joint appointment posts, and those posts are not being filled, it is in our interests to consider the reasons for that. In total, we fund 86 posts, and we are well short of that. We must ask what impact that has on future training needs, coming, as it does, at a time when we have substantially increased the number of doctors in training in the past few years. When the Committee discusses the issue with the trusts, Queen’s University and the Department, it will see what needs to be done.
The Deputy Chairperson:
The current review does not include dentistry. Will anything that is implemented as a result of the review also apply to dentistry funding?
Ms Helena Brown (Department of Health, Social Services and Public Safety):
The dentistry budget has not been included in the consultation document, and it was agreed at the outset that it would not be included. The situation has been reviewed over the past five years and, at the moment, it is at the best possible stage that it could be at.
Dentistry training is totally different to medicine, and the application of this to dental students is totally distinct from its application to medical students. Dental students treat patients, medical students do not. We provide funding for dental students’ SUMDE, but part of the budget is top-sliced and treated in a different way.
Mr Gregg:
I will add to that. We are certainly further ahead in dentistry. We have a mechanism in place with the School of Dentistry on the Royal Group of Hospitals site to track the hours that are needed to train dental students as against what they deliver for the service. That mechanism is in place, but it is complex. We are continuing to work on getting the information correct and satisfying ourselves that it is so. It is an ongoing process, but it is ahead of the process for medical students.
Ms H Brown:
A totally different set of statistics is used, and there is no comparison between dental and medical SUMDE. It is traceable.
The Deputy Chairperson:
I may have picked something up incorrectly in the previous evidence session, but I thought that that was an assumption made by Queen’s University.
Ms H Brown:
It was clear in the university’s response to the review that that is its assumption. However, Queens’s University is the only respondee that took that view.
The Deputy Chairperson:
I will seek further clarification on that.
Dr Deeny:
This is an interesting debate. I will change it a little, however. Everyone has talked about the future. We want to produce, attract and keep the best doctors and dentists.
Both Norman Bennett and Professor Paddy Johnston mentioned the issue of graduate entry into medical school. I have thought about that, and I would like the Department’s views on it. I understand that, this year, our 16-year-olds have to get six A* grades and three A grades in their GCSEs even to be considered for medicine and dentistry, and that is quite apart from the A-level requirements. We are challenging people to achieve very high grades at a very young age. Norman referred to the fact that, in medicine, we are missing out on many people who have much more experience of life.
I should not admit to it, but I graduated 29 years ago last Friday. I spoke to a colleague in Cork with whom I had graduated in Dublin. He said that graduate entry to medicine is being introduced in the South. People with degrees, who are a little more mature and decide at a later stage in life that medicine is the career for them, could turn out to be wonderful doctors. Here, such people are excluded. Many other GPs and I wonder about that. In many areas of medicine, students who graduated recently are excellent academically but do not have good social skills. That is important not only in general practice in all aspects of medicine. Has the Department a view on that?
It is accepted that some of our young boys are a little slower, and they hit their academic peak at a later age. However, from the age of 16, they may be excluded from becoming doctors. Has the Department a view on graduate entry to medicine? Should a change be in the pipeline? Perhaps that question should be answered by university personnel. Many doctors of my generation are commenting on the issue. The decision seems to be taken for children at an early age, and many students graduate from medical school as very good doctors but are short on life experience. Others have greater life experience but are excluded from becoming doctors because they did not have the required qualifications at 16 years of age.
Ms H Brown:
There are programmes available in the rest of the UK for graduate entry. As I understand it, the Department’s workforce review concluded that we needed approximately 250 students a year to provide a sufficient service. That is the route that we have taken.
