Postgraduate Medical Education and Training Tariffs Alex Glover Local Director Prof Namita Kumar Postgraduate Dean

Junior Doctors in Training Junior doctors in training, in England, currently form 39% of the medical workforce There are specific requirements of the roles they undertake, the supervision they require and the GMC standards to which these are delivered Much of the work they do is service provision. Particularly the case for out of ‘standard’ hours working and on call rota provision Many acute specialties the junior doctors are the first point of contact in a multi-tier system.

Learning is quite rightly partly experiential and apprenticeship in nature, and should allow appropriate responsibility - allocated by graded clinical supervision The tension between service and training has always been present and there has as yet been no effective way of teasing out the proportion of both for all specialties. This impacts on perceived components of pay. Due to the nature of different experience in more junior training grades, some specialties eg Radiology have far more training to deliver in the early years of the training scheme as opposed to others eg Core Medical Training. This means that the service provision is proportionately less than in later years but should increase with years in training.

In the North East and Cumbria 3000 trainees Foundation Trainees employed by acute trusts Lead employer Trust (LET) for specialty trainees GP trainees employed by combination – looking to develop a LET

Previous funding arrangements National view MADEL allocations to LETBs were based on 2007/08 activity data and unit rates The levels of funding to be utilised on individual elements within the overall allocation were not set by DH Payments to providers were locally negotiated Payments made in ‘bundles’ to trusts

Previous arrangements Mixed economy Posts variably funded -per trust -per programme -per specialty No uniform method of post distribution Cost of trainees to the service (remember service provision) Some trusts had been supported more than others Virtually all our trusts are Foundation Trusts

Split of Funding Sources for North East Medical Trainees

MPET Review Resulted in the establishment of tariffs for three of the funding streams for education and training with NHS trusts. Non-medical placement rate of £3,175 per wte Undergraduate medical placement rate of £34,623 per wte Postgraduate medical tariff of 50% salary support plus a placement rate of £12,400 per wte The 50% salary support of the postgraduate medical tariff will be paid as 50% of the mid-point for F1, F2, ST1, ST2 and ST3 lower. Any trainees at ST3 higher and above will be funded at 50% of the mid-point of an ST5. This is because of the assumption that higher trainees provide more than 50% service support and so the trust should contribute more. These changes are due to be implemented from April 2014.

Postgraduate Medical Tariffs in secondary care Set at a level affordable from utilising the existing secondary care national funding allocation of £1.26bn Based on 2010/11 activity data tariff was set at 50% salary support plus a placement rate Implementation from 1 April 2014 Payments still made in ‘bundles’ – but what is and is not contained in them?

What is in the Placement Fee? - Foundation doctors HEE guidance outlines that the placement fee covers “standard costs relating to the post, such as”: Administration costs of the placement Infrastructure costs Access to Library services Study Leave Funding for Study Leave was included within the bundle to acute trusts totalling £600 per F2, £350 of which is ‘top sliced’ to enable each F2 to undertake Advanced Life Support. F1 doctors do not receive Study Leave. From April 2014, F2 Study Leave will be part of the placement fee and reach acute trusts in this way so was removed from the bundle.

Foundation Trainees: From April 2014, the new tariff meant: For F1/F2 posts 100% trust funded: No change (zero funding received from HENE) For F1/F2 posts 100% NFS funded: Acute employing trusts will receive 50% of salary plus placement fee of £12,400 plus “market forces factor” which will vary by Trust For F2 posts 50% NFS funded: Acute employing trusts will continue to receive 50% of salary plus will also now receive placement fee of £12,400 plus “market forces factor”

What we did not include: The Foundation School continues to re-imburse acute trusts for travel expenses incurred by F1 and F2 doctors rotating through community placements (including GP and Psychiatry) as per the established policy for this process available on the Foundation School website.

