Submission to “Shape of Training” Review

The Shape of Training Review is looking at potential reforms in the structure of Medical Education in the UK. As I was not part of any organisation, or acting in a representative capacity, my response is a more personal reflection on the key issues in post graduate medical education in the UK at present (and hence the reason for adding it to my blog!)

My key recommendations were as follows (followed by responses to each of the questions)

1) The training of Doctors is not seen in isolation of the potential large upheavals needed in acute and community care. Any significant changes in training pathways must be future proofed to be able to flexible to changing patient demographics and service requirements.

2) HEE and the (National Commissioning Board/ NHS England) should agree a joint strategy and policy for proportion of care delivered by health care professionals in training.

3) The AoMRC should produce a joint statement on watershed roles between specialties in relation to service delivery and education. This would inform the specialty/generalist debate started by the RCGP.

4) If this review is to alter the CCT (certificate of completion of training) as an endpoint the views of trainees and newly qualified consultants must be heard during oral evidence.

5) A core group of Stakeholders including but not restricted to the FMLM, Academy of Medical Sciences, Academy of Medical Educators and  Health Policy Groups should meet to plan a strategy for expanding the Walport scheme beyond academic training.

1. Over the next 30 years, how do you think the way patients are cared for will change?

 It is unlikely that despite advances in technology (heart surgery, prosthetics, drug delivery etc.) the fundamental nature of health care professional interaction with their patients will alter. There will always be a need for face-to-face contact, communication skills demonstrating empathy, examination skills that elucidate key findings and an ability to make decisions based on clinical, social and ethical factors.  Regardless of the state of finances, political systems or even the construct of the NHS training doctors in good patient interaction, history taking, examination and technical intervention will be no less needed than it is now.   It is likely that more practice will happen via teleconference, closer to patients home or by non-medically trained practitioners. This does not diminish the need for well trained medical staff with core skills in history, examination and management.

2. What will this mean for the kinds of doctors that will be needed in primary care? In secondary care? In other kinds of care?

What is almost certain is that doctors will work in different ways and with different medical devices. Therefore as well as maintaining high standards of care doctors will also need to be able to respond to a rapidly changing technological arena.   The changing demographic of the population will mean a breaking down of divisions between primary and secondary care and re-thinking of this arbitrary divide. The concept of a community specialist or a hospital acute generalist are likely to become increasingly common. It is vital that the Royal Colleges are flexible and engaged with workforce needs to avoid ‘silo’ roles developing and there being inflexibility in career pathways.

3.  What do you think will be the specific role of general practitioners (GPs) in all of this?

The fundamental right to see a health care professional regarding a range of health issues, at a local level, who has a skill set to manage minor illness but be simultaneously cognisant of serious and rare disease is unlikely ever to be allowed to diminish by the general public and profession alike. Regardless of the changes made to delivery of care to patients requiring ‘admission’ GPs will need to retain a breadth of experience and expertise. This will be the only way to ensure quality care is received in the most relevant location for patients.

4. If the balance between general practitioners, generalists and specialists will be different in the future, how should doctors’ training (including GP training) change to meet these needs?  

The foundation curriculum has helped to some extent but we are still not entirely clear on the attributes we would like all doctors to have. We are also tied to a system that means everyone has experience of acute medical care. It is right and proper that this is the case but it has meant hospitals have always had their basic service commitments fulfilled by an excess of doctors at a junior level (but who often only perform very basic tasks or tasks beyond their competence – Collins Report)   If the balance of doctors is to change; the environment in which doctors can learn the requisite skills to move from having knowledge (medical student) to applying practice (foundation doctors) to delivering care (specialty trainees) will need to change as well. This does not just involve curriculum alteration but will require a system wide evaluation of the deployment of foundation doctors in the acute care system.

5. How can the need for clinical academics and researchers best be accommodated within such changes?  

I contributed to this question on behalf of the Academy of Royal Colleges Trainee Doctors Group. Please see their response as well.

It is important to differentiate between the need to train the whole medical workforce in the core principles of research, related ethics and good clinical practice (GCP) and those who will become established academics with a full or partial whole time equivalent research brief. It should not be the case that there is a clear divide between the two but ignoring the needs of either group risks jeopardizing both the strong UK academic standing in medicine and ultimately patient care. Currently there remains an artificial, and sometimes stereotypical, divide between those with a clear research interest and those without. This is not aided by poor awareness of where to seek advice on academia and research. A recent survey of paediatric trainees revealed only a third were able to identify who their local regional academic advisor was and other surveys of specialties suggest similar results.

