What is policy?
The question ‘what is policy?’ should not mislead us into
unexamined assumptions about policies as ‘things’:
policies are also processes and outcomes.
Ball SJ (2006) What is Policy? Texts, trajectories and toolboxes
In: Education Policy and Social Class: the selected works of Stephen J Ball
London: Routledge.
Policy analysis:
contexts of policy creation
Context of
influence
Context of policy
text production
Context of
practice
Bowe R, Ball S & Gold A (1992) Reforming Education and Changing Schools
London: Routledge
Policy contexts
• Context of influence
Where interest groups struggle over construction of
policy ‘discourses’. Public arena but private concerns
and interests are acknowledged.
• Context of policy text production
Where ‘text’ represents policy –the outcome of struggles
and compromises.
• Context of practice
Where policy is subject to interpretation, creation and recreation in implementation.
Policy as text
• Policy ‘texts’ are not necessarily clear or closed or
complete
• Policy texts are the product of compromises as various
stages
They are typically the cannibalised products of multiple
(but circumscribed) influences and agendas
Ball, 2006, p 45.
Policies do not normally tell you what to do,
they create circumstances in which the range of
options available in deciding what to do are
narrowed or changed or particular goals or
outcomes are set. A response must still be put
together, constructed in context, off-set against
other expectations. All this involves creative
social action not robotic reactivity.
Ball 2006, p 46.
NHS REFORM
And the demise of medical apprenticeship?
A worked example
NHS Policy Trends
De-centralisation and
greater productivity
(1980’s)
II. Economy, efficiency
and effectiveness
(1990s)
III. Professional regulation
and accountability
(2000s)
IV. NHS plc?
PGME Landmarks
I.
• Calman Report (1993)
• Modernising Medical
Careers (2005)
• Shape of Training Review
–Greenaway Report
(2013)
• GMC Adapting for the
Future (2017)
De-centralisation and greater productivity (1980s)
• Creation of internal market, incentives to ‘improve doctors
working lives’
• More ‘flexible’ staffing arrangements (non-medical
managers, consultant-led services, delegation of ‘routine’
care to other HCP)
• Growth in medical student numbers
• Shortening of medical training, more explicit training
curricula and assurances of opportunities for
progression (Calman Report 1993)
Economy, efficiency and effectiveness (1990s)
‘Patients will be guaranteed national standards of
excellence so that they can have confidence in the quality
of services they receive. There will be new incentives and
new sanctions to improve quality and efficiency.’
Department of Health 1997: point 1.5
New managerialism - policy trends
• Increased productivity linked to performance related
incentives
• Introduction of quality targets and clinical governance
• Diversification of the healthcare workforce
• Work traditionally the domain of medical staff being
assumed by others
‘ Doctors’ work is skewed by a huge number of targets that
they have to achieve (…) Targets are more easily applied
to clear-cut treatments like minor surgery or time to be
seen in A & E, but a large proportion of medicine is far
less quantifiable and is far more complicated. Simplisitic
targets can easily introduce perverse incentives that
disrupt the equitable provision of healthcare according to
need.’ DoH 2001.
Skewing of doctor’s work?
• The Doctor as Teacher (GMC 1999)
• Concerns raised about amount and quality of clinical and
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•
•
•
educational supervision (Calman 1992, Donaldson 2003)
Diversification of medical workforce to include
‘educationalists’ who could develop the teaching skills of
medical faculty (DoH 2004)
Need for ‘new types of learning and teaching’ (DoH 2004)
Production of Generic Standards for Training (PMETB
2006)
GMC Approval of Trainers’ Project (2013) – approval of all
trainers (UG and PG) project to be implemented in 2013
MMC – Modernising Medical Careers
‘The apprenticeship model, long the bedrock of training in
the past, remains important but now needs to be set
within efficiently managed, quality assured training
programmes compatible with the Working Time Directive.’
DoH 2004
Changing times?
‘These are bewildering times for doctors who teach
medical students. The UK General Medical Council has
reminded them they have a duty to teach, yet stirred up
such radical change that their task is un-recognisably
different from what they themselves experienced as
students.’ Dornan 2005: 91
What next?
• (Further) ‘professionalisation’ of PGME
• (Further) reform of PGME
• (Further) radical reform of the NHS
Shape of training review
‘It will look at potential reforms to the structure of
postgraduate medical education and training across the UK
and will consider issues such as the proper balance
between specialism and generalism in medicine, the
implications for education and training of more healthcare
being delivered in the community, how to balance better the
workforce demands of health services with the learning
needs of trainees and how to create flexible models of
training that can respond to the changing requirements of
both patients and healthcare services.’
http://hee.nhs.uk/work-programmes/shape-of-trainingreview/
Adapting for the future (2017)
• Postgraduate training
• GMC problem with
is slow to adapt
• Early specialisation
limits opportunities for
curricula to have
common components
• Training does not
recognise what is
common across
specialties
curriculum approval
processes (long time
to make changes due
to complexity)
• Rigid training
structures make rota
gaps worse
Guiding metaphor(s)?
• Training does not recognise what is common
between specialties, making it difficult for doctors
to move to new areas of practice outside of their
specialty without unnecessarily repeating training
already acquired. GMC 2017 p 12
Mission statement?
• We want twenty- first century training to support the
aspirations and commitment of twenty- first century
medical professionals to meet the needs of patients. To
achieve this, postgraduate medical training must change
– in structure, provision and approach. Doctors will gain
more flexible options throughout their careers. The real
benefit will be improved patient care. Doctors will share
expertise with the specialties to which they naturally link.
This will allow them to work more effectively in their teams
and across care contexts. Doctors will also be trained
from the outset for the important leadership role they play
within healthcare.
Changes?
• Shifts from time-based approaches to high level outcomes
• Curricula will explain what a doctor should know and be
•
•
•
•
•
•
capable of doing at key points in training
New standards, based on generic professional
capabilities framework
Emphasis on all doctors as leaders, able to work well in
multi-professional teams
Related curricula will share outcomes across specialties
Reduce burden of approval process
Promote existing structures for flexible training
Review the accreditation of transferrable competences
framework (AoMRC)