UK Shape of Training steering group: report annexes

Annex 6: UKSTSG assessment of tangible benefits that would arise from implementation of the SoTR

Tangible benefits arising from the implementation of the Shape of Training Review

Background

The Shape of Medical Training Review ( SoTR) was established by UK Ministers to consider how medical training could better meet the present and future needs of patients. The review group reported their findings in October 2013 making 19 recommendations.
( http://www.shapeoftraining.co.uk/reviewsofar/1788.asp)

It recognised that the needs of patients in the UK are changing, and identified that measures are required to meet the needs of an ageing population who are more likely to have chronic illness and multiple co-morbidities. The SoTR acknowledged that strategic policy commitments were focused towards more integrated care models, and suggested that in order to meet this challenge more doctors will be required to have and maintain generic rather than specialists skills that enable them to work within and across care services. It also noted that medical training in the UK is longer than in any other comparable Country and perhaps it could be shortened.

Although Ministers accepted the report in principle it was recognised that it was a broad framework for future medical training rather than a detailed description of curricula and structures. For example, the recommendation that training might be organised into broad patient care themes lacked detail and required further consideration. As such, further work was required to understand the implications of implementing the recommendations and to consider how they would work in practice. The UK Shape of Training Steering Group ( UKSTSG) was convened for that purpose and to provide policy advice to Ministers. A key role of the UKSTSG is to maintain a UK consensus on medical training while recognising that specific strategic priorities may differ across the UK.

In the first instance, the UKSTSG sponsored 6 workshops involving a wide range of stakeholders to consider the Review's key recommendations. This led to the publication of a UKSTSG position statement in February 2015 that outlined the next steps. This included a request that the Academy of Medical Royal Colleges should undertake a mapping exercise of current training curricula and consider how these may be modified to fulfil the key recommendations of the SoTR. The draft report arising from this exercise was presented to the UKSTSG in November 2015.

The SoTR has described in broad terms the current and anticipated future needs of patients and the types of skills doctors will need to respond to such needs. In considering the output from the Academy Mapping Exercise, the UKSTSG must be satisfied that any proposed changes to current curricula and training pathways will meet the needs outlined in the SoTR, thereby delivering tangible benefits for patients and rewarding, more flexible and sustainable careers for doctors. Identifying these tangible benefits will also be important in providing policy advice to Ministers.

This paper describes the tangible benefits for patients and service providers that would be expected to accrue from implementation of the SoTR recommendations. It has been developed primarily as a resource for use by the UKSTSG but may also be of assistance to other stakeholders.

The Key Recommendations

Although the Shape of Training Report made 19 recommendations these were précised at the beginning of the report to the following key recommendations:

1. "Patients' interests and needs must be considered first and foremost as part of changes to medical education and training"

The SoTR is clear that meeting patient needs must be pre-eminent in any consideration of changes to medical training. Consequently this is also a key principle of the UKSTSG. In implementing the recommendations from the SoTR the UKSTSG must be satisfied that first and foremost benefits will accrue for patients.

Tangible Benefit

• Recommendations for implementation of any aspects of the SoTR will describe the benefits that will accrue for present and/or future patients.

2. "Patients and the public need more doctors who are capable of providing general care in broad specialties across a range of different settings. This is being driven by a growing number of people with multiple co-morbidities, an ageing population, health inequalities and increasing patient expectations"

3. "Postgraduate training needs to adapt to prepare medical graduates to deliver safe and effective general care in broad specialties"

Over the past 25 years hospital doctors have become increasingly specialised and this has weakened the provision of generic/holistic care to patients. Many specialists now state that this is why they cannot contribute to emergency on-call rotas. Since >50% of all hospital admissions are unscheduled, staffing sustainable on-call rotas has become a major challenge for service providers. Although other factors such as the implementation of the European Working Time Directive has contributed to this, sub-specialisation within the traditional general specialties has played an important role.

A key recommendation of the SoTR was that the Service needs more doctors with generic skills while recognising that there will still be a requirement for specialists. It is important therefore to understand where within the Service doctors with generic skills are required and where the requirement for specialists will remain. Understanding the correct balance in each area of medicine is critical.

There are at least three clinical areas where the UKSTSG has identified a clear requirement for more "generalists".

(a) The provision of care for unscheduled patients in secondary care

The greater concentration on narrowing specialism in acute hospitals has reduced the number of doctors available to provide both immediate and ongoing general care for unscheduled patients. This is most evident in the broad disciplines of general surgery and of general medicine. Implementation of SoTR must be driven by meeting the needs of patients and ensure that doctors in appropriate clinical areas have and can retain the general skills to provide unscheduled care throughout most of their careers.

