Professionalism and Excellence in Scottish Medicine - A Progress Report

Chapter 2

Response to the Professionalism 'Challenge' in Medical Education and Training

2.1 Undergraduate Training

'Tomorrow's Doctors' www.gmc-uk.org/education/undergraduate/tomorrowsdoctors_2009.asp defines the outcomes which the GMC expects medical schools to deliver and what employers of new graduates can expect to receive. The outcomes are grouped as follows:

• Outcome 1 - The doctor as a scholar and scientist
• Outcome 2 - The doctor as a practitioner
• Outcome 3 - The doctor as a professional

The third of these details 27 specific actions required of the graduate, who is expected to:

• Behave according to ethical and legal principles
• Reflect, learn and teach others
• Learn and work effectively with a multi - professional team and
• Protect patients and improve care.

The parameters of medical professionalism are therefore clearly set out from the date of graduation for 'tomorrow's doctors'.

2.2 Postgraduate Training

Unarguably, the quality of clinical expertise, the ability to educate junior colleagues and above all the ability to lead, are common to all specialties. It is entirely reasonable to expect all trainees to possess or to develop the ability to communicate effectively, empathise, be diligent and conscientious, and lead. These are the kinds of knowledge, skills and behaviours which are complementary to doctors' clinical skills but which, crucially, are integral to their professional practice.

Over the last 6 years there has been a shift towards a more standardised approach to the requirements for all specialty curricula. To set this in context, currently there are some 65 medical specialties and 36 sub specialties each with its own curriculum approved by the GMC. These are delivered in over 100 approved training programmes across the UK. The standards for Curricula and Assessment Systems, originally introduced in 2006, were a step forward in bringing greater consistency to the design and expectations for curricula delivery. In 2009/10, when curricula were reviewed, the opportunity was taken to incorporate some non-clinical elements considered relevant to trainees in all specialties, as preparation for their future roles as consultants or GPs. Recommended by colleges and faculties and approved by the GMC, the new elements reflected the guidance in the Medical Leadership Competency Framework and also the Common Competences Framework for Doctors. However there remains variability in the coverage and depth of non-clinical aspects in curricula across the medical specialties.

The GMC is currently examining the scope for introducing some generic streams into the postgraduate specialty curricula, and over the next year, working with partners, will attempt to establish consensus on these themes, and how they can be expressed and assessed as outcomes. Explicit reference to professionalism in current postgraduate curricula is inconsistent, but the expectation is that convergence will be achieved through the GMC work on generic competencies associated with professionalism. The Scottish Academy of Royal Colleges has indicated it is happy to take the lead in this area. There are already examples around professionalism being explicitly adopted into curricula, for example that of the Royal College of Anaesthetists: Professionalism in Medical Practice www.rcoa.ac.uk/CCT/AnnexA.

The Scottish Academy is a lead partner in the Professionalism and Excellence agenda and is centrally involved in promoting and supporting medical leadership development, and promoting specialism through quality improvement. This builds on the work of various colleges including the Royal College of Physicians: Learning to make a difference; the Royal College of Surgeons of Edinburgh work on Human Factors in Training and the Royal College on Anaesthetists training module on improvement science. The work links with that of NES in the Launchpad for Leadership, and will complement quality improvement training and development in foundation training (see Chapter 3).

Quality improvement methodology is currently being promoted by the UK Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement as part of their medical leadership competency framework. Improvement science is recognised as a powerful tool in implementing meaningful change and it is recognised there is a link between change management and leadership as well as professional attitudes to work. Section 13 of Good Medical Practice (April 2013): www.gmc-uk.org/guidance/good_medical_practice.asp states that doctors 'must take steps to monitor and improve the quality of their work'. Doctors are also required to produce evidence of QI activity as part of their appraisal and revalidation documentation. The Scottish Academy's objective is to promote cross specialty spread of improvement training in the postgraduate curricula and in the delivery of the postgraduate training programmes.

NHSScotland Quality Improvement Hub (QI Hub) www.qihub.scot.nhs.uk/home.aspx was formed in 2010 to provide a focus for the collective professional aspirations in this area. It is a national collaboration between Special Health Boards and Scottish Government Health Directorates which aims to support NHS Boards with implementation of the Healthcare Quality Strategy through provision of support, education, training and technical expertise in improvement science.

The work of the Hub is organised around 4 key workstreams:

• Implementation support that is flexible and responsive
• Education and learning opportunities that are accessible and relevant
• Measurement for quality improvement that is meaningful
• Facilitation of quality improvement networks for NHS staff.

The QI Hub works directly with clinicians, frontline staff and managers on a range of programmes and activities designed to build capacity and capability in improvement. The QI Hub web site also provides a wide range of educational and improvement resources focused around the improvement journey.

Key issues for trainees

As has already been stated, changes including the New Deal, EWTR, introduction of the Foundation Programme and MMC have reduced both time spent in training, and the proportion of trainees' time spent in the base team. Given the importance of mentoring by senior colleagues in the development of a set of professional values and behaviours, this breakdown of the traditional team structure (a loss regretted by the medical profession, particularly in secondary care), can only have had a negative effect on the development of professionalism.

The Scottish Academy Trainee Doctors Group has developed a number of themes in a paper on rotas, rotation, working patterns and professionalism with 5 key recommendations:

1. Intelligent rota design is key to providing a framework for training and service to be delivered in complement rather than conflict to each other. A centralised electronic platform with sharing of best practice will help facilitate this.
2. Continuity of the training team within on-call rotas and rotation blocks is imperative to enable adequate mentoring and evaluation of professional skills.
3. A meaningful clinical induction establishing roles, responsibilities and training opportunities for all trainees should be offered by each unit.
4. Development of professionalism requires mentoring and supervised practice within the context of service provision. Training opportunities within the working week need to be identified and made explicit.
5. Treating trainees as professionals will encourage professional behaviour in return.

This work is being developed in partnership with the Scottish Directors of Medical Education (DME) group, SGHSCD Workforce, and with member Colleges & Faculties through the Scottish Academy.

The Scottish Academy Trainee Doctors Group has described barriers to professionalism in some detail, covered at Annex A.

2.3 Scottish Government work on rota design

The current contractual provisions for doctors in training are a significant barrier to professionalism. The 'compliance' culture in which trainee doctors have been working for the last 13 years has resulted in a large degree of inflexibility and can create a difficult working environment. Scottish Government is therefore working with the other UK nations and the BMA around a potential review of the Junior Doctors' contract. This is supported by the DME Group who feel that organisationally, NHSScotland must look again at all doctors' contracts, within primary and secondary care, to ensure that these support professionalism.

As part of the modernisation of rostering practices, Scottish Government continues to work towards a Full Business Case for the development and procurement of an electronic rostering system. It is believed that automation of rostering will bring multiple benefits to trainee doctors, giving them the tools to take greater control over the rostering process. Automation of the process also has the ability to end the practice of fixed annual leave which has been raised as a concern by the Scottish Academy Trainee Doctors Group.

All working patterns in Scotland continue to be approved by the Scottish Government's Medical Workforce Adviser, who provides best practice feedback on rota patterns and designs. Examples of well designed rotas have been published on www.newdealsupport-wp.scot.nhs.uk/ and the Trainee Doctors Group has been asked to continue to send examples for publication.