The creation of the Walport training scheme has transformed the ability of a core group of potential academics to learn and develop research skills. However, as with all pathways, there is the potential to reduce opportunities to those uncertain about careers choices in their early clinical years. Any system of developing a future academic workforce needs to be cogniscent of the fact that research interests develop over time, that certain specialties have optimal and suboptimal periods of undertaking substantial research endeavors and that for many pursuing a long term academic career is not viable or desired.

In developing a new training structure the following should be considered:

i. It should be the responsibility of LETBs (in England), Deaneries (elsewhere in the UK) and Colleges, in collaboration, to establish fail safe mechanisms for trainees to access individuals and resources to advise on research and academic careers.

ii. Mechanisms for advancing and assisting those with potential and a clear interest must exist at all levels of training e.g. Medical School MB-PhDs, Foundation Year Academic Programmes and Academic Clinical Fellow/Lecturer posts.

iii. It should always be possible, but not necessarily an individual guarantee, to be able to undertake research activity within a training programme even if an accredited research pathway is not being undertaken.

iv. The concept of OOPE should be expanded to be able to undertake small research projects, as well as QI initiatives and education fellowships. These should be considered distinct from OOPR which should be reserved for those on research degree programmes. LETBs should ensure that work force planning and service needs allow for a number of OOPEs to be always available across specialties for those with an interest in research, but without funding, to undertake activity which may lead to a higher degree but also allows for return to clinical work without prejudice.

6. How would a more flexible approach to postgraduate training look in relation to: 6a.  Doctors in training as employees?

Doctors have traditionally been employed by their trust. Employing doctors at a regional (or even national level) would enable great flexibility in rotations and remove issues with multiple CRB checks and some parts of induction.

6b. The service and workforce planning?

 The fundamental problem with developing a flexible and dynamic training programme is that it is designed around service needs rather than vice-versa. It is clearly not simple to suggest that trainees are placed into training posts once the service needs have been met. But it would be possible over the next decade to start thinking about the need to make this change. It will not be possible to allow a flexible training programme if for example only one OOPE is available at any given time.  A debate on “extra-curricular” training i.e. skills in education, research, leadership and policy development must be had. One to determine why it is current training is felt to be inadequate to develop these skills (as evidenced by the high number of requests to undertake such activity) and secondly to understand how important they are in sustaining a high quality medical workforce in the future.

6c. The outcome of training; the kinds and functions of doctors?

 Is this question asking whether it is possible to have an endpoint of training that doesn’t produce an independent practitioner (whether GP or Consultant)?  Decisions made by junior doctors to apply to specialty or VTS training is made on the basis of reaching the consultant or GP end-point. Ensuring flexibility in training must always bear this in mind, and while some trainees, wish to undertake SASG roles there is no convincing evidence that this is their primary intention (further research is clearly needed in this area). The public also have a clear understanding of what a consultant or GP is. Therefore a flexible approach to training would still need to maintain a clear standard to achieve at its completion. The definition of a independent, unsupervised practitioner is a standard that is clear to all who aspire to do it and regulate its attainment.

6d. The current postgraduate medical education and training structure itself (including clinical academic structures)?

6d and 6b are integrally linked. There already exists a huge flexibility in the system from anaesthetics trainees being supernumerary in the first few months, to the cohort of medical director clinical fellows and also the integration of academia as evidenced by the Walport scheme. The ACCS programme has demonstrated, as will hopefully the broad based training pathway, how rigidity can be taken out of current training programmes to the benefit of trainees.   Perhaps no new flexibility is needed just an increased opportunity for trainees to partake in the experiences on offer. This is entirely dependant on service need and its potential reconfiguration.

7. How should the way doctors train and work change in order to meet their patients’ needs over the next 30 years?  

There have been few fundamental reforms of medical education since the Flexner report at the beginning of the last century. Of course nominology has altered, the training time frame has been adjusted and curriculums have been completely revised. But the core nature of medical training has stuck to some fundamental principles: At medical school a framework of basic science and key skill sets in each of the specialties learned. In the early years doctors clerk new patients and perform routine day to day care.  As they progress skills widen with experiences in clinics and theatres while greater responsibility is placed on leading juniors and making decisions.   Both the Temple and Collins reports highlighted current issues with this approach.

1) The need to provide a constant 24/7 general acute service was reducing learning opportunities once the core skills sets of dealing with acutely unwell patients had been learnt.

2) Supervision from supervisors was inadequate.

Neither report mentioned another issue with current education policy: “one size does not fit all in medical education”. Although generic skills are vital it cannot be the case that the training of a surgeon should match that of a psychiatrist. The current debate on working hours has always been flawed in its approach that everyone needs 56+ hours or that all patients are potentially unsafe unless we are rigid with 48 hours.   A surgeon may get rest at night and have their learning enhanced by operating on the patient they saw the night before whereas it would be catastrophic for a neonatal SpR who will have had little rest on a night shift in a tertiary NICU to have to continue onto an out patient clinic.   It should not be for this review to determine the individual needs of each specialty and I don’t think it intends to. However recommendations on training pathways must be flexible to individual specialty needs and in keeping with current workforce policy and regulations.