Tangible benefits

• patients, and their families, receive the highest quality of care from skilled, knowledgeable and compassionate doctors who listen and involve them in treatment and care decisions
• equips doctors with the skills and capabilities to work in integrated care services of the future
• enables service providers to achieve sustainable working patterns
• will support the design of work schedules for individual doctors that provide for a focus on training requirements while ensuring that doctors avoid fatigue and practice safely with a view to improving the quality of patient care doctors provide when on duty
• will create a pool of doctors who are trained to treat those elective patients who do need generalist care rather than specialist interventions (such patients constitute a large proportion of the elective clinical workload) allowing the delivery of more efficient elective services impacting favourably upon patient outcomes and experience
• allows for a more adaptable and flexible medical workforce as patient needs change
• ensures medical trainees have clarity on the expectations of their medical career pathway, and arguably creates a more interesting and flexible career for doctors

(b) Continuity of clinical care in Acute Hospitals

Specialism in hospitals has contributed to a loss of continuity of care especially of unscheduled patients. This is occurring because when declared specialists contribute to on-call rotas they often transfer the care of the patient to another doctor the next day. This can result in the patient having several responsible doctors over a short time period. Independent reviews of poorly performing hospitals have identified this as an important contributory factor in the delivery of poor patient care that requires urgent action. It has been recommended that all hospital patients should have a single named consultant who is responsible for their care throughout their hospital admission. A tangible outcome of implementing SoTR must include a requirement for clinicians in appropriate clinical areas to have and retain the general skills to provide ongoing clinical care for unscheduled patients.

Tangible benefits

• will reduce the "pass the patient phenomenon" - the handing off of patients to other clinicians - that has been identified to be detrimental to patient care and clinical outcomes
• will ensure clarity of the role of the named clinician with responsibility for continuity of patient care which will improve patient care overall
• will enable the provision of a single point of contact for patients and those supporting patients thus improving communication. Failure of communications to and from patients is the most common cause of complaint
• will ensure effective multi-disciplinary team working benefiting both patient care and improving junior doctors' training experiences
• contribute to the improvement of the engagement of junior doctors with their workplace and colleagues

(c) Doctors who can work at the interface between primary and secondary care

In addition to increased specialisation of hospital doctors, over the past 30 years there has been significant growth in hospital admissions, a significant proportion of which might have been better dealt with in the community. For more than a decade Hospital admissions have been rising at unsustainable rates of 4-5% per annum. Although this has been driven in part by increased technology and complexity of care, the King's Fund has reported that at present 25% of patients in acute hospitals could and should have been treated in the community. A large proportion of this later group is elderly with multiple co-morbidities. Given the demographic trends for the elderly population, and in view of Governmental policies to transform health and social care delivery, it is necessary to achieve an appropriately trained workforce to provide care for this group of patients in the community.

General practitioners already undertake "general training" and have been described as the only "true generalists" in as much as they treat all conditions at all ages. In order to facilitate more care in community-based settings, GPs will require appropriate support and to have the opportunity to enhance their skills in the management of patients with complex co-morbidities. This was described in the Shape of Training Workshops as a "community physician" role.

Tangible benefits

• will reduce hospital admissions and increase timely hospital discharges. This is key to the future sustainability of acute hospitals. Will contribute to ensuring that hospital admissions are more often the best option for patients who require the services of a high technology hospital
• will enable more patients to be treated more appropriately nearer to home. Patients repeatedly say that this is their preferred option
• has the potential to improve the structure and delivery of out of hours (OOH) services
• should enable innovative redesign solutions for OOH services and care in the community with stronger links to social care services
• has the potential to enhance care in the community in a range of clinical areas.

4. "Medicine has to be a sustainable career with opportunities for doctors to change roles and specialties throughout their careers"

The SoTR identified the rigidity of the current medical training pathways as an important area for attention. The future medical workforce must be adaptable and responsive to changing patient needs, innovations and the introduction of new technologies. Medical training must also be responsive to a workforce that requires the opportunity for part time working, periods of leave and a desire for portfolio careers. A tangible output from the implementation of SoTR should include the incorporation of flexibility within and between curricula in both primary and secondary care.

This lack of flexibility in training pathways is most marked between primary and secondary care. At present this is an impediment to developing policy solutions to "blur the interface" between primary and secondary care as recommended in the SoTR. Consideration requires to be given to developing a range of options including training doctors who can work both in the community and in hospitals. The UKSTSG may wish to commission further work to consider this.

Tangible benefits

• will better use the entire medical workforce offering better opportunities for flexible working options throughout careers
• will better encourage the return to work of doctors who have taken career breaks
• will more flexibly respond to local and National service needs
• the development of doctors better able to work at the interface will be valuable for service providers in better meeting the needs of patients
• recognising previous learning will reduce the current overall training time for doctors who wish to change career

5. "We will continue to need doctors who are trained in more specialised areas to meet local patient and workforce needs"

The SoTR recognised that there will continue to be a need for specialist and sub-specialist doctors, but did not indicate which specialties will be required and how these should be deployed.

On the basis of studies drawn mostly from complex craft specialties, there is evidence that specialisation improves patient survival. As such, the UKSTSG will want to identify and support specialisation in these areas ( e.g. neurosurgery, cardiac surgery, pancreatic surgery, cardiology etc.). It should be noted however that those studies did not examine the detrimental consequences of specialisation - the improvements arising from specialisation may disguise consequential disadvantages in other service provision. The challenge for the UKSTSG will be to identify from the AoMRC mapping exercise those areas within traditional "general specialties" that merit sub-specialisation given the proposal that most doctors in future must remain "general enough" to provide unscheduled care.

