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2015 Medical School Annual Return (MSAR)

Submission deadline 8 January 2016

The following table has been pre-populated with our latest records, please amend as required.

Name of Medical School:

Bristol Medical School

Name of Dean/Head of School:

Name of Quality Lead:

Name of Quality Assurance Administrative contact:

Name of Senior Manager (signing off

quality and accuracy of MSAR

on behalf of school):

Please include additional details of anyone who should receive feedback and other communications regarding the MSAR. Senior Managers signing off on behalf of the Medical School are responsible for assuring the quality and accuracy of the return. Please indicate who will be the primary point of contact for the MSAR above. Data processing notice:

The GMC will handle any personal and sensitive personal data provided in the MSAR in line with the Data Protection Act (1998). Information provided to the GMC is subject to the Freedom of Information Act (2000).

The GMC will publish the following sections on our website by medical school and may share the information with other organisations including the Medical Schools Council and in response to Freedom of Information requests:

Section A – Questions exploring the Tomorrow’s Doctors (2009) domains and Promoting excellence themes

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Section B - Quality Management

Information provided in Section C may be published on our website or shared with others, such as the Medical Schools Council and in response to Freedom of Information requests:

C1 - Student Profile

C2 - Student Progression

C3 – Student Fitness to Practise

C4 – Placement

Potentially identifiable information, such as name, job title or other protected characteristic, should only be provided if it is essential to your response.

Information will be anonymised or redacted before publication to protect privacy.

Data may be shared with data recipients, in accordance with the Data Protection Act. Data recipients may include the following non-exhaustive list: Medical Schools Council.

Information may be used for statistical and research purposes.

Medical Schools should submit information to the GMC in line with their established privacy agreements.

Changes to 2015 MSAR Template

The questions in Section A have been split into two sections; A1 and A2. Please ensure that all questions in Section A1 are answered. Questions in Section A2 only need to be answered if there have been any changes since the previous MSAR.

Guidance for Section C3 - Student Fitness to Practise

Please provide details of all low level professionalism concerns that have reached stages A and B of the process as well as all fitness to practise cases reaching stages C and D of the process.

Tomorrow’s Doctors (TD09) and Promoting excellence

The new standards ‘Promoting excellence’ bring together the standards for undergraduate training; ‘TD09 with postgraduate training’ and ‘The Trainee Doctor’. They were released in July 2015 and come into force in January 2016. This document references the relevant TD09 domain, and also includes the appropriate reference to the new standards ‘Promoting excellence’.

The deadline for submission of this MSAR is 8 January 2016.

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If you need any help with completing this return, feel free to contact Joseph Sadowski or another member of the team on quality@gmc-uk.org or 020 7189 5327.

MSAR 2015 – Section A

Section A1

Please answer all questions in this section

Patient Safety - TD09 domain 1 and Promoting excellence

theme 1

Question 1: In light of the recent publication, ‘First, do no harm: enhancing patient safety and teaching in undergraduate medical education’, the GMC are collecting data about how medical schools teach students about patient safety and equip them with the skills to contribute to safety improvement as doctors.

a) What is your approach to teaching the discipline of patient safety? (Please provide a brief – 2/3 paragraph – summary, highlighting any key innovations or particular areas of good practice.) As well as students observing practice in hospital and community settings, undertaking audits themselves as part of the Student Selected Component projects and attending hospital and general practise based audit meetings, there are a number of structured events which embed Patient Safety and Quality Improvement throughout the programme. Appendix 1 highlights specific activities within Units where this discipline is further explored. A significant development in this area is the inclusion of Patient Safety within the mandatory Consultation and Procedural Skills (CAPS) logbook (Appendix 2). This logbook contains the 32 core skills required by the GMC in which students are required to show competence. Over the years, a small number of additional skills (now 5 in total) have been added to ensure that this logbook represents a full range of competencies Bristol students should demonstrate. One of these (number 37 / Bristol 5) is Patient Safety. The objectives for this skill are as follows:

The student will understand the importance of patient safety within the NHS and understand the key steps to minimise the risks.

