Reviewing the impact of Tomorrow's Doctors - GMC

30 October 2012 Undergraduate Board

5 To consider Reviewing the impact of Tomorrow’s Doctors (2009) Issue 1. A work programme to review the impact of Tomorrow’s Doctors (2009) and the preparedness of recent graduates. Recommendation 2.

To endorse the approach proposed for reviewing the impact of

Tomorrow’s Doctors (2009) and the preparedness of recent graduates

(paragraphs 6 to 67).

Further information 3. If you require further information about this paper, please contact us by email: [email protected] or tel. 0161 923 6602

Background The Education Strategy 2011-2013 said that we would ‘evaluate the impact of Tomorrow’s Doctors 2009 in providing greater assurance about the consistency of outputs of the UK’s 31 medical schools’. The evaluation ‘will be thorough, measured and inclusive’. 4.

5. The Business Plan 2012 states: ‘In 2013 and 2014, we will complete our review of the standards we set for medical education and training, and assess what impact Tomorrow’s Doctors (2009) has had’. Discussion

Structure of the paper This paper sets out a potential way forward for evaluating the impact of Tomorrow’s Doctors (2009) (TD09) and more generally considering the preparedness of new graduates. 6.

7.

High-level objectives for the evaluation are set out.

8. There follows a discussion of probable limitations for the evaluation and its potential scope, which might cover both matters of curricular detail and fundamental questions about medical education and how it should be regulated. 9. The following section summarises studies and research relating to the impact of previous editions of Tomorrow’s Doctors. 10. We then set out potential components of a package of new research looking into the preparedness of recent graduates. 11. Alongside the new research to be commissioned, the GMC will be able to draw upon information that it is collecting, and projects that it is undertaking, primarily for other purposes. 12. A further section of the paper summarises some projects outside the GMC which will also generate information that could contribute to consideration of the preparedness of new graduates. 13. Finally, a section on the way ahead summarises how this work could be taken forward up to 2014.

Objectives 14. The thorough evaluation of the impact of Tomorrow’s Doctors (2009) (TD09) will provide an evidence base to allow the GMC to address key issues in the regulation of undergraduate education.

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15.

The evaluation will inform: a. Consideration of the outcomes and standards that we set for undergraduate curricula particularly in light of both our responsibility for the continuum of education and training and also the needs of patients, the public and employers. b. Consideration of the strengths and weaknesses of the case for introducing a national licensing examination for UK undergraduates or new graduates, or less radical steps towards greater UK-wide consistency in summative assessment around the point of graduation and initial registration. c. A review of the GMC’s approach to regulating assessment, covering both undergraduate and postgraduate stages. d. Identification of other potential reforms to medical education and training and in particular its regulation and its interface with service, and close consideration of those options with our partners.

Limitations and scope 16.

It will be important to avoid an unduly restrictive approach to the evaluation.

Limitations on the project For one thing, in 2013 it will be too early to assess the full impact of Tomorrow’s Doctors (2009). Medical schools were expected to comply with the 2009 edition only from 2011-12 and are continuing to work through the implications of the new requirements with support from the GMC. The full impact will be felt over a longer period. 17.

18. In any case, it will always be difficult to be confident about the impact of the 2009 edition, given many other factors that are contributing to changes (and continuities) at medical schools and on the competence and confidence of new graduates. The requirements in Tomorrow’s Doctors in any case reflect developments and needs in medical education and practice, not least due to our commitment to a collaborative and consultative approach in developing our outcomes and standards.

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19. Even more fundamentally, the characteristics of a ‘good doctor’ are much debated. It may never be possible to say with certainty whether graduates from 2012 onwards are generally ‘better’ than previous cohorts, and views differ as to what constitutes ‘better’. There is an unresolved debate around where to strike a balance between ensuring immediate preparedness for practice as a F1 doctor, and ensuring capability to embark on a rapidly changing career likely to last 40 years or more. It is unhelpful, to say the least, that there continues to be disagreement on such a fundamental point. Even in respect of preparedness for F1, proxy measures are of course possible but may place too much emphasis on quantifiable aspects and, especially if chosen or developed by people associated with UK medical education or regulation, may largely reflect back, rather than challenge, the perspectives incorporated in Tomorrow’s Doctors. 20. Nevertheless, good progress has been made and can continue to be expected in developing an evidence base and consensus view of the ‘good’ doctor. The recent review of Good Medical Practice, work we are doing on generic outcomes in postgraduate education – for example, leadership, resilience, team-working and communications – and the imminent introduction of revalidation provide an opportunity to take a consistent approach to the structure of attributes required of a doctor. The trainee and trainer surveys provide quick feedback on developments in the service. Reviewing the outcomes expected of new graduates every five years or so allows us to keep the regulatory expectations contemporary and valid without creating rapid change that would present difficulties to medical schools in designing and delivering curricula. Scope of the project 21.