8. Are there ways that we can clarify for patients the different roles and responsibilities of doctors at different points in their training and career and does this matter? 

This does matter but requires national co-ordinated action. If each LETB/Trust etc. choose a different method it would cause confusion.

9. How should the rise of multi professional teams to provide care affect the way doctors are trained?

Currently there is little work done on assessing health care professional interaction and learning in a post graduate medical education context. Simply encouraging engagement will have little training benefit unless some core competencies can be defined. The rise of MPT in more integrated services will mean this area must be explored.

10. Are the doctors coming out of training now able to step into consultant level jobs as we currently understand them? 

Yes they are – there is little evidence of serious harm although it is clear the support given by colleagues is much improved from a decade ago.   The problem for this review of post graduate medical education is that it depends on the concept of a consultant/GP remaining static otherwise the end product will not meet the current health system requirements.

11. Is the current length and end point of training right?

Interesting question as the length of training is substantially different between specialties. Despite not feeling confident many trainees do feel competent to be consultants (anecdote I’m afraid!) although this maybe biased because they have deliberately extended their training. Qualitative and Quantitative research in the patient and personal outcomes of specialty trainees who have completed training entirely according to the pathway i.e. ST1-6 with no breaks and are no consultants is needed.

12. If training is made more general, how should the meaning of the CCT change and what are the implications for doctors subsequent CPD? 

This is an interesting question as it implies training may be made more general. What if the question were if training became more specialist?   As stated previously a CCT should remain as the benchmark to reach when you can be an independent practitioner. If less specialty accreditation was on offer the meaning of the CCT should remain unchanged. It would be possible post CCT to pursue education in more specialist areas but this would not devalue the important or relevance of CCT.

13. How do we make sure doctors in training get the right breadth and quality of learning experiences and time to reflect on these experiences?

HEE and the Commissioning Board must meet and re-appraise the core duties of junior doctors in providing acute care. Although it is not necessary in all specialties and environments it is quite clear that Emergency Medicine is suffering from trainees having little time to do anything other than constantly see patients. Although this is clearly a fundamental part of their training, only reflection and mentoring can avoid poor habits becoming ingrained and learning from mistakes turned into a positive experience.

14. What needs to be done to improve the transitions as doctors move between the different stages of their training and then into independent practice? 

The introduction of accreditation of educational supervisors will be instrumental in improving mentoring of doctors and providing better and more comprehensive cover of their transitions. It is vital that the GMC are robust in their processes to ensure that standards remain high.

15. Have we currently got the right balance between trainees delivering service and having opportunities to learn through experience?  

 No (The Temple and other reports demonstrate this)   Confusion has been created by the belief that trainees either deliver service or they don”t. In order to learn doctors must see patients in a supervised manner. However currently some patients are dependant on trainees for the care they receive i.e the medical assessment unit staffed overnight by an ST4 and two ST2s. It is entirely reasonable for learning experiences to take place in this setting. Unfortunately pressures on acute services will mean those doctors will see patients in a way that ensure throughput rather than learning opportunity. The same unit with additional SASGs, nurse practioners and consultants takes the pressure off, especially junior staff, meeting trust targets as well as meet the needs of their curriculum.  As stated previously changes in population demographics mean the Health Service must examine who is providing patient care and what is a sustainable way of delivering education. The two are intertwined but should not be dependant.

16. Are there other ways trainees can work and train within the service? Should the service be dependent on delivery by trainees at all?

See question above. Service entirely independent of trainees would be a tough financial and workforce ask. The review of Emergency Medicine by the Department of Health is a good example of work that could be performed in all specialties to review the delivery of acute (and community) care.

17. What is good in the current system and should not be lost in any changes? 

Clear steps from Novice (Foundation) to Expert (Consultant)  A defined end point  The ability to undertake OOPE and OOPT.

18. Are there other changes needed to the organisation of medical education and training to make sure it remains fit for purpose in 30 years time that we have not touched on so far in this written call for evidence?

The Walport system has transformed academic training. Although there are still some bugs to be ironed out the inception of protected out of clinical time is clearly beneficial. This principle should and could be applied to Medical Education, Leadership and Management and Health Policy.  Leadership and Management, especially in the light of Francis, have been neglected for decades in the training of junior doctors. It is vital if we are too develop a generation of consultants and GPS who can transform services and deliver high quality care that this is remedied. The FMLM response to shape of training has clear recommendations in this regard.

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