The Competence and

Curriculum Framework for the

Medical Care Practitioner
A RESPONSE FROM
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

2006
   THE COMPETENCE AND CURRICULUM FRAMEWORK FOR THE MEDICAL CARE PRACTITIONER RCS RESPONSE

Introduction

The College welcomes the opportunity to respond to the public consultation on the medical
care practitioner (MCP) role. The introduction of the care practitioner roles to support the
physician is generally supported by the College; the possible future development of the role
does cause concern. This concern is exacerbated by the changes in the delivery of care from
hospitals to general practice.
This response addresses those areas and questions outlined in The Competence and Curriculum
Framework for the Medical Care Practitioner. The College Council supports the initiative and
emphasises that:
> the MCP must be part of a team and not an independent practitioner;
> the MCP must be directly supervised by a consultant or general practitioner;
> the MCP should be regulated as a new profession;
> a probationary period is in the interests of patient safety;
> the prescribing formulary should be limited to the level of practice; and
> all referrals must be done by a consultant or general practitioner.
 RCS RESPONSE THE COMPETENCE AND CURRICULUM FRAMEWORK FOR THE MEDICAL CARE PRACTITIONER   

General Comments

a. Curriculum framework for the medical care practitioner as the basis for
the development of educational programmes
The curriculum framework is an important document which ensures a national standard
for MCPs in the UK. It has developed a style of presentation seemingly suitable for physi-
cians, however some of the technical aspects (surgical procedures) would benefit from being
brought into line with the surgical care practitioner curriculum.
Professional values are an important aspect of any practitioners practice and the curriculum
framework states that it is based on values but no explicit values are stated.
The curriculum framework is based on competencies and relies heavily on competencies for
assessment but does not take a holistic approach to the practice of the practitioner. There is
confusion between the meaning of competence and competencies. Competence by defini-
tion is holistic and competencies refer to skills. (See page 6 and ‘…the need to break down
competence into component parts’.)
The matrix for the categorisation of clinical conditions is innovative however the College has
doubts about its functionality in practice. For example, there seems to be many overlapping
disease groups but no clear explanation on how the matrix will be applied.

b. Entry routes
The entry routes to the MCP programme are potentially wide compared to the other care
practitioner roles.
The College does not support independent practice or unsupervised practice by non-medi-
cally qualified practitioners in the clinical environment. Practitioners must be responsible to
a named consultant or general practitioner.
Moreover, the College remains sceptical that an individual without a healthcare qualification
in the first instance would be a wise investment in training and physician time. But the Col-
lege does recognise that there may be exceptions to the rule, for example, medical techni-
cians/assistants from the armed forces. Even though the MCP programme is a three-year
competency-based course, before widening the traditional recruiting base, the experience
gained from the initial intake should be examined.

c. Core competences at qualification

The listed core competences seem to be a reasonable start but history and examination is
unclear in its application. Is it meant to be tailored to a specific speciality?

d. Core procedural skills

The core procedural skills listed infers that all MCP trainees must complete before qualifica-
tion. Considering the wide range of areas of practice for MCPs, it does not make sense that
all MCPs need to be able to pack a nose or identify and reduce a dislocated shoulder.
    THE COMPETENCE AND CURRICULUM FRAMEWORK FOR THE MEDICAL CARE PRACTITIONER RCS RESPONSE

e. Core clinical conditions which the MCP will meet in practice and the level
of competence required
The core clinical conditions stated are a sensible method of defining the conditions and the
depth of knowledge required to manage patients. However, some clinical conditions are
incomplete, for example, phlebitis and thrombophlebitis are listed but venous thrombosis
(presumably DVT) is not. The two conditions often exist together.

f. Arrangements for teaching and supervision

The document does not clearly state the roles and responsibilities of supervisors and does
not mention mentors. There is no level of physician supervision specified in the document
unlike that of the surgical care practitioner which is regarded to be essential

g. Methods of assessment, pre- and post-registration and national support

structures
The curriculum framework proposes a national standard but it does not identify who will set
this. Will it be the RCP and RCGP?
No specific assessment processes are described. It would be helpful to ensure that for surgi-
cal skills, for example suturing, the assessment methods proposed for SCPs be considered for
the MCP. (Will surgical skills be taught by a surgeon or a physician?)

