UK Shape of Training steering group: report

Appendix 1: Royal College responses

1. The Joint Royal College of Physicians Training Board ( JRCPTB)

The clinical service requirement

Service providers have reported that the single most important unmet patient need relating to this clinical discipline is the supply of doctors who can support the unselected unscheduled "take" and can provide continuity of care. This often involves the management of elderly patients with multiple chronic conditions. The challenge was characterised in a Royal College of Physicians, London report as follows:

"All too often our most vulnerable patients - those who are old, who are frail or who have dementia - are failed by a system ill-equipped and seemingly unwilling to meet their needs".

(Royal College of Physicians London, 2013)

and

"older patients with an ill-defined acute illness and multiple comorbidities are much more commonly encountered on the acute medical take. There is increasing evidence of substandard care provided to many older patients with care poorly coordinated and reports of patients being moved between wards and within wards 'like parcels'".

(Royal College of Physicians London, 2013)

The Current training pathway

• The training pathway for most physicians is 7 years comprising an initial 2-year of general medical training leading to the award of the MRCP.
• Trainees can then choose to continue in general internal medicine or to enter one of 27 sub-specialties by competitive entry and undertake a further 4-6 years of training. At the end, a certificate of completion of specialty training ( CCT) is awarded.
• Some specialties do not contribute to the "general medical take"; those trainees are awarded a single CCT. Those that do can 'dual' CCT in internal medicine and the specialty. The general component however is held in relatively low regard and most physicians prize their specialty or "ology".

The SoTR recommended that patients need doctors with more general skills that can be delivered in a variety of clinical situations. The UKSTSG has agreed that in the context of secondary care this means that doctors will require to retain sufficient breadth in their practice to contribute to the "acute take" and to provide continuity of care.

The current pathway fails to meet these requirements because the general component of training stops for many trainees after year 2. Thereafter, and throughout a physician's career, the emphasis is on specialism.

The proposed training pathway

The "Joint Colleges" have proposed the following staged pathway in response to the SoTR:

Stage 1 - a three-year training program in internal (general) medicine leading to the award subject to examination of the MRCP. During this period doctors in training, as at present, would contribute to the "acute take".

Stage 2 - a period of specialty training (indicative time 4 years) that includes an element of training in internal (general) medicine with an expectation that trainees will contribute to the "acute unselected take" during the entire training pathway.

Further discussion is taking place with regard to the proposed training pathway for medical oncology, palliative medicine, dermatology and neurology to ensure that these training pathways fulfil the principles of the SoTR.

At the end a dual certificate of completion of training ( CCT) will be awarded. This will indicate that the doctor has the skills of a general physician with an interest in a specific specialty. In order to fulfil the needs of patients in the future, service provider organisations will require to employee physicians who will contribute to the acute unselected take and provide continuity of care thereafter. It is proposed that a small number of the 27 specialties, due to the configuration of their work, will not participate in the acute unselected take as consultants. These trainees would obtain a single CCT in their specialty.

The proposal also includes a commitment to more flexibility in recognizing previous learning based on the GMC's generic professional capabilities.

General medicine is an important discipline providing skills that are applicable and transferable to other areas of clinical practice such as general practice and child health, The Physician Colleges will have an important role in developing doctors with the skills to work at the interface between primary and secondary care and in the community. The UKSTSG are especially supportive of an initiative being undertaken by a College to develop modular training jointly with the RCGP.

The UKSTSG response

The UKSTSG welcomes this proposal and recognizes that it fulfils many of the principles outlined in the SoTR. The Colleges are committed to increasing flexibility in training and are actively involved in developing measures to support the delivery of more care in the community. In particular, more doctors will have and retain the skills to contribute to the acute unselected take both during training and as consultants. The concern is that the expectation they will make such a contribution is translated into reality and it will be for employers to ensure that job descriptions include this and the delivery of continuity of care thereafter. At the same time it is proposed that the option of the single CCT in general (internal) medicine is retained to help meet predicted future service needs.

The proposal that most physicians will retain an element of specialist training within the CCT pathway could be viewed as contrary to the recommendation within the SoTR that specialist training should be undertaken as a credential. In the current absence of detailed plans to support credentialing however, the UKSTSG considers that this proposal makes significant progress towards achieving the principles of the SoTR. In the meantime as per our recommendation the development of credentialing should be progressed as a priority. There is also a requirement to "model" these proposals in order to determine the financial implications of proceeding to implementation.