They should understand the important role that doctors and other health care professionals play in developing systems that improve patient safety.

Understand the role of safety netting in GP consultations

Understand what a ‘Never event’ is and how systems have been developed reduce the chance of these happening

Understand which NHS procedures are at ‘high risk’ from human errors and what safety nets are used to reduce accidents occurring e.g. blood transfusion and insulin prescribing

Understand the pathways to follow if you perceive a patient at risk or aspects of the system that could expose patients to unnecessary risk In terms of the revised curriculum (MB21), which will be implemented from 2017, one of the new Helical Themes is “The Doctor as Professional and Agent of Change”. An important and underpinning constituent subtheme is patient safety and quality improvement. Helical

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themes will be used to define, construct and deliver learning outcomes for, and learning opportunities within, the curriculum. There will be patient safety/quality improvement projects in years 3 and 5 and all assessments will be constructed with an emphasis on patient safety.

b) How do you ensure students understand why health-care professionals make errors? (see WHO patient safety curriculum guide Topic 5)

c) How does your curriculum cover the objectives and relevance of clinical risk management strategies in the workplace?

Throughout the programme, there are opportunities for students to encounter issues of clinical risk in different settings both in a structured way within the curriculum (see Appendix 4), and through opportunities for which attendance is not mandated or formalised. These include audit meetings, and morbidity and mortality meetings in surgical specialities. As part of the Year 3 and 4 SSC programme students undertake a wide variety of audit projects. In 2014/15 around 20 % of SSC audits incorporated aspects of risk management strategies in the workplace. Appendix 9 provides a selection of Year 3 and Year 4 External SSC project titles to illustrate this. The MB21 curriculum development work is exploring whether all medical students should complete the Health Education South West Deanery online induction that is undertaken by all new trainees in the Severn Deanery. The curriculum hopes to make students more embedded in the teams delivering clinical care and therefore they will be significantly more

There are a number of themed activities in the current undergraduate programme which relate to the teaching of patient safety and these contribute to the understanding of how and why errors happen in health-care. Particular attention is paid to this issue in the following areas:

All students in clinical attachments (Years 3-5) are familiarised with the Bristol

Prescribing Chart which focuses particularly on allergies and drug intolerance, and

on prescribing of thomboprophylaxis , antibiotics and insulin (Appendix 3).

The PSA examination has now been incorporated as part of the Year 5 Finals as an

independent indicator of student understanding of the importance and

complexity of prescribing medicines

A Patient Safety component has been introduced into the CAPS Logbook

(Appendix 2). See information in Question 1(a) above.

The MB21 curriculum review is cognisant of the fact that there is no such thing as the “perfect doctor”: hence error and dealing with uncertainty is part of the day to day reality of clinical practice. MB21 is building on the good practise that exists in the current curriculum and exploring the possibility of input from healthcare psychologists in teaching about human factors and errors.

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familiar with clinical governance meetings, mortality and morbidity meetings, audits, quality improvement projects, safeguarding and reporting incidents.

Quality Management – TD09 Domain 2 and Promoting

excellence theme 2

Question 2: We are interested in the nature of issues being raised as student complaints to the Office of the Independent Adjudicator (OIA) (England and Wales), the Scottish Public Services Ombudsman and the Visitorial scheme (Northern Ireland). Please provide details so that we can further understand the nature of appeals to student ombudsman services, and learning from these cases can be shared more widely to increase awareness among medical schools.

a) During 2014-15 were there any investigations into student complaints by the OIA, the Scottish Public Services Ombudsman or Visitorial scheme in Northern Ireland concluded in relation to your medical school? [Information redacted] b) What, if any, changes to policies or processes has your medical school implemented in response to investigations by the Office of the Independent Adjudicator, the Scottish Public Services Ombudsman or Visitorial scheme in Northern Ireland?

Equality, diversity and opportunity – TD09 domain 3 and

Promoting excellence theme 2

Question 3: It is important for medical schools to meet the equality and diversity requirements set out within TD09 and their replacement, ‘Promoting excellence’. Examples of how this is captured include analysis of admissions and student profile, progression, academic appeals, and fitness to practise data.

a) When you have found evidence of differences (e.g. in admissions, student profile or those listed above) on the basis of gender, ethnicity, socio-economic status or other characteristics, what actions have you taken to understand or address this difference?