General Practice within Foundation Year 2 HEE have confirmed that the tariff only covers secondary care placements; therefore, GP/F2 primary care placements are excluded from the tariff. From April 2014, GP/F2 posts continued to be 100% funded to the employing acute trust by HENE via the bundle and trainer grants continued to be paid directly to GP practices

Academic FP (within Newcastle and South Tees Trusts) = subject to tariff Academic FP posts have historically been funded from the MADEL envelope (i.e. not from specifically ‘badged’ Academic funding streams); therefore, AFP posts are subject to the tariff. From April 2014, AFP posts (F1 and F2) will be 50% funded, plus the placement fee.

GP Trainer Grants GP Registrars £7751 per trainee per annum Foundation Pro rata per F2 per 4 month rotation

Psychiatry placements within FP = subject to tariff HEE advised this was a local decision. The following approach was agreed at the HENE Board in February 2014: SALARY The acute employing trust receives 50% of salary from HENE in the bundle The mental health trust funds 50% of the salary whilst the trainee is on placement. This will be managed through a recharge arrangement between the mental health trust and the corresponding acute employing trust who will continue to pay the FP doctor

FOUNDATION SCHOOL FUNDING FLOWS

PLACEMENT FEE FOR F1s ROTATING THROUGH PSYCHIATRY F1- The placement fee (pro-rata for each rotation populated) is received by the mental health trust via a recharge arrangement with the acute trust F2- The £600 study leave element is retained by the acute employing trust who manages F2 study leave. The remaining placement fee (pro-rata for each 4 month rotation established) is received by the mental health trust via a recharge arrangement with the acute trust

F1 Shadowing = now included within the tariff HEE have confirmed that F1 shadowing is included within the tariff for F1 trainees. This means therefore that HENE are not providing additional funding to acute trusts for the shadowing period immediately prior to F1 employment

IN THE BUNDLE OUTWITH TARIFF Notes relating to 2013/14 Financial YearFROM APRIL 2014 Clinical Tutor SalariesFunding of Clinical Tutors across all Trusts Non-Tariff, funding continues via bundle FP Tutor Funding FP Tutor Funding – pro rata per Trust, 1 PA for every 30 FP Trainees in Trust Non-Tariff, funding continues via bundle Trust Admin Support Admin support to each Trust to support delivery of FP, 1 WTE NHS Band 3 salary for every 60 FP Trainees in Trust Non-Tariff, funding continues via bundle GP/F2 posts GP/F2 posts across NFS Non-Tariff –GP/F2 posts remain 100% funded via bundle F1 Professional Development £300 for every F1 in School provided to Trusts to support Professional Development Non-Tariff, funding continues via bundle

TARIFFNotes relating to 2013/14 Financial YearFROM APRIL 2014 F1 Numbers Established F1 posts across the region funded at 100%TARIFF APPLIED F2 Numbers F2 Posts which NFS contributes to the funding of- 50% funded as per previous SHO funding arrangement. This includes the F2 growth posts awarded to Trusts via a bidding process from August TARIFF APPLIED Small Specialty (F2 posts) 9 Trusts, 18 F2 posts in total; established August 2006 (historically 100% funded) TARIFF APPLIED FP Academic Posts Academic FP Funding for posts established within Newcastle & South Tees Trusts TARIFF APPLIED F2 Professional Development Top sliced from F2 Study Leave budget = £150 for every F2 in School provided to Trusts to support Professional Development Programme. TARIFF: Now part of placement fee ALS Training Top sliced from F2 Study Leave budget = For Trusts to deliver ALS for all F2s (calculated on assumption of £350 per F2). TARIFF: Now part of placement fee Study Leave Remaining F2 Study Leave budget = £100 per F2 for individual trainees to apply for using NFS policy, managed at Trust level. TARIFF: Now part of placement fee ShadowingFunding to Trusts to pay for incoming F1s to be paid for 6 days shadowing pre-employment TARIFF: Now part of placement fee

Issues raised nationally Treatment of the placement rate Activity changes Pay scales Trust funded posts Reference costs Financial incentives for quality

Issues raised locally Huge financial loss to one trust due to tariff How posts are distributed regionally and impact on service delivery Residual differences in the ‘cost’ of training some trusts receiving approx £19k per trainee others £26k Resolving to the region’s benefit Impact of Foundation Trust financial governance

Thank You