We are proposing to review the impact of TD09 in two respects.

22. First, we can consider recent developments in the design and delivery of curricula, including assessments. One aspect could be attempting to reach a view on the extent to which the changes result from TD09 and aspects of TD09 that do not appear to be fully reflected on the ground. It might also be helpful to consider how far those curricular changes are in line with developments that would be favoured by postgraduate bodies and by employers and how well they fit with, and provide a solid foundation for, developments at other stages of medical education and training. In addition, it could be an opportunity to review how specialty-specific education is delivered at the undergraduate level. We will be able to draw on the considerable information already collected by the GMC for quality assurance purposes, possibly supplemented by additional research.

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23. Second, we can consider the preparedness of recent graduates and any change in preparedness compared to earlier cohorts. This would relate largely to the competence (overall professional ability) and competencies (specific skills) of new graduates in relation to the expectations of new graduates entering the Foundation Programme as trainees and the service as employees. It would also be appropriate to attempt to take a view on their preparedness for further stages in the continuum of education and training and a career of medical practice in health care organisations, subject for example to appraisal and revalidation and the expectations in Good Medical Practice. 24. We will need to consider whether it would be helpful to focus on particular areas given the potential scale of this exercise. For example, in relation to outcomes for graduates, we could focus on scientific or specialty-specific knowledge, prescribing skills and/or professional behaviour. In relation to standards for the delivery of curricula, we could consider assessment and/or the effectiveness of mechanisms to assess students’ conduct or health or to ensure that students who are not well suited to medical practice are supported into other careers. We could also undertake one or more focused studies of the relationship between teaching of a speciality in undergraduate education and known problems of perception and recruitment in that speciality in postgraduate education. Psychiatry faces particular challenges of these kinds, for example. 25. A key element will be aiming to clarify whether new graduates meet minimum criteria. These could be focused on the outcomes in TD09 but might also extend more generally to their ‘fitness to practise’ in relation to GMC procedures and Good Medical Practice, and their ‘fitness for purpose’ or employability or suitability to enter the Foundation Programme. It will be important to know whether there is significant variation between medical schools in the numbers of graduates failing to meet these minimum criteria. The distinctions between the possible criteria would need further consideration. (Data in the UK Foundation Office report for 2011 shows that 185 doctors – 2.5% of the total – could not be ‘signed off’ at the end of F1, and 276 – 3.5% - could not be signed off at the end of F2. Reasons included moving to more flexible training and absence for longer than four weeks – which might well be unrelated to issues of performance or educational quality – but also included undergoing remediation or for being dismissed or resigning. Overlapping this group, other doctors had been identified as ‘doctors in difficulty’ requiring additional support to help them progress. It will be important to analyse these groups to identify any factors potentially linked to their undergraduate education.) 26. More generally, we may wish to investigate the extent of variation in the performance of graduates above the minimum criteria. While medical schools will properly vary in their curricula and in their intake, and individual graduates will properly vary in their abilities, there may also be advantages for employers in greater consistency in competence and competencies. We will need to consider whether that is a proper concern for the GMC as the regulator of medical education and medical practice (see paragraph 40c).

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27. We will also need to consider respects in which the evaluation of the impact of TD09 should pay regard to equality and diversity considerations and in particular the impact on students and graduates with the statutory protected characteristics. Some fundamental questions 28. This will be an opportunity to consider both matters of curricular detail and fundamental questions such as: a.

the granularity of the outcomes that we set

b. whether we should specify outcomes for shorter periods of training (even individual years) c. whether we should take a more specialty-oriented approach to regulating undergraduate curricula d. how far the standards for undergraduate and postgraduate education should be brought closer together e. whether regulation should be more concerned with characteristics of individual graduates and less with the processes of medical schools f. the various pressures on the curricula – from the GMC, the government, Medical Education England / Health Education England and NHS Education for Scotland, universities, postgraduate bodies, employers, patients and the public, and so on – and whether particular partners should have greater or lesser influence; and if so how that should be achieved.