h.Title for the new role

The title used by non-medically qualified practitioners should make it quite clear to patients
and other staff members that they are not medically qualified. The ever increasing assortment
of titles is making it more difficult for the general public and staff members to understand
the roles and medical qualifications of those who see and treat patients. The term medical
care practitioner is too close to the title medical practitioner and may result in the general
public believing that the MCP is a doctor. This is not an acceptable position for patients.
The Royal College of Surgeons of England supports the generic title healthcare practitioner
(medicine) to signify the discipline to which the care practitioner practices and believes that
all care practitioners across disciplines should have a title that is similar but indicating the
speciality in which they practice.
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Questions

Competence framework
1. Do you believe that the practitioner should have access to a prescribing formulary identical to that of their
supervising physician and to be used within local agreed guidelines?
No. Access to a prescribing formulary identical to the supervising physician, albeit within
locally agreed guidelines, by MCPs should be based on the specific need within the area of
practice and supported by an in-depth course in pharmacodynamics and pharmacokinetics.
There also is a consideration as to why MCPs would need the full formulary based on their
level of practice in comparison to a physician or GP.
2.What are your views on the proposed standard of proficiency as set out in the preceding sections, which focus
on competence, procedural skills and core clinical conditions, in terms of the level at which the practitioner will
practice upon registration.?
The matrix provides a good overview of the skills/supervision but as the Royal College of
Physicians recognises, it may be too simple to cater for the more complex problems. While
in general terms it works well, from a urology perspective however, members of the British
Association of Urological Surgeons would find it inappropriate for non-medically qualified
practitioners to be responsible for both diagnosis and management of potentially dangerous
urological conditions.

Curriculum framework
3.Would you agree that there should be a period of ‘probationary practice’ post academic qualification and prior
to formal registration as an MCP?
The need for a period of probation prior to formal registration is very much dependent upon
the confidence in the assessment during the clinical phases of the MCPs’ training. The cur-
rent system of probationary period works well for medicine and there is value in adopting a
similar system for MCPs.
4. If you agree that there should be this period, how long should it be and what should be the outcomes?
The probationary period should be twelve months and on successful completion of the pro-
bationary period, formal registration as an MCP
5. During this period would you agree that the practitioner should have their own case load?
Definitely not. MCPs should however have defined roles and responsibilities within a depart-
ment. Defined case load is a hostage to fortune because it will invite invidious comparisons
and implies no need for medical supervision.
6. During this period would you agree that the MCP should be able to refer on to other practitioners including
hospital consultants, therapists and other specialist medical services?
MCPs under probation should not be able to refer patients to other practitioners. Referrals
should be done by the supervising physician.
7.Would you agree that arrangements need to be put in place to assimilate practitioners who meet the
competences of the MCP into the regulatory process?
The regulatory process is a means of ensuring that the individual’s skills are at the required
standard and that there is a process to manage deficient performance. This aspect of regula-
tion contributes to patient safety. The MCP will be expected to make diagnoses and prescribe
treatment based on this diagnosis, including medication. For this reason alone, it is necessary
that the MCP be subject to a regulatory framework.
    THE COMPETENCE AND CURRICULUM FRAMEWORK FOR THE MEDICAL CARE PRACTITIONER RCS RESPONSE

8.Who should be responsible for this?

The development of the regulatory framework for the MCP should be collaboration between
the National Practitioner Programme, the Royal College of Physicians, the Royal College of
General Practitioners and professional associations. This collaborative approach will ensure
that all the concerns of the representative groups can be addressed and any initial dealings
with the regulator are with one voice.
9. Do you think that the above proposals regarding APEL process provide sufficient protection for public safety
whilst not being too restrictive?
No comment