Subject to these caveats around costs and ensuring greater contribution to the acute unselected take, and a satisfactory conclusion to the on-going discussions, the UKSTSG supports the proposal in principal as an interim measure until credentialing becomes available. At that time a further review of the training pathway will be required. The UKSTSG recommends that consideration should then be given to developing specialty components of the current curricula as post CCT credentials.

Anticipated Benefits

It is anticipated that this proposal would bring the following tangible benefits for patients, doctors and service providers.

• Improve patient care
• Improve the continuity of patient care
• Allow service providers to proceed with plans for more integrated care models
• Increase the number of experienced trainees who contribute to the "acute unselected take".
• Increase the number of consultants who will contribute to the acute unselected take sharing the burden more evenly
• Provide greater support to trainees performing the role of medical registrar. (Trainees report that the requirement to undertake this role is a principle reason for not choosing a career in a medical specialty that has a general internal medicine component).
• Will increase the profile and status of general/internal medicine
• Will increase flexibility with the training pathways of other disciplines
• Will improve training in key areas such as geriatric medicine and High Dependency and Intensive care

2. The Royal College of Surgeons England ( RCSEng)

The UKSTSG has endorsed a proposal for a new curriculum and training pathway to improve training in general surgery (improving surgery training initiative or IST). The historical context was that Health Education England ( HEE) in conjunction with the Royal College of Surgeons of England was undertaking work independently of the UKSTSG to review training in general surgery.

What is general surgery and why should we change the training pathway?

General surgeons ( GS) have a key role within the hospital service delivering elective and emergency surgery. They treat patients with abdominal conditions such as gallbladder disease and cancer. They also treat breast & endocrine disease. In the emergency setting (which involves> 50% of their work) general surgeons ( GS) treat patients with conditions such as bowel obstruction, appendicitis and abdominal trauma. Traditionally GS have undergone a broad training to allow them to deal with this range of clinical conditions.

Over the past 20 years GS have become increasingly sub-specialised in their elective work. As a consequence they are losing the range of skills required to deliver emergency care. This is challenging the sustainability of emergency general surgery services particularly in district and rural hospitals and has adversely affected the continuity of patient care.

The UKSTSG are aware however that sub-specialism within general surgery in areas such as oesophageal and pancreatic surgery has been reported to improve patient outcomes. General surgery is a key clinical discipline where it is important to train the correct proportion of generalist and specialist surgeons to meet the future needs of patients and service providers.

The proposed general surgery curriculum and training pathway

A curriculum has been proposed that will equip trainees with the competencies to deliver elective and emergency general surgery in a district general hospital setting under the improving surgical training initiative. The recognised requirement for a proportion of general surgeons to become sub specialists will remain. At present sub-specialist surgeons have usually undertaken post CCT Fellowships. In the future it is envisaged that this need will be met by credentialing with the number and scope of credentials met by local patient and service need.

The Improving Surgery Training Initiative

With the endorsement of the UKSTSG, the Royal College of Surgeons of England ( RCS) is working with HEE to take forward the Improving Surgical Training ( IST) initiative that will pilot a new competence-based training programme in general surgery from August 2018. The pilot is being undertaken in association with the Joint Committee on Surgical Training ( JCST), which works on behalf of the four Surgical Royal Colleges of the UK and Ireland for all matters related to surgical training. Further details on the project are available on the College's website.

The IST pilot aims to create an improved surgical training system that produces competent, confident, self-motivated professionals who are able to provide the highest quality of care to patients in the NHS. It aims to do this by:

• providing them with an appropriate balance between service and training;
• professionalising their trainers;
• introducing a curriculum (subject to regulatory approval) that is truly competence-based within a learning environment that embeds and enhances simulation; and
• ensuring that the existing end-of-training product continues to meet current and future patient needs

The IST pilot also represents an opportunity for trusts to develop an alternative workforce model, maximising productive training time and making use of the focused specialisms of members of the extended surgical team.

The IST pilot will offer the following benefits:

For patients

• Training of consultants better-suited to provide the highest quality of patient care, to meet current and future patient needs.
  • Retains the capacity for patients to access sub-specialists when appropriate
  • Will improve the continuity of patient care

For the service

• Opportunity to develop an alternative, more sustainable model of service delivery as described in the strategic aims of the four health departments.
• Support for workforce transformation in relation to non-medical roles.
• Support for rota redesign.
• Reduced reliance on locum staff.
  • Develops surgeons better able to work in remote and rural locations

For training providers

• Ability to influence new educational delivery models.
• Opportunity to improve trainee and trainer morale.
• Focused support throughout the duration of the pilot.