[Information redacted]

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b) Is there a formal process for appeals made to schools about decisions on reasonable adjustments? If so please provide details on how appeals are handled

The School has found no significant difference on the basis of gender, ethnicity, socio-economic status or other characteristics, in terms of progression, admissions, complaints or appeals. We reviewed student performance at the year 5 written exams in 2013-14 and 2014-15, as pass or fail (above or below a pass mark as defined by standard setting). The year 5 written paper is taken under exam conditions and students names do not appear on the marked paper. The only recognisable distinguishing feature is an eight digit number. All the exam papers are marked anonymously by a scanning machine which generates a report of the number of correctly answered questions etc. We used the following criteria: disability, ethnicity (white/non-white), nationality (British/non-British) and gender (male/female) and discussed this data at the Annual Programme Review event. This data has been analysed by a statistician and their report is attached in Appendix 5. The report found that when the results are adjusted for confounding variables the factors which had a negative impact on passing final written exams were age and ethnicity. Older students were more likely to fail (particularly those students aged over 30 years). In the subsets of students with available data on their secondary school, it appeared older students were slightly more likely to come from state or low performing schools. We are unaware of previous work on this particular issue. There is also modest evidence that students from non-white ethnic backgrounds were more likely to fail exams. Numbers for each non-white group were small and sub group analysis was not feasible. This effect does not seem to be related to nationality. These are very complex areas to address. Multiple publications have been presented in the scientific literature (e.g. BMJ. 2011 Mar 8; 342: d901; BMC Med. 2007 May 3; 5: 8.) on analysis of assessment tests carried out in both the undergraduate and postgraduate arenas of medicine. These published results have tended to demonstrate that people from ethnic minorities do less well in the range of UK assessments in medicine. The School will continue to monitor equality, diversity and opportunity and discuss at Annual Programme Review with a view to taking any appropriate action in the light of our findings and any external recommendations.

Students wishing to submit an appeal based on a decision about reasonable adjustments are required to follow the University’s appeal processes described here: http://www.bristol.ac.uk/media-library/sites/secretary/documents/student-rules-and-regs/exam-regulations.pdf

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Design and delivery of the curriculum including assessment – TD09 domain 5 and Promoting excellence

theme 5

Question 4: We are working on options for a UK Medical Licensing Assessment (UKMLA) which will be consulted on during 2016. We would like to ensure we have comprehensive and up to date information on when medical schools hold all components of their final assessments so we can understand how a UKMLA could fit in.

Please tell us when you hold each component of your final assessments, including re-sits by completing the following table. If you permit more than one opportunity to re-sit without repeating a year please include details in the relevant row below.

Assessment Term or equivalent

Year of study

(penultimate or final

year)

Maximum number

of re-sits (if

applicable)

Knowledge

The current situation

is:

Single best answer

papers (SBA) & Bristol Clinical Data

Examination (BCDE) in

December. Prescribing Safety Assessment in

February

From the academic year 2020/21:

Final SBA papers will be at the end of our

penultimate year of study. The Prescribing

Safety Assessment will

remain in the final year.

Final Year Final Year One re-sit

during the same

academic year and opportunity to repeat

the year

First knowledge re-sit

Single Best Answer

Papers in May

Prescribing Safety Assessment in March

Final Year

Second knowledge re-sit (if applicable)

Prescribing Safety

Assessment in May

Final Year

Clinical

The current situation is:

Clinical Competence

Final Year

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Assessments from

November to March

From the academic

year 2020/21:

Final

clinical exams will be split between the

penultimate year of study and the final

year. The OSCE will be

at the end of the penultimate year and

the clinical competence assessment will be

conducted over the course of the final year

First clinical re-sit April Final Year

Second clinical re-sit (if applicable)

May Final Year

Question 5: We would like to gain a greater understanding about how GMC ethical guidance is taught in medical schools and how we can support this.