Earlier research on Tomorrow’s Doctors and preparedness 29. The 1993 edition of Tomorrow’s Doctors is widely regarded as having had a significant impact on education and training. Various pieces of research have looked into this and into the related question of the preparedness of graduates. The research into preparedness has looked largely at the perceptions of trainees and of those in a position to have a professional view of their competence and competencies. There is also occasional reference in the literature to the results of tests of particular competencies of students near graduation or of new graduates. Findings related for example to an apparent decline in the teaching of basic sciences including anatomy and in the knowledge base of new graduates; but an apparent improvement in the ability of graduates to deal with uncertainty, know their personal limits and assert their right for support, and a new emphasis on communication skills.

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30. Michael Goldacre and colleagues have surveyed junior doctors on whether they feel their medical school prepared them well for medical practice. Comparing 1999/2000, 2002 and 2005 there was a steady improvement in graduate preparedness in the view of doctors in their first year of practice but a steady decline in the view of doctors in their third year. But only 3% of respondents said that being unprepared was a serious problem. ‘There were significant differences between graduates of different medical schools in their views about being well prepared.’ 31. The GMC had a three-year programme of informal visits to medical schools, starting in 1995, to review implementation of the 1993 edition. That edition included 13 principal recommendations and a journal article reported that 3 had been implemented in nearly all schools and 8 in most schools with slower progress in relation to health promotion and assessment. The 2009 edition does not include a comparable list of key recommendations. 32. The GMC commissioned research from Professor Janet Grant and Professor Trudie Roberts on the impact of Tomorrow’s Doctors and related themes and the final report was submitted in February 2007. The research involved an analysis of medical school curricula, a series of semi-structured interviews and a modified Delphi enquiry to identify relevant factors. The report concluded that Tomorrow’s Doctors ‘stimulated changes in assessment, in ideas of professionalism in the basic curriculum, and in clinical skills training (including communication)’ but also that ‘the scientific basis of medicine is no longer taught and learned adequate to need’. 33. We also commissioned research from Dr Jan Illing and colleagues. They conducted a series of interviews with a sample of graduates from three medical schools at the start of the Foundation Programme, after their first placement and on completion of F1. They also interviewed other clinicians and analysed more than 550 questionnaires. In addition they reviewed learning portfolios of F1 trainees and the results of assessments of prescribing. Conclusions were: a. ‘Graduates looked forward to ‘being a doctor’, fulfilling years of training and finally having a proper role to play in a clinical team…’ b. ‘While communication is a strong area at graduation, F1s were underprepared for some complex communication tasks…’ c. ‘Other clinical skills are well practised as undergraduates, but not in contexts which sufficiently mimic the real clinical environment, involving multiple demands on time, the need to prioritise, and the responsibility of dealing with acute cases.’ d. ‘Knowledge of non-clinical areas such as legal and ethical issues, and the operation of the NHS, was lacking at the start of F1…’ e.

‘Prescribing is a significant area of under-preparedness...’

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34. Clearly those five conclusions could helpfully be revisited as part of the review. 35. As part of the consultation on the 2009 edition, Skills for Health carried out a series of 230 semi-structured interviews with a range of NHS staff. While this was not an academic research exercise, the report provided a helpful insight into the perspective of employers on the strengths and weaknesses of recent UK graduates: ‘Interviewees were keen to say that some junior doctors are excellent and some respondents thought that standards were generally improving. The message from many respondents was, however, that junior doctors are generally not meeting the needs and expectations of the current NHS. The main areas which cause difficulties are lack of confidence and competence in clinical-decision making, clinical procedures and prescribing in practical situations, lack of understanding of the NHS and how it works, and standards of professionalism which are below those generally expected of NHS employees.’

Research to be commissioned 36. We propose to commission new research into the impact of TD09 and the preparedness of recent graduates. 37. While not wishing to close down options at this early stage, the research could cover: a. A literature review of relevant research including grey literature. (This could be undertaken in-house.) b.

TD09.