Assessment
10.What are your views on the proposal for a single national assessment for the profession?
The assessment of professional examinations through either an examination board or a professional body is
the usual route prior to regulation. However on becoming part of a statutory register there is a requirement
for qualifications to be independently assessed and quality assured and therefore requires professional body
examinations to be embedded within the HEI sector. Should the regulator be the sole assessor of educational
programmes?
Essential. The development of the modern NHS has resulted in the overlapping of roles
between medically qualified and non-medically qualified. The care practitioner development
in all its guises has increased this overlap to the point where non-medically qualified are
making key decisions on the treatment of patients. The non-medical regulators do not have
as part of their staff structure, individuals who possess the body of knowledge for the role
to adequately assess educational programmes without the assistance of the respective medi-
cal royal college which represents a particular discipline. Therefore the assessment of educa-
tional programmes should be a collaborative effort between the regulator and the respective
medical royal colleges in association with the medical specialist associations.
11. Periodic re-registration through the passing of a re-accreditation examination is a relatively new process for
healthcare professions. Do you foresee any issues with the introduction of this process?
Inevitable. The requirement for all MCPs to undergo a re-accreditation examination has
merits and similar concepts exist in other non-healthcare occupational groups. However,
there is a notional problem where one group of practitioners are required to be re-assessed
every six years where other similar practitioner groups are not required to do the same.
Inconsistent re-validation requirements across the non-medically qualified practitioner roles
does not contribute to team working as it leads to resentment on one hand and elitism on
the other.
12.What are your views on compulsory periodic assessment?
The assessment would need to be relevant to the practice and not just a test for tests sake.
All too often (as seen in other countries) it might turn out to be exam. This is not appropri-
ate. A programme of compulsory periodic assessment has its merits as long as it is applied
across all disciplines. Other industries or occupational groups conduct periodic assessment
to ensure standards of practice and knowledge remain at or above the minimum acceptable
standard. This is usually accomplished by maintaining a standards and evaluation unit which
is responsible for the assessment.
For the assessment to be meaningful there needs to be defined clear responsibilities and
powers that the periodic assessment team would have, for example, the power to mandate
additional training in a particular deficient area of knowledge and/or skill before the practi-
tioner is permitted to treat patients again. The assessment team members must not be mem-
 RCS RESPONSE THE COMPETENCE AND CURRICULUM FRAMEWORK FOR THE MEDICAL CARE PRACTITIONER   

bers of the unit being assessed. This allows the assessment team to evaluate with an open
mind and not be influenced by local political and staff relationship problems. However these
may be listed as factors for poor performance for an individual or unit. National support for
such an assessment concept would give ‘teeth’ to the recommendations from any assessment
and would contribute to patient awareness and safety. The downside to such a programme is
the possible political uses of the assessment results by politicians in national debates on the
performance of the NHS adding to the woes which may exist within some units.
13. Do you have any suggestions regarding how this periodic re-assessment will be funded whilst remaining
independent?
Funding for periodic re-assessment should be funded by the Department of Health as a
national policy and the medical royal colleges should be responsible for the re-assessment.
The NHS already spends hundreds of millions of pounds in compensation to patients for
negligent acts by staff. The periodic assessment could be used as a tool to reduce the inci-
dence of negligent behaviour which is the result of sub-standard knowledge, out of date
skills, poor application of diagnostic reasoning or simply incompetence.
An alternative would be for the practitioner to pay for the re-assessment but in so doing
receives some taxation relief as a cost of continued employment.

Core syllabus
14.This is not exhaustive, but do you think that there is a core theoretical knowledge area that is missing?
There is a shift in the provision of basic surgical services away from hospitals to general prac-
tice. Accordingly, as part of this development, it would be wise to include basic surgical prac-
tice, anaesthesia, pain management and tissue viability (relating to wound healing and wound
management) for those who might be including these areas of practice in their remit.
15.What is your opinion of the weighting that should be given to each core theoretical knowledge area, ie what
are the priority theoretical knowledge areas?
No comment

Validation, accreditation and evaluation of the programme

16. Do you think it is appropriate that until the regulatory body is established that the accreditation function
be carried out by a panel drawn from the Curriculum Framework and Competence Steering Group,The MCP
National Programme Board and participating HEIs?
This question very much depends on what the accreditation means. If the programme is to
be accredited by the Royal College of Physicians and the Royal College of General Practi-
tioners, then the evaluation leading to accreditation should be only performed by selected
members from the royal colleges. Members of the competence steering group and participat-
ing HEIs may have conflicts of interest which will invalidate any recommendations made by
an evaluative group.

Regulation and accountability

17.The issue of eventual title of the role has been contentious. Ultimately the title should be one that the public
are able to recognise as a descriptor of the role.The title is not a beauty contest and neither should it be a
descriptor of ‘rank’ in a team. Do you have a suggestion that meets the needs of the patient and one that the
profession will be happy to adopt?
See paragraph h above.
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Proposed timeframe
18. Do you anticipate that the proposed timeframe is adequate?
I do not think regulation is likely by 2007 but the framework needs to be in place and 2007
seems a possible timescale for this.
19. Have you any further comments regarding the process, the document and the role?
Strong links with other care practioner programmes must be kept as there will inevitability
be overlapping of roles and practice. Surgical procedures should be taught and supervised
by surgeons.
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