What is your approach to teaching students about the professional standards expected of them, including raising awareness of the GMC’s ethical guidance?

Ethics and law is a theme that is taught (and assessed) throughout the curriculum. The teaching and assessment is co-ordinated by the Centre for Ethics in Medicine. Ethics and law features especially in Years 1, 3 and 5, although there is also relevant teaching in Years 2 and 4. GMC ethical guidance is specifically referred to in much of this teaching. The most significant examples are: Year 1: In Year 1, medical students have an introduction to ethics and law during their unit Human Basis of Medicine. All Year 1 students undertake a 5-week element on Foundations in Ethics and Law. The ethics teaching covers the following topics:

An Introduction to Ethics and Law in Medicine

Moral Theory

Justice and Healthcare

Confidentiality

Medicine and the Law

The lecture and tutorial on ethics, cite GMC Duties of a Doctor

The lecture on confidentiality, cites GMC Confidentiality guidance

Assessment in this unit comprises a case study analysis in the Human Basis of Medicine exam.

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Year 2:

In Year 2, medical students develop their knowledge of ethics and law in seminars and lectures covering such topics as:

Consent and the first clinical attachment

Diagnosing death and dealing with patients with disorders of consciousness

Ethical issues in reproduction, reproductive technologies and termination of pregnancy

Responsibility for health

This teaching includes a lecture on coma and brain death, citing GMC End of Life guidance

Year 3:

All students complete a 2 day ethics course while in the clinical Academies. Case based learning is

used to explore:

Ethics and Law,

Confidentiality ‘refresher’,

Principles of Adult Consent in Clinical Practice,

Consent in Children and Young People,

The Mental Capacity Act

Research Ethics.

Materials for Academy teaching are provided by the Centre for Ethics in Medicine. A half day of a central teaching day for the whole year uses case based learning and plenaries to explore GMC guidance on Fitness to Practice and workplace based behaviours around professionalism. Assessment in this Unit comprises an Ethics case study (due in week 8) and multiple-choice questions in the end of Unit exam.

Year 4

In Year 4, ethics and law feature particularly in teaching on Care of the Elderly and Reproductive Health and Care of the New-born. Amongst the topics covered are:

Care of older patients

Care of critically ill new-born patients

Sterilisation

Disclosing (and not disclosing) HIV status

Pre-natal testing Year 5

In Year 5, ethical and legal issues are particularly considered in relation to Oncology and Palliative Medicine and to Preparing for Professional Practice. Amongst the topics covered are:

Withholding and withdrawing life-sustaining treatment

Current and advance refusals of treatment

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Relieving intractable symptoms

Assisted dying This teaching includes reference to the GMC End of Life Guidance.

Management of teaching, learning and assessment – TD09 Domain 7 and Promoting excellence theme 2 & 5

Question 6: New standards, ‘Promoting excellence’, covering all stages of medical education and training will come into force on 1 January 2016. To help us to support medical schools it would be helpful to know about any changes you need to make or challenges you have identified in relation to implementing the new standards.

Please provide us with details of any changes planned, areas under review and any challenges you have identified in relation to implementing the new standards

1. Changes Planned In 2013, the University instigated a Biomedical Review. One of the outcomes was a requirement to undertake a fully comprehensive MB ChB curriculum review (from September 2014 – ongoing). Appendix 6 summarises the processes undertaken and outlines the proposed curriculum (MB21) which will be implemented from September 2017 (for Years 1 and 5). The first cohort will graduate in 2022, a year after the anticipated changes to registration at graduation in 2021. It is intended that Year 5 will be re-structured early in the implementation phase to accommodate the changes to teaching and clinical exposure required to deliver medical graduates fit for immediate registration. The Curriculum Review Working Groups are all using Promoting Excellence as guidance within their developmental work, in particular the Governance Working Group. 2. Areas under Review The Promoting Excellence document places patient safety at its core. This is an aspect being addressed as part of the continuous improvement of the existing curriculum and of the revised curriculum from 2017; however, it is recognised that further work is required to embed patient safety more effectively. The current working programme to improve the awareness of patient safety and quality assurance in health care is attached (Appendix 1). As part of the ongoing curriculum review work, a governance sub-panel has been convened and will complete its recommendations in early 2017. This subgroup is mapping the governance model on to the new GMC’s Promoting Excellence document. There will be aspects of this work that will be implemented before the new curriculum commences in 2017. In addition, our documentation, such as service level agreements with NHS Trusts and GP practices, will be updated to reflect the new emphasis on patient safety and quality improvement. Following the Assessments Quality Visit in September 2014, extensive work has been