Tangible benefits

• patients will continue to have the services of specialists when it is required
• specialist doctors will be able to focus upon their specialist skills, while recognising the context of the whole patient care and treatment needs
• will provide opportunities for service planners in reconfiguring specialist services

6. A clear explanation why all training programs cannot be undertaken within 6 years.

The SoTR suggested that specialty training programs that predominately comprise generic components should normally be achievable within a maximum of six years. The UKSTSG has noted that many training pathways are already 6 years or less.

There was a clear consensus in the SoTR workshops that progression through training should be predominantly based on the achievement of necessary competences and that prescribing a time period for training was less important.

It is the case that all comparable Countries in the World can train hospital-based doctors in 4-5 years and the clinical outcomes in these Countries are equivalent or superior to those achieved in the UK. The principle argument against shortening training in the UK is that while doctors can achieve the required competencies within 6 years they may lack the clinical experience to progress directly to the independent consultant grade. Others may progress to the consultant grade soon after completing training but feel in transition to the more senior role in need of coaching and mentoring to better support them in working towards more senior and autonomous practice. Concern about lack of clinical experience has been expressed in some specialties as a result of the implementation of the EWTD.

In considering this issue the UKSTSG noted that a proposal for instituting a period of formalised mentorship/supervision after appointment as a consultant was offered as a potential solution within the workshops and during the AME. Mentoring is already considered to be good practice and happens under various informal arrangements in employment and within Royal Colleges. The institution of more formal mentoring with a common and consistently applied structure as a component of a training pathway would also fulfil recommendations 8 and 9 of the SoTR which state:

"Appropriate organisations, including employers must introduce longer placements for doctors in training to work in teams and with supervisors including putting in place apprenticeship based arrangements"

"Training should be limited to places that provide high quality training and supervision, and that are approved and quality assured by the GMC."

Although the SoTR did not recommend formalised mentorship, UKSTSG has suggested that further work be undertaken to understand the implications of instituting a period of formal mentorship, particularly at times of career transition such as on promotion to consultant doctor grade posts.

Tangible benefits of formal mentoring

• mentoring is recognised to be good practice. Formal mentoring would reassure patients that CST holders would have formal support from more senior colleagues to help them through the rigours of the early years of a consultant post
• this will improve patient confidence, care and safety
• mentoring should also help mitigate stress at times of career transition and improve retention and engagement of doctors
• formalising mentoring would potentially allow training pathways to be shortened while safeguarding patient care and supporting doctors in early years practice as they gain experience. This would improve patient care and safety
• during the period of mentoring as doctors gain more clinical experience in a senior role they would be contributing to patient care in the workplace

7. "Appropriate organisations, including postgraduate research and funding bodies, must support a flexible approach to clinical academic training"

Doctors in academic training pathways need a training structure that is flexible enough to allow them to move in and out of clinical training while meeting the competencies and standards of that training.

It is important for patients that medical training produces doctors who can teach and inspire future undergraduate students and postgraduate trainees. There is also a requirement to develop a cohort of doctors who can undertake clinical and scientific research. The major risk to this group of doctors at present is that current training pathways may not be flexible enough to permit both clinical and research training. A clear outcome from the implementation of this SoTR recommendation must be that training pathways are flexible enough to accommodate this group of doctors.

Tangible benefits

• reassurance that the UK will continue to have doctors who can deliver high quality medical education and training
• the continued development of doctors who can undertake work that may lead to innovative scientific advances

8. Local workforce and patient needs should drive opportunities to train in new specialties or to credential in specific areas.

SoTR recommended that a process is required to ensure that local patient needs should influence the opportunity to train in the various areas of medical practice. A structure to permit this to occur requires to be developed.

Tangible benefits

• patient and Employers' needs would influence the planning of the numbers and design of training opportunities
• patients will be able to influence GMC and Medical Royal Colleges' curricula design and scrutiny arrangements. This will require to be better promoted by these organisations
• patient representative groups involved (perhaps by developing networks of 'Lead' individuals) in the development and scrutiny of local workforce plans
• assurance that locally determined need is met to a consistent National standard

9. "Implementation of the recommendations must be carefully planned on a UK-wide basis and phased in. This transition period will allow the stability of the overall system to be maintained while reforms are being made"

10. "A UK-wide Delivery Group should be formed immediately to oversee the implementation of the recommendations"

Tangible Benefits

• the scrutiny and implementation of SoTR recommendations will be overseen on a UK-wide basis during the transition period. This will ensure the maintenance of a UK consensus
• implementation plans in each UK Nation should be developed, and overseen by stakeholder participation and scrutiny. This will allow for strategic priorities in each Country to be pursued while maintaining an overall UK consensus

Note: In the recommendations, appropriate organisations must include the Sponsoring Board organisations, the four UK departments of health, employers, and both patient and professional interests.