An analysis of changes made in medical school curricula in response to

c. An analysis of the approaches to specific specialties reflected in medical school curricula. d. Interviews, focus groups or surveys to gather perspectives from relevant parties including some or all of: i. employers (including chief executives, medical directors and other executive directors) ii. postgraduate bodies (including senior postholders in deaneries, medical royal colleges and faculties and other organisations) iii. trainers (including educational supervisors and clinical supervisors), but avoiding duplication of the GMC survey of trainers iv. other medical and professional colleagues (including nurses and pharmacists)

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v. trainees and students, but avoiding duplication of the GMC survey of trainees vi.

patients and members of the public.

e. The outcomes of local tests of the skills of imminent or recent graduates required by employers, such as any prescribing assessments. f. Information on preparedness among Foundation Programme trainees derived from learning portfolios, support for trainees in difficulty and other sources. 38. We are considering whether this research should be commissioned as one package or as separate elements which could be completed by different research teams.

Information available to the GMC 39. In addition to commissioning new research, we should also make use of information that is already available to the GMC or that we could obtain through processes already in hand. Information from quality assurance activities 40.

In particular we should draw on: a. The thematic review of assessment arrangements. This includes a survey of medical schools’ summative assessment arrangements, a review of information from visits relating to the assessment requirements in TD09 and a review of information from visits relating to feedback. b.

Information from surveys of trainees and trainers.

c. The reports of visits to medical schools and postgraduate deaneries including the rolling programme of regional reviews and the programme of visits to consider aspects of TD09 that have proved particularly challenging. d. The Medical School Annual Return and the twice-yearly return from the Postgraduate Deaneries. Specific questions could be developed for the 2013 templates perhaps relating to curricular changes and information derived from the tracking of graduates, for example. Other relevant data from the returns should also be analysed. e. The views of GMC Visitors perhaps through a dedicated survey or events. Related GMC reviews

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41. In addition, other GMC reviews will raise questions relevant to the issues being considered through the review of the impact of TD09. These include: a. The review of Good Medical Practice will result in a new edition with a structure and a set of emphases. Our starting assumption is that in formulating outcomes for education and training we should, unless there is a compelling alternative, mirror the structure of Good Medical Practice. In time, this would create a consistent framework for the attributes of doctors throughout their careers from medical school, through postgraduate training, to revalidation and continuing professional development (CPD). b. The review of our quality assurance (QA) of medical education and training, including the review of standards in 2013, will also raise relevant questions. Given that TD09 came into force in the 2011/12 academic year, the focus of the QA review may be primarily on postgraduate rather than undergraduate standards. Even so, given our interest in taking a coherent regulatory approach across all stages of education and training, the conclusions reached in relation to quality assurance and standards may have wider implications, eg for assessment, for our undergraduate standards and for the case for more consistency and confidence in relation to medical school finals. c. The review of PLAB is considering issues about how international medical graduates should be assessed at the level of entering UK medical practice as a doctor in the second year of the Foundation Programme. We will need to consider whether there are implications for the assessments and the curricula that apply to UK graduates. More specifically the terms of reference for the review include the feasibility of using the PLAB test for the purposes of a national licensing examination if the GMC Council decides to introduce one. Learning from key interests 42. We also regularly meet partner organisations providing many opportunities to collect perspectives on the impact of TD09 and the preparedness of UK graduates. Where appropriate dedicated meetings could be organised. We might for example wish to ensure that we have a clear picture of the perspectives of: a.

Medical Schools Council

b. Medical Education England / Health Education England; NHS Education for Scotland c.

Quality Assurance Agency

d. Postgraduate bodies – Foundation Schools, Deaneries, medical royal colleges and Faculties, Local Education and Training Boards – and associated national organisations e.

NHS Employers and its Medical Workforce Forum

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f.

Foundation Trusts

g.

Association of UK University Hospitals

h.

Skills for Health

i.

National Association of Clinical Tutors UK

j.

Academy of Medical Educators

k.

Higher Education Academy.

43. We could also conduct focus groups for example of new graduates and their trainers and employers. However, this option may be covered by the research that we propose to commission. 44. We could also make use of the GMC Reference Community of doctors and lay people who have previously proved very useful in education policy development. 45. The GMC has also been compiling an Issues Log of items relevant to the requirements we set for undergraduate curricula, including 60 items to date. These items should also be considered as part of the review of the impact of TD09.