Dr Woods:
I do not think that any conclusion was reached about the point at which potential graduates would be recruited into a medical training programme. I am not aware of the details of that. The Department does not wish to exclude anybody from accessing undergraduate medical training, whether or not they are already graduates. You are quite right that such people would bring additional attributes to medicine that those recruited exclusively from schools may not bring. That is certainly the experience elsewhere in the world and can be seen in the United States, where entry to medical school is exclusively graduate. However, I am not aware of any definitive policy on that matter, but, by the same token, I am aware that there is no policy that excludes such people. There may be mechanisms by which the availability of undergraduate funding in the education system may preclude that option.
Mr Gregg:
My notes remind me that QUB has made proposals to expand the graduate intake from 15 to 30 students. That may be what you are talking about. The Department receives much correspondence in relation to the lack of financial support for graduate entry students. In response to that, the Minister indicated that there was insufficient funding to allow the development of the graduate intake in 2008-09. He acknowledges that problem, and he has asked that we examine the position throughout the comprehensive spending review period and liaise closely with our colleagues in the Department for Employment and Learning on support issues.
The Deputy Chairperson:
If you have any further information, perhaps you could write to the Committee.
Mrs Hanna:
You mentioned that the funding was based on something from 1996; I do not know if you mentioned a person’s name. Will you tell me more about that? You also mentioned the MSMG, which includes some people from Queen’s, and the new SUMDE, which is still part of the old SUMDE. I am not sure whether you agree with the proposal from Queen’s and its preferred new model. Will you tell me more about that? Will you also give me some detail on where the £19·2 million on infrastructure has gone? You also spoke about joint appointments. Reading between the lines, I think that it is obvious that there are difficulties and tensions there. As the Deputy Chairperson said, if we are thinking about good long-term outcomes, perhaps you could keep us informed about how that is going.
Mr Gregg:
The bulk of the SUMDE funding — £19·2 million — is for infrastructure. The model that was set up by Winyard, and the model in operation before that, provides for a basic 80:20 split, so that 80% of the funding is for the costs associated with providing the infrastructure needed to train medical students. By infrastructure, I mean lecture theatres, rooms and facilities, and so forth, to enable a large cohort of students to have access to certain facilities on site at hospitals. It was recognised that there were additional costs involved in that. Therefore, the Department is proposing changes to the smaller amount of funding for clinical placements.
Mrs Hanna:
What is the thinking behind that?
Mr Gregg:
The thinking concerns the amount of money that follows a student, which is the principle behind all this. We can introduce a teaching-unit-style formula to track more easily how that money is being used, and we are trying to implement that through the review.
There is a longer-term question about infrastructure money, because, as Professor Johnston said, Altnagelvin Area Hospital and other hospitals also have infrastructure needs. Traditionally, that infrastructure money has gone to the big Belfast hospitals, and it will still go to them, bar a very small amount of funding.
Mrs Hanna:
However, that money was not improving outcomes when it came to clinical teaching for students.
Mr Gregg:
We have expanded the School of Medicine, and we will depend more on hospitals outside Belfast to deliver teaching. Therefore, logic tells us that that infrastructure funding will also have to be redistributed. We need to be very careful because most of the large pot of money still goes to the Belfast Trust. We cannot change that overnight. That redistribution must be phased in.
Mrs Hanna:
I am trying to get a better feel for the issue. You said that the money should follow the student. Are we, therefore, talking about only one element of the money and not the infrastructure money?
Mr Gregg:
We are talking about only the clinical placement money. At this stage, that money is built around new students. The difference between the students who came in 2005 and the previous batch is that we have set up a mechanism to try to audit and track the amount of time that they spend on clinical placements. If they go into a certain hospital or trust, we can tell how much teaching they are receiving, what it is costing the service and the cost of consultants taking time out to train them.
It is about taking the money that was put into that. There is now a better accountability system for tracking those costs. If all goes well, and subject to agreement by the medical student management group, that system will be introduced for all 250 student placements. That is seen as an ongoing review process over a number of years. However, we must also tackle the infrastructure issue.
