Progressing through training
A competence standard is defined in the Equality Act 2010 as ‘an academic, medical or other standard applied for the purpose of determining whether or not a person has a particular level of competence or ability'. In postgraduate medical education, competence standards are included in the Foundation Programme curriculum and specialty curricula, produced by the AoMRC or medical royal colleges and faculties and approved by the GMC.
Disabled doctors in training told us that one or a few competence standards sometimes kept them from progressing. As a result, they had to change careers or leave medicine all together.
Colleges and faculties should remove or revise any redundant aspects of the curriculum, not crucial for meeting the required standard, that may disadvantage disabled doctors.
We empower colleges and faculties to make such changes to their curricula via our standards and requirements for postgraduate curricula in Excellence by design (CS2.3, CS5.1-2,CR5.3).
Colleges and faculties will be revising their curricula to describe fewer, high level generic shared and specialty specific outcomes. During this review cycle, they should consider whether they can support disabled doctors in training by removing or revising elements of the curriculum that are redundant.
We give advice on how to make curricular changes to support disabled doctors in our Equality and diversity guidance for curricula and assessment systems.
We were part of the working group led by the Academy of Medical Royal Colleges (AoMRC) that produced their guidance on reasonable adjustments in high stakes assessments.
Taking Excellence by design and the AoMRC guidance together, key points for organisations designing assessments are as follows.
- The learning outcomes described in postgraduate curricula are seen as competence standards for the purposes of the Medical Act 1983. The purpose of any support implemented is to help the doctor achieve the level of competence required by the curriculum - and not to alter or reduce the standard required.
- Organisations designing assessments, mainly royal colleges and faculties, have to decide exactly what standard is being tested through the specific assessment. Organisations will do this by blueprinting the curricular learning outcomes to the assessment. This must be decided before considering reasonable adjustments, because it will influence what components of the assessments reasonable adjustments can be made to.
- Organisations designing assessments have an anticipatory duty to expect the needs of disabled candidates.
- That does not mean they have to anticipate the individual needs of every single candidate.
- It means they must think about how the assessment is designed and carried out, and how it might affect disabled candidates. If the way the assessment is designed or carried out puts barriers in place for disabled candidates, then organisations need to take reasonable and proportionate steps to overcome them.
- Barriers can be overcome through changing things in the physical environment (eg accessible venues), or providing auxiliary aids (eg coloured paper) or anything else around 'the way things are done' in respect of delivering assessments.
- Organisations should give candidates an opportunity to request support and reasonable adjustments for taking the assessment, and have a method for capturing these requests. Some organisations find it helpful to have a policy about evidence they need (eg report from treating physician) to consider the request, and a deadline for requests.
- Organisations must consider all requests and make a decision on a case-by-case basis.
- Panel 16 may be helpful in deciding what is reasonable when considering the requests.
- It is good practice for organisations to keep an audit trail of discussions and considerations leading up to the decision.
- If a request is declined, it is good practice for the organisation to give reasons. A form of a reasonable adjustment is to make changes to 'the way things are done'. This may include the college or faculty considering whether a candidate can be allowed extra attempts, in cases where a disability was diagnosed or the appropriate reasonable adjustments were agreed after a number of attempts had already taken place.
- Organisations should consider developing an appeals process, which candidates would be made aware of.
- Ultimately, the question of what is reasonable is a decision for a court or tribunal and organisations should consider seeking independent legal advice to assist their decision making in respect of what adjustments to provide.
- Organisations must provide a rationale that explains the impact of the assessments, including on disabled doctors.
Annual Review of Competence Progression (ARCP)
The Annual Review of Competence Progression (ARCP) aims to judge, based on evidence, whether the doctor in training is gaining the required competences at the appropriate rate, and through appropriate experience. Every doctor in training has an ARCP normally done at least once a year.
For disabled doctors in training, the preparation and evidence submitted for the ARCP can be an opportunity to escalate previous discussions they have had about
- the support they are receiving to meet the required competences or to gain the appropriate experience in the clinical setting
- changing to or from less than full time training.
- the environment in which they are training - for example, whether it is supportive, and any concerns about harassment, bullying or undermining behaviour (see the Gold Guide 7th edition, paragraph 4.56)
- any concerns they may have about the potential impact of their health condition or disability on their practice, progress or performance.
If the ARCP panel is discussing concerns about the progress or performance of the doctor, then the panel members can also explore whether there are any underlying health issues the doctor needs additional support for.
The ARCP process is also a way to decide whether a doctor can be supported to meet the competence standards at their stage of training. The ARCP panel will recommend one of the eight outcomes. The decision can be informed by a judgment on the doctor's knowledge, skills, performance (including conduct), health and individual circumstances. There are provisions within the ARCP process to do this, as described in the Gold Guide (7th edition). The doctor in training can be offered additional or remedial training to demonstrate they can meet the competence standards. Exceptional additional training time must be approved by the postgraduate dean, and this can be considered as a potential reasonable adjustment for disabled doctors (paragraph 4.85).
HEE reviewed the ARCP process in 2017 with the aim of ensuring a fairer, more consistent process for all doctors, and produced short guides to the process for doctors in training.