External sources and developments 46. Other developments may provide information relevant to the review of the impact of TD09 and/or context for consideration of the issues involved. Assessing skill in prescribing 47. Good progress is being made on the development of the Prescribing Skills Assessment (PSA) by the Medical Schools Council (MSC) and the British Pharmacological Society. It is envisaged that the PSA would be taken by undergraduates in their final year and also by non-UK graduates in F1. A pilot at all medical schools will take place in 2013 and the PSA should be ready to go live in 2014. This should produce information on the prescribing skills of UK graduates generally and for each medical school. 48. Information might also be available from employers who conduct tests of prescribing skills (although this might be incorporated in the commissioned research). Sharing content for finals

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49. Separately the MSC Assessment Alliance (MSC-AA) is taking forward the bank of examination items inherited from the former Universities Medical Assessment Partnership (UMAP). It is possible to compare the performance of students across schools that use the same questions. In her presentation on Collaborate Content to the Undergraduate Board on 26 April 2012, Professor Val Wass, chair of MSC-AA, pointed out that variation in assessment standards across medical schools has several sources. These include differences in examination formats, the timing of finals and processes of student selection and standard setting. She argued that serious shortcomings in UK graduates are rare and often relate to their professionalism or their health rather than their knowledge and skills. A phase 1 feasibility study due to report in autumn 2012 would provide an opportunity to explore variances in the processes of assessment, but without taking account of the difficulty of specific examination items. In a phase 2 hypothetical standard-setting exercise, all medical schools would set a pass/fail cut-off for a set of 100 questions blueprinted against Tomorrow’s Doctors. A longer term project, concluding by 2014, would be able to control for key variables, such as examination difficulty, in determining the extent of variation in the pass mark across the medical schools. ‘The psychometrics to assess “real life” practice may take longer.’ The Foundation Programme 50. The project on Improving Selection to the Foundation Programme followed widespread concerns about the effectiveness of arrangements for applying to the Foundation Programme. The ISFP project has two components which will apply for selection to the Foundation Programme in 2013. The Educational Performance Measure is based on performance at medical school and other academic achievements. In addition, candidates must take a Situational Judgement Test (SJT) designed to assess the professional attributes expected of a Foundation doctor, with 70 questions to be answered over two hours and 20 minutes. The SJT for the 2013 entry must be taken on 7 December 2012 or 7 January 2013. The SJT is intended to rank applicants and not to fail poor candidates. Nevertheless, it may result in identifying F1 doctors who would particularly gain from close support and supervision. Data would be relevant to the review of the impact of TD09. 51. Pertinent data (see paragraph 25) may also be available about the progress of Foundation Programme trainees linked to their medical school of origin for example in relation to: a.

trainees in difficulty

b.

trainees not successfully completing the first year or the second year

c.

issues considered by the National Clinical Assessment Service (NCAS)

d.

fitness to practise concerns handled locally or referred to the GMC.

52. Looking ahead, the Foundation Programme is due to be reviewed in 2015 and in any case its curriculum is periodically reviewed for approval by the GMC.

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Specialty training 53. Also it may possible to consider information about the progress of trainees through specialty training including differences between medical schools or differences between groups of trainees with various protected characteristics. Data could come from the Annual Review of Competence Progression (ARCP) and from specialty examinations. 2013 would be too early to draw any conclusions regarding the impact of TD09 but the data may still be of interest more generally. 54. The GMC is supporting the independent review of the Shape of Training which will be considering the scope for changes to make postgraduate training more flexible and more in tune with the requirements of the health service. This may have implications for the generic competencies expected of new graduates and how they should best be assessed. The Shape of Training review is due to report in September 2013. A national licensing exam? 55. In the meantime, the national examination issue has been raised both by a report from the NHS Future Forum, Education and Training – next stage, and in the consultation document from the Law Commission on reforming the legislative framework for the regulation of health and social care professionals. 56.

In January 2012, the NHS Future Forum report said (paragraph 87): ‘We have heard, in some detail, the concerns of NHS organisations and others about the preparedness of some medical graduates to enter the workplace. The GMC has addressed this in part, but a case remains for greater consistency in the final undergraduate examination, with consideration of registration at the end of the undergraduate period. This will need to be balanced against the advantages of the current system, which many believe stimulates innovation and quality in graduates.’

57. This led the NHS Future Forum to recommend: ‘[The GMC] should lead discussions on the desirability of implementing a national exam in medicine that would support alignment of registration and qualification’.