Mrs Hanna:
I am trying to get a better understanding of how decisions are made on how much funding should go to clinical practice and how much to infrastructure. You said that a lot is going into the Belfast Trust and that it will take time to change that. Has it been decided to spend that money on the students? Does the Department agree with the proposed model? I am still not sure where the differences lie, other than it will take time to remove money from the Belfast Trust. However, I am not sure about the rationale behind that.
Mr Gregg:
We have to be quite upfront about this. The mechanism that has existed here in and in the rest of the UK is based on the Winyard Report. Other than saying that there is a block of money that should be split 80:20, it did not go into how to track an account for the use of that money. That is the core problem that we are trying to unravel. We are trying to understand how that funding is being used. We are trying to account for it to ensure that it is being spent on the purposes for which it was intended. However, it is, overall, a supplement. The question is: how far can we track the minutiae of every penny?
Mrs Hanna:
I am trying to tease out the last part of your answer. Will another £35 million come along next year?
Mr Gregg:
Yes; it will come along every year.
Mrs Hanna:
Can it be tracked down to, not the last penny, but to the last £1,000 or £500, starting from scratch, to see where next year’s funding will go?
Ms H Brown:
It is a stepped process. You cannot fix the whole without fixing the little steps first. The first step is to get a financial model that discovers, protects and accounts for all the money. The first step in the process is to sort out the financial model, after which we can follow each step for all SUMDE money.
Mr Gregg:
Will you explain the distribution of the £1·5 million? That is the new SUMDE money for redistribution to the glide path, and that will change the funding.
Ms H Brown:
With the proposed new model, there will be a total loss to the Belfast Trust of approximately £2 million — £1·8 million to £2·25 million, depending on what model is used. That will be taken from the infrastructure money. There will be no change in the budget; the changes in the new model will be taken from the infrastructure. The infrastructure will be better redistributed and that can then follow on as the model progresses.
Mrs Hanna:
Does that mean that the Belfast Trust would still have £17 million? I do not really understand, but I am looking at the new model in your submission and how much agreement there is with the proposals from Queen’s University. How much of a meeting of minds is there as to how that money should be spent — to follow the student more holistically and follow what happens to the money if there is an additional £35 million? I cannot quite understand exactly what the plan is.
Dr Woods:
We are moving from the situation in the early 1990s where there was a totally opaque system. To a large extent, the 80:20 split represents a pragmatic decision on how those finances were divided up, because there was no underlying evidence or financial base on which to come up with a better split. It is a question of the additional medical students who were invested in in 2005 having provided an opportunity to revisit an element of the system. That is the element that is related to clinical placements. It is a question of having two different systems to deal with that. The first step is for the clinical placement element to be open and transparent so that everyone can understand it. It is difficult to explain and convey because it is difficult to understand.
Mrs Hanna:
The very use of the word “opaque”, and the fact that only a small amount of money seems to be changing, makes it difficult to understand.
Dr Woods:
Just as it is with the interaction that occurs when teaching medical students in a clinical setting, even relatively small financial adjustments can have adverse effects on the service sector. Whatever comes to pass, it will be necessary for a gradual change so that the service sector can adjust. However, it will be much easier for all of us if the system that is in place is transparent and relatively easily understood. I do not think that we will ever have a very simple system, but we certainly should be able to get to a point at which we all understand the basic mechanics that are at play. It is important to get back to day one. We were talking about an opaque system, or a knock-for-knock system, in which it was assumed that, if there was investment from the health sector or the education sector, there would be benefits to both. In the early 1990s, however, when there was an attempt to disentangle the situation, it was found to be almost impossible, and a pragmatic decision was taken. All of this is based on an original and pragmatic —
Mrs Hanna:
That is fair enough. However, I still do not understand why, from next year, it does not become a transparent system. After all of that, I cannot understand why we are unable to see where the £35 million is going next year. Why should it take several years before the picture becomes clearer? I will leave it at that.