For trainees

• Greater quality of training, provided by professional trainers.
• Greater quantity of training, with improved balance between training and service.
• Enhanced trainer/trainee relationship through an apprenticeship training model
• Competence-based training
• Reduction in duties of low educational value, through reduced administrative responsibilities and support from the extended surgical team.

For trainers

• Greater recognition of training role with dedicated training time in job plans.
• Enhanced training for trainers.
• Enhanced trainer/trainee relationship through an apprenticeship training model.

Such is the interest and enthusiasm for the project, urology and vascular surgery also now wish to be included. HEE has recently endorsed their inclusion with a view to introducing pilots in these specialties in August 2019.

3. The Royal College of Obstetricians and Gynaecologists ( RCOG)

The RCOG proposal is based on the premise that the current and anticipated service requirements and duties of a consultant in obstetrics and gynaecology will not change in the foreseeable future. As such consultants will require to have the skills to provide the full range of elective and emergency obstetric care and emergency gynaecological care in the district hospital setting. Evidence was presented that currently approximately 80% of O & G consultants across the UK participate in general on call.

On this basis the RCOG has proposed that the current training pathway, which has an indicative duration of 7 years beyond foundation, is broadly fit for purpose and fulfils the principle of the SoT Review that doctors should be sufficiently general to allow them to participate in the emergency care of acutely ill patients.

At present, years 6 and 7 of the pathway are considered by the College to be optional advanced training and are designed to accommodate trainee preference. The College has identified at least four of these areas of advanced training that would be suitable for recognition by credentialing. The UKSTSG has suggested that this should now be discussed with the GMC. When credentialing has been developed the residual curriculum would then require to be reviewed.

The College has also agreed to adopt a more flexible approach to recognising competencies obtained in other disciplines and will consider this further when the GMC formally publishes guidance with regard to generic professional capabilities.

O and G consultants currently provide a range of services in the community and are working with the RCGP to develop training modules for this purpose. This aligns with the strategic aims of the UK Health Departments to deliver more care in the community. The UKSTSG strongly supports these initiatives and encouraged the College to prioritise further work in this area.

Benefits

• Provides a general training program as recommended by the SoTR
• Supports the clinical service for patients.
• Supports strategic plans for more care to be delivered in the community
• In due course transfers optional specialist components of training to credentials

4. The Royal College of General Practitioners ( RCGP)

Current training pathway and proposal

The current training pathway for general practice is a three-year programme leading to CCT. Thereafter some GPs have the opportunity to undertake a post CCT fellowship in order to develop their skills in a specific area. The RCGP proposed that the initial 3-year programme should increase to four years with the additional training occurring within general practice. The rationale for this change is that the current structure and length of training fails to equip trainees with a sufficient level of skill and confidence in several areas including mental health, paediatrics, dermatology and the assessment & management of frailty and complex multiple co-morbidity. The College also believes that the role of the GP will change in the future with more emphasis on the leadership and management of multidisciplinary teams in the community. This will require new skills.

UKSTSG response

The UKSTSG broadly accepted that there is a requirement to enhance the skills of general practitioners to allow them to fulfil the new roles that are envisaged in integrated health systems. The Group were of the view however that the proposal as it was presented to them did not embrace the recommendations of the SoTR in a number of ways.

The UKSTSG also noted that alternative models for enhancing skills such as one-year post CCT Fellowships had been developed across the UK and these were generally proving to be popular with trainees. This can be described as a "3 plus 1" model of training.

Panel members considered that the 3+1 model better aligns with the principles of the SoTR. It allows flexibility since the "plus 1 year" can be undertaken during the formal structured training programme, immediately after training or flexibly during a doctor's career. The content of such an additional year would add skills beyond those that are required for CCT and would be responsive to local provider and patient needs. It also closely follows the Shape of Training vision for credentialing and would support Government strategies for delivering more complex care in the community. Most importantly the Panel believes that this model would help meet the demands of current trainees for portfolio and flexible careers.

The UKSTSG agrees that the core content of the GP training programme leading to CCT must continue to cover the elements required of an independently practicing GP in the NHS.

An important consideration is the impact that any change to the training programme will have on the recruitment and retention of doctors in general practice. The UKSTSG was told that the current four-year continuum training programs, where they exist, are proving to be unpopular with trainees despite many having a high quality educational content.

Conclusion

In conclusion the UKSTSG agree with the RCGP that there is a sound educational case for reviewing the way in which GPs are trained but was not convinced that an extension of the core element of CCT training as it was proposed to them is the most suitable way to achieve this. For the reasons outlined above the UKSTSG has written to the RCGP indicating that in considering the two options it prefers where appropriate a "3 plus one model" because it more closely fulfils the key Principles of the Shape of Training Review.

