The role of the clinical tutor

Evolution of the post

The development of the post mirrors changes in the provision of postgraduate medical education that have been brought about by government initiatives, inquiries, and legislation. The first clinical tutors and postgraduate education centres were established in hospitals in the early 1960s after concerns were raised by Sir Robert Platt, chairman of a government joint working party, about the standard of training for junior doctors in the newly created senior house officer and registrar grades. The Pickering report in 1963 recommended that within each district the provision of postgraduate medical education be supervised on behalf of the postgraduate dean by a clinical tutor, who was usually chosen from among the consultants. Subsequently, the Royal Commission on Medical Education, chaired by Lord Todd in the mid-1960s, reported that doctors in training required consultant supervision and formative assessment and that clinical tutors would coordinate the supervision of all trainees within local health districts.

The Merrison Committee of Inquiry into the Regulation of the Medical Profession in the 1970s again recommended close supervision of trainees and said that the General Medical Council should be responsible for standards of specialist education. The GMC delegated the monitoring of these national training standards and accreditation to the royal colleges and joint committees rather than postgraduate deans, who acted at a more local level. This was enshrined in the Medical Act of 1978 and led to the formation of college tutors in health districts and to the inspection of posts by colleges. In 1980-1 the Social Services Committee of the House of Commons, chaired by Renee Short, inquired into medical education with special reference to the number and career structure of doctors in training. Careers advice and counselling were to be organised by postgraduate deans and clinical tutors. In 1987 the paper Achieving a Balance recommended careers counselling for all trainees (again!), but this time the Joint Planning Advisory Committee would advise on the numbers required in each specialty to aid those giving and receiving such advice to make informed career choices. In 1990 the health secretary Kenneth Clarke empowered postgraduate deans by making them responsible for funding of postgraduate medical education for trainees, charged them to monitor the delivery and standard of such education at local level. Currently, all salaries for preregistration house officers and half of that for other trainees come to trusts directly from the district's dean. This means that deans can insist that standards of educational content and supervision are met by trusts, and they have the power to withdraw educational approval and funding of posts from trusts if these standards are not met. The introduction of the specialist registrar grade by Sir Kenneth Calman, to bring Britain into line with European specialist training, brought a new bureaucracy of educational supervision, training plans, and assessments, monitoring, and documentation as detailed in the “orange book.”1 It seems likely that similar provision will be made for senior house officers in the future.

Appointing a clinical tutor

A clinical tutor is appointed by an individual trust. There are no rules dictating the procedure for appointment, but most trusts do so by internal, occasionally national, advertisement and formal interview by a panel that includes the postgraduate dean, the chief executive, the medical director, and the regional representative of the National Association of Clinical Tutors. Tenure varies but is usually for three to five years, subject to annual appraisal and review, usually by the medical director and chief executive. The post is often seen as a stepping stone towards further managerial posts because of the organisational and financial responsibilities it carries. Ideally, the appointment is proleptic, allowing the appointee a period of overlap with the outgoing clinical tutor. The main duties of a clinical tutor are:

• Identifying the training needs of trainees—All trainees need thorough induction to a trust on first joining (particularly those who have not trained in Britain and are taking up their first post). The clinical tutor is responsible for setting up and monitoring the trust-wide and departmental induction process. Trainees must have personal development portfolios to indicate whether they are being educated in line with royal college curriculums; they must have an achievable educational timetable; and they need to be appraised and assessed regularly. The clinical tutor liaises with specialty and college tutors to oversee this.

• Evaluating the quality of education provided—Formal evaluation of education within trusts is by means of visits made by royal colleges, regional training committees, and the postgraduate dean, but informal evaluation is by talking to trainees and educational supervisors and by “satisfaction questionnaires.”

• Providing career and personal counselling—Many trusts appoint a counselling tutor, whose main responsibility is to provide career counselling, and sometimes personal counselling, to trainees. The counselling tutor may either be the current clinical tutor or has previously been the clinical tutor. Sharing these posts allows some flexibility and allows one tutor to deputise and share responsibilities for the other.

• Managing the postgraduate education centre—The day to day running of the postgraduate education centre is done by a manager, but the clinical tutor is responsible for organising the regular educational programme and the budget devolved from the postgraduate dean to the trust for running the postgraduate education centre, study leave, and library services.

• Providing educational leadership—by representing the training needs of medical staff at trust level and by working in an environment where change has to be made by consent among those involved. Inevitably, this involves membership of committees. These vary according to local structures for management and decision making, but most trusts have a postgraduate medical and dental education committee and other committees which consider postgraduate medical education, medical staffing, and wider educational, training, and development issues. These may be chaired by the clinical tutor or director of human resources and attended by senior management; college tutors; medical representatives from departments; university representatives (if appropriate); representatives from professions allied to medicine, the library, information technology, and the general practitioner vocational training scheme; and the general practitioner tutor.

• Liasing with the postgraduate dean—The clinical tutor acts as a direct link between the postgraduate dean and the trust, disseminating information in both directions, and may be asked to represent the dean at appointment committees and monitoring visits.

The duties usually take up two notional half days, and the post usually attracts an honorarium equivalent to one notional half day. In addition, protected time should be arranged by paying the appointee's directorate appropriate sessions to compensate for their reduced departmental activity. Sessional payments are sometimes made for the counselling tutor. The National Association of Clinical Tutors recommends that in each trust there should be a formal job description and contract for the clinical tutor and counselling tutor which describe areas of responsibility, details of remuneration, and sessional commitments. Frequently, extra professional leave is made available by the trust to acknowledge the extra meetings, committees, and duties that the post entails.

Training for the post

The basic training course of the National Association of Clinical Tutors, “How to be an effective clinical tutor,” should be completed within 12 months of taking up the post. The training includes three modules: essential skills for clinical tutors, making use of assessment in education and clinical governance, and counselling skills. Membership of the National Association of Clinical Tutors is strongly recommended, and members are encouraged to attend the biannual national meetings of the association. Many deaneries hold meetings to discuss local initiatives and problems.

The future

Clinical tutors are becoming key members of trust committees overseeing clinical governance because of their understanding of the need for ongoing medical education. They often have skills in counselling and appraisal that make them able to advise on consultant appraisal and assessment. It is likely that in most trusts the post of clinical tutor will evolve into that of director of postgraduate medical education and will gain a position on the executive committee or trust board.