Mr Gardiner:
It is nice to see you again, Peter. Although I do not agree with everything in your presentation, it was somewhat disappointing, because the review is to do with the modernisation of SUMDE, which includes “dental education”. The QUB presentation dealt mainly with the shortage of dentists and the standard of dentistry in Northern Ireland. It is saddening to learn that Altnagelvin Area Hospital is 25 years out of date, but that that is the best that we have. Ms Brown’s body language told me that she is not geared up to talk about dentistry today. Am I right or am I wrong?
Ms H Brown:
That is correct. SUMDE is the supplement for medical and dental education. The terms of reference state that dentistry is not included, but SUMDE is —
Mr Gardiner:
Is it on the radar at all with you?
Ms H Brown:
Yes, of course it is.
Mr Gardiner:
When will it be implemented? When will we raise the standard of dentistry in Northern Ireland? We are very much behind and out of date.
Ms H Brown:
That is a matter for the dental division to deal with. We are involved only with the supplement for dental education. We are not involved —
Mr Gardiner:
Are you responsible for funding it?
Ms H Brown:
We are responsible for funding the supplement. We are not responsible for funding dental education.
Mr Gregg:
To be fair, Sam — or Mr Gardiner, I should say —
Mr Gardiner:
Sam is OK.
Mr Gregg:
Helena is right in that the review has focused on the supplement. The word “dental” is on the title page, and that would lead people to think that it is a review of dental and medical provision. I understand the reason for that confusion.
Mr Gardiner:
We will come back to this topic.
Mr Gregg:
We will certainly come and talk —
Mr Gardiner:
We all expressed our concerns about the low standard of dentistry in Northern Ireland. Some dentists are not even up to date. I have a good dentist, but we heard stories about dentists’ chairs being 20 or 30 years old. Fortunately, my dentist has modernised in the past year and a half. If people want a good dentist, they should come to Upper Bann and we will get them sorted out. I am not happy, Madam Chair; there are crossed wires somewhere, and things are not clear. The issue of dentistry needs to be examined urgently.
The Deputy Chairperson:
The confusion arises because the review refers to “medical and dental education”, but the review is not concerned with the funding of dentistry.
Mr Gardiner:
The Department needs to look at the issue and speed it up.
The Deputy Chairperson:
The confusion was identified at the start. I thought that the review would automatically have an impact on dentistry, but you are saying that it does not.
Mr Gregg:
There is a supplement for dentistry. It is a different system. I am quite happy to come here again with the Chief Dental Officer to explain how that works and to hear your concerns about the School of Dentistry and the training and teaching of dentists.
You mentioned dental chairs. The School of Dentistry on the Royal Group of Hospitals site has dental chairs that are more than 15 years old. The Department currently has a business case to replace those outdated chairs.
The Department has another tracking system, or mechanism, to examine how the supplementary dental money is used. I do not have that information with me today, but I would be quite happy to return to the Committee with that information as soon as possible.
Mr Gardiner:
The Committee has only one more meeting before the summer recess. Therefore, it will be September before the Department can provide any further information to the Committee on that issue, and further time will be lost. There has been a misunderstanding somewhere along the line, and I ask you to return to the Department and urgently examine the issue of dentistry. If not, the Committee will write to the Minister and ask him to sort his Department out.
The Deputy Chairperson:
The Committee has taken a keen interest in that issue, and it will continue to do so. In your paper, you state that you will speak to the Minister about implementing the review. Is that correct? Will the Department also consult the MSMG?
Mr Gregg:
The Department will consult the MSMG. I am trying to pull the group together again in July, but, given that it mostly comprises medical directors from the various trusts, that will be a challenge. Realistically, the Department hopes to have a full meeting of the group towards the end of August; we have been trying to get diary dates for a while. The Department will present the results of the consultation to the group for discussion and agreement, and, depending on the outcome, it hopes to put recommendations to the Minister in the early autumn. Perhaps, at that stage, we could return to the Committee and — taking on Carmel’s points — articulate what that will mean in practice.
The Deputy Chairperson:
We will leave it there for the present. Thank you all very much for appearing before the Committee today.