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undertaken in order to finalise and implement the School’s Assessments Strategy. This Strategy maps onto the relevant themes within Promoting Excellence and the GMC Outcomes for Graduates document.

3. Challenges There is a noticeable shift in the philosophies embedded in the Promoting Excellence document with a move towards maintaining environments and cultures. Demonstrating features of the culture requires evidence about the environment, attitudes and opinions expressed. These features will take longer to embed compared with ensuring the delivery of relevant teaching sessions in the programme. The MB21 Programme Directors are ensuring all Promoting Excellence themes are embedded into the new programme.

Question 7: A small number of newly qualified doctors may complete an overseas GMC approved programme for provisionally registered doctors or the recognised F1 training year overseas. If this applies to your graduated students, we would like to know how you effectively quality manage these posts.

If none of your graduates go on to train overseas as described, please tick the box stating ‘No graduates continuing their training overseas’.

☒ No graduates continuing their training overseas

a) How do you ensure that overseas training provides suitable curriculum coverage and that doctors in training receive an appropriate level of clinical and educational supervision?

b) How do these doctors record their progression?

c) How do you ensure that doctors meet all of the required outcomes for the F1 year and are signed off in order to meet the requirements for full registration with the GMC?

None of our newly qualified doctors go overseas to any GMC approved programmes for provisionally registered doctors.

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Section A2

The questions in Section A2 need only be answered if there have been changes since the MSAR you submitted in December 2014

Equality and diversity and opportunity – TD09 domain 3

and Promoting excellence theme 2

Question 8: It is important for medical schools to meet the equality and diversity requirements set out within TD09 and Promoting excellence. Examples of how this is captured include analysis of admissions and student profile, progression, academic appeals, and fitness to practise data.

[Information redacted]

a) Briefly tell us if you have made any changes, in the academic year 2014/15, to the way you use evidence to monitor how you are meeting the equality and diversity requirements.

b) Do you have any examples of challenges you have had or actions you have taken to ensure fairness and equality in medical education and training (since your last submission).

c) Please include details of any changes you have made to the way students can access advice on reasonable adjustments and support in making sure agreed adjustments are implemented – including on placement.

d) Please provide us with details of any changes you have made since the last MSAR in relation to how the curriculum addresses providing appropriate healthcare and understanding health inequalities, particularly relating to people from lower socioeconomic backgrounds, lesbian gay bisexual or transgender people, and people with learning disabilities?

[Information redacted]

[Information redacted]

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Student Selection – TD09 domain 4 and Promoting

excellence theme 2

Question 9: Each year we ask you to check and update the flow charts showing, at a high level, the admissions processes you use at your school.

You will find the flowcharts you submitted for the 2014 MSAR in the Excel template tab ‘Annex A – Q9’.

Please let us know of any changes made to your process for student selection to any of your programmes by ticking the box below and updating the excel worksheet.

☐ Our student selection processes have changed

☒ No change to our selection processes

Design and delivery of the curriculum including assessment – TD09 domain 5 and Promoting excellence

Question 10: Please raise any issues you would like us to consider around the outcomes for graduates and practical procedures currently in TD09. Your input will make sure that medical school perspectives and knowledge are reflected and logged when we scope the case to review the outcomes.

Have any issues emerged since last year’s MSAR which suggest the GMC might consider revising the Outcomes for graduates and the associated list of practical procedures in which graduates must be competent?

Please describe the issues and the implications for the Outcomes for graduates and the list of practical procedures.

In the Year 3 Central Study Days we have introduced teaching to increase awareness and understanding of the challenges faced by members of the LGBT community. Please see Appendix 7.