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58. In their consultation from 1 March to 31 May 2012, the Law Commission asked whether the powers of the regulators should extend to matters such as a national assessment of students. The Commission contrasts an approach based on visits/inspections and approval of courses or programmes with an approach based on assuring that newly qualified individuals have the right qualities for practice and which ‘could involve, for example, a national assessment of students or auditing data which highlights individual progression’. It would appear that any powers to implement a national assessment would be enabling and permissive so that even if the Law Commission decided that regulators should have the powers, the GMC would not be obliged to use them. The Law Commission plan to publish a final report with a draft Bill in 2014: ‘It will be for Parliament to decide whether to change the law’. While this may be too late for the review of the impact of TD09, the Law Commission project has implications not only for the question of a national licensing examination but more generally for the GMC’s approach to the regulation of education and training. Other research 59. Lastly, results may emerge from relevant external research projects (which would also be identified through the research that we propose to commission). For example Clare van Hamel is leading research commissioned by NACT UK into the views of trainers about recent graduates, following research into the views of F1 trainers: http://bma.org.uk/news-views-analysis/news/2012/august/survey-checksf1-readiness 60. There is not a firm distinction between information that should be provided or analysed by the research teams we commission and the information that we should provide or analyse ourselves. In any case, our developing intelligence should be fed into the research teams.

The way ahead 61. In summary, we envisage commissioning research into the preparedness of new graduates in light of Tomorrow’s Doctors (2009). In addition, we will take a more systematic approach to identifying and making best use of information and analysis that bears on graduates’ preparedness but that is produced primarily for other purposes, both by the GMC and by partner organisations. 62. We envisage that tenders for the research project or component parts would start to be invited in early 2013 and that the project would be for a year, reporting in summer 2014. During 2013 we will also be able to take forward the review of the impact of TD09 and the preparedness of recent graduates through consideration of: 63.

a.

reports from the GMC’s thematic review of undergraduate assessment

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b. data generated by the GMC’s surveys of trainees and trainers and its rolling quality assurance activity c. reports from the GMC’s review of quality assurance (including standards) d.

outcomes from the PLAB review

e. any data available from the 2012 pilot and the 2013 application process for the Foundation Programme f. any data available from the 2013 pilot of the Prescribing Skills Assessment g. any data available on the use of MSC-AA Collaborative Content and from the earlier phases of the MSC-AA project on Collaborative Content h. 64.

the report of the Shape of Training review.

In 2014 we would be able to consider: a.

the results of phase 3 of the Collaborative Content project

b.

the final report from the Law Commission

c. further pertinent data that becomes available through annual or other rolling exercises d.

further findings from external research.

65. On this basis, we will be able in 2014 to bring forward any proposals for significant change relating to our standards and outcomes, assessment arrangements or other aspects of the organisation and regulation of undergraduate medical education. Major proposals would need to be addressed through a full, formal consultation. 66. It will be important to involve staff across the GMC, covering Education policy and quality assurance as well as colleagues involved in Standards and PLAB for example. 67. We will also need to consider how best to secure the involvement of our partners. This will be for the new Council to determine, but the starting point is that we wish to be as inclusive as possible while ensuring the review is independent and avoids dominance by any particular interest group(s). Recommendation: To endorse the approach proposed for reviewing the impact of Tomorrow’s Doctors (2009) and the preparedness of recent graduates.

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Resource implications 68. The proposed literature review could cost around £45,000 if commissioned externally. 69. The cost of commissioning the other research projects could be around £170,000 in addition. These costs will be included in the proposed budget for 2013. 70. No other significant costs for 2013 are envisaged arising from the activities proposed in the paper, apart from the opportunity costs associated with the staff time that would be involved. Equality 71. It will be important to consider carefully the impact on equality and diversity as we take forward the work proposed in this paper. Tomorrow’s Doctors (2009) placed a new importance on equality issues and particularly on support for disabled medical students which is being taken forward in other workstreams. Research by Woolf et al published in the BMJ 2011 found that ethnic differences in academic performance are widespread across different medical schools. The review will be an opportunity to explore the complex reasons for the gap in attainment set out in this paper. Separately, the research we have commissioned on student selection is examining the relative success of different approaches to widening participation from those from lower socio-economic backgrounds. In addition, we may wish to consider how well medical students are prepared to deliver non-discriminatory and appropriate healthcare to diverse populations. Communications 72.

This paper is not confidential.

73. A communications strategy will be developed as we work up the proposals for the review in the light of the Board’s discussion.

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