The RCGP has also been encouraged to look at different ways of enhancing GP training to meet the needs of the workforce by reviewing what can be achieved by a Fellowship year, what could be achieved by an integrated 3 year training plus 12 months post CCT and the impact of Transferable Competencies on trainee competence and confidence.

Benefits

• Enhances the skills and status of general practitioners
• Contributes to flexibility in the training pathway to meet the demands from trainees for flexible and portfolio careers
• Allows training to better respond to local provider and population needs
• Supports the delivery of more complex care in the community within integrated health systems.

5. The Royal College of Paediatrics and Child Health ( RCPCH)

The service requirements

It was agreed that the predominant service and patient requirement in district general and rural hospitals is for general paediatricians who can contribute to the emergency service. In large city hospitals there is a requirement for both general and sub-specialist paediatricians. The Shape of Training Review ( SoTR) stated that a requirement for specialists will remain in the future but suggested that sub-specialty training may best be met by the development of credentials. The challenge for the Panel was to understand the relative requirement of the paediatric service for sub-specialist and generalist paediatricians in the context of the sustainability of services. The Panel was told that Health Education England ( HEE) is undertaking work to identify this for England and that data would be available during 2017.

It was also noted that the paediatric service faces challenges with regard to recruitment and retention of medical staff.

The current training pathway

• Level 1 2-3 years training (ST1-3) in basic general paediatrics and neonatology. At the end of this program trainees undertake the membership examination.
• Level 2 Intermediate level training for 2 years (ST4-5) including 6 months exposure to each of general paediatrics, neonatology and community child health.
• Level 3 a further 2-3 years (ST 6-8) in either general paediatrics or a sub-specialty of paediatrics by competitive entry. This culminates in a CCT in paediatrics; those who undertake a sub specialty have this recognised by the GMC in brackets after the entry CCT paediatrics.
• Most trainees take approximately 8 years to complete training (50% of trainees take more than 8 years on a WTE basis). It is estimated that approximately 28% of the current trainees are awarded a CCT with a sub-specialty component. There is a perception that the specialty CCT is prized over a general CCT.

The proposed training programme

The RCPCH has convened a shape of training group and has proposed the following training program. The previous three-tier program will be amended to constitute 2 levels;

• New Level 1 - Training in paediatrics in general. The indicative length will be 2.5-4 years but successful completion will be capability rather than time based. Trainees will be expected to complete membership during this period.
• New Level 2 - The indicative length will be 2.5-4 years - The first year will be common to all in general paediatrics followed by either (a) three years in general paediatrics or (b) a sub-specialty of paediatrics. The balance between the number of training posts in general paediatrics and the range of sub-specialties would be determined by service need and workforce planning decisions. It should be noted that all paediatric trainees, including sub ‑specialty trainees will continue training in generic paediatrics and thus contribute to the acute unscheduled care.
• It was suggested that many trainees will be able to by-pass the first year of level 2 by demonstrating appropriate capability. This will be further facilitated by the fact that the proposed curriculum review will remove some repetitive elements. As at present, trainees will continue to obtain either a CCT paediatrics or a CCT paediatrics subspecialty.

Other proposed changes include:

• Increased flexibility for trainees by permitting periods of training out of program in other disciplines and by facilitating trainees from other disciplines, such as general practice to train in paediatrics.

The College is broadly supportive of the recommendation to deliver more care in the community. This includes a willingness to develop a post CCT Fellowships in paediatrics for general practitioners and to encourage secondary care doctors to support paediatric care in the community.

The UKSTSG response

Flexibility of training

The College is committed to increasing flexibility for trainees within the training pathway. This will include the adoption within the curriculum of the generic professional capabilities work described by the GMC allowing the recognition of previous learning. The College is also committed to accommodating the needs of trainees who wish to undertake a period of academic research or work towards a higher degree. The discipline of paediatrics is also popular with trainees in other training pathways such as general practice. The College is committed to providing opportunities for trainees from other disciplines to undertake periods of training in paediatrics.

Measures to facilitate blurring of the interface between primary and secondary care

The College is supportive of measures to deliver more care to children in the community. There are already numerous examples across the UK where this is occurring. In the context of the SoTR the College would support measures such as the development of post CCT fellowships in paediatrics for GPs.

Training more generalists and identification of aspects of the current curriculum that would be suitable for credentialing.

In considering the overall structure of the training pathway, the UKSTSG welcomes the proposed more "efficient" 2-tier model with progression based on capability rather than time. The Group also supports the proposed training pathway for general paediatrics leading to the award of a CCT Paediatrics. In all these aspects the RCPCH proposal fulfils the principles of the SoTR. The Group accepts however that further discussion will be required with the further development of credentialing to consider the future balance between sub-specialty training and credentialing.

Overall the UKSTSG welcomes the proposals from the RCPCH and recognises that for the most part it fulfils the principles of the SoTR. Further discussion is planned between the UKSTSG panel and representatives of the College to identify the correct proportions of specialists and generalist that are required to meet patient need in this specialty and to discuss further the place of credentialing within the proposed structure.

Benefits arising from implementation of these proposals:

• Promotes the status of the general paediatrician
• Ensures that the proportion of training posts in general versus sub-specialist paediatrics meets the needs of patients
• Allows more flexibility in training within paediatrics and between paediatrics and other clinical disciplines.
• Will support the delivery of more paediatric care in the community.
• Stream lines the current training pathway for trainees and should make paediatrics an even more attractive career option.

6. The Royal College of Anaesthetists ( RCoA)

The clinical service requirement

There are currently 10 million procedures performed per annum in the UK that involve the administration of an anaesthetic. Of these, 250 thousand are considered to be high-risk often occurring in an emergency setting. Further, in the course of routine elective work anaesthetists are required to deal with patients who have a wide range of clinical conditions and co-morbidities. It is essential therefore those anaesthetists are equipped with the broad skills to deal with this diverse workload.

The Current training pathway

The College submission suggested that the current training pathway is broadly fit for purpose since it produces doctors with the skills that patients across the UK require. It is a broad based training program configured in 2 stages as follows:

Stage 1

- Core Anaesthetic training (indicative duration 2 years)

or

- ACCS (Acute Care Common Stem) with an indicative training time of 3 years. This includes a minimum of 6 months training experience in each of the acute specialties of emergency medicine, intensive care medicine and acute medicine.

Stage 2

- a 5-year program of higher training in anaesthesia. Trainees have the opportunity to undertake up to one year in a sub-specialty of anaesthetics such as cardiac or neuro-anaesthesia, pain management or obstetric anaesthesia. This is normally undertaken in year 4 or 5. There is no formal recognition of this period of sub-specialty training but anaesthetists who subsequently work in a district general hospital ( DGH) often "major" in that area. Doctors who wish to be sub-specialist anaesthetists normally undertake a post CCT fellowship.

UKSTSG response

Flexibility of training

The College proposed that this would be achieved by the adoption of the generic professional capabilities work described by the GMC. The College is also committed to flexibility with regard to accommodating trainees who wish to undertake a period of academic research or work towards a higher degree. The College indicated that any further flexibility in recognising previous training is at present limited by the current Legislative requirements that training can only be recognised if it has taken place in a recognised training program.

Measures to facilitate blurring of the interface between primary and secondary care

The College presented an innovative proposal to undertake all or part of pre-operative assessment in the community thereby avoiding the need for patients to attend hospital or to use hospital beds for this purpose. The College also suggested that there would be opportunities for anaesthetists with an interest in clinical areas such as chronic pain management to undertake more work in the community. It is not envisaged however that anaesthetics will be routinely administered in a community setting in the future.

Training more generalists

The UKSTSG accepted the College position that most anaesthetists undergo broad general training and utilise these skills in both their elective and emergency work thereafter. Most contribute to emergency on-call rotas. In this respect the current training pathway fulfils this key principle of the SoTR.

Identification of areas of specialist training within current curricula that are suitable for credentialing

There are specialty components of the current training program that are not undertaken by all trainees and are not formally recognised. These would appear to be suitable for credentialing.

Although the meeting was not convened to consider the training pathways for intensive care medicine the Panel identified this as a potential area for credentialing in the future for trainees who have a CCT in anaesthetics.

Conclusions

The UKSTSG broadly accepted that the current training pathway fulfils the principles of the SoTR with regard to producing generalists, including flexibility and seeking to deliver more care in the community. The UKSTSG recommends that the College should work collaboratively with the GMC to identify those areas of the current curriculum that may be suitable for credentialing.

7. The Royal College of Ophthalmologists ( RCOphth)

The clinical service requirement

At present most ophthalmologists in both district general and large city hospitals participate in the appropriate emergency on call rota and undertake clinics that deal with general ophthalmology. They can do this because the current curriculum provides the broad range of skills that are required. A particular feature of ophthalmology training is the requirement for trainees to develop the technical skills to perform accurate and intricate work.

The current large volume patient and service needs are for the treatment of cataracts, macular degeneration and glaucoma. The College has also identified that there is a rapidly rising demand based upon demographic change for the care of patients