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☐ No issues to raise

Question 11: Medical schools provided information in last year’s MSAR on how issues related to the care of dying people were covered in their programmes. Please provide an update if there have been any changes this year.

We have recently published an update to last year’s, ‘One chance to get it right report: Improving people’s experience of care in the last few days and hours of life’ setting out progress since last year: [One chance to get it right: one year on report].

Since the last return in 2014, have there been any changes in the way end of life care is taught at your school?

Please provide any examples of good practice that you would like to share with other schools.

We have previously pointed out the additions we have made to the list of 32 core skills which the GMC expect our graduates to be competent in A1.1a - they are listed in the Clinical Skills logbook (Appendix 2) and are appended here for ease of review:

In order to further highlight the importance of patient safety, in 2015/16, a further skill- Bristol 5: Patient Safety – was introduced into the CAPS Logbook.

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☐ No changes

Question 12: Please tell us about any changes in the way your medical school handles the Prescribing Safety Assessment (PSA) since last year’s MSAR submission.

☒ No changes to report

a) Does your medical school require that its final year medical students take the PSA?

☒ Yes

☐ No

b) If so, is the PSA used formatively or summatively?

☐ Used formatively

☒ Used summatively

c) Please summarise the School’s position and intentions with regard to the PSA.

There have been two major changes: Firstly, the majority of students attend a study day rather than a part study/part clinical day at the hospice in Bristol. This is because of the difficulties of enabling contact with patients who are bound to be very ill and frail, for a large number of students. This study day has been evaluated well. Secondly, workplace-based assessments have been introduced into year 5 to mirror those that the students will meet within their foundation programme. To retain assessment of palliative care and oncology, one of these assessments will be run during PPP as a workshop-based mini-CEX based around end-of-life care.

We intend to continue the use of the PSA in the MB21 curriculum.

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Support and development of students, teachers and the local faculty – TD09 domain 6 and Promoting excellence

theme 3

Question 13: Medical students should have access to career advice and opportunities to explore different careers in medicine.

We would like to know if there been any changes to how your school attempts to increase students’ attraction to specialties with particular recruitment challenges including general practice. Please provide any examples of good practice that you would like to share with other schools

Section B – Quality Management

Please answer all of the questions in this section.

To answer the questions below, please use the ‘Section B – Quality Management’ tab in the accompanying Excel spreadsheet

Question 14: We would like to know about any issues relating to student clinical supervision and patient safety. How do you address these issues, and what subsequent evaluation or monitoring is in place and current status.

This information will be cross-referenced with information we hold about postgraduate training delivered in the same LEPs to highlight areas of potential concern.

a) Have you identified, in the last academic year, any issues with clinical supervision (supervision by clinicians during clinical placements) within your Local Education Providers (LEPs) and if so what steps are you taking to resolve them?

Medical schools should have systems to monitor the quality of teaching and facilities on placements. Your responses to this question will be cross-referenced to evidence gathered from postgraduate training and education.

b) Please provide details of any concerns or areas of good practice identified during monitoring visits. Please include actions you have taken to address concerns or promote good practice.

Please see attached Appendix 8 [information redacted]. This highlights the approach and strategies being undertaken to attract students to General Practice.

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We would like to hear about any instances of good practice. Please detail the relevant TD09 domain or Promoting excellence theme in your examples.

c) Please tell us about any innovations you are piloting or potential areas of good practice.

Section C

Please complete the information required in Section C – excel spreadsheet

Section C1 – Student Profile

Section C2 – Student Progression

Section C3 – Student Fitness to Practise

Section C4 - Placement

Thank you for completing the questions for the 2015 MSAR. The deadline for this return is the 8 January 2016; please ensure you have completed each of the following: ☒ Section A (Word) – MSAR qualitative questions

☒ Section B – Quality Management (Excel)

☒ Section C (Excel) – Worksheets

We want to make completing the MSAR as easy as possible, so if you need any help with completing this return, or have any suggestions, feel free to contact Joseph Sadowski or another member of the quality team on quality@gmc-uk.org or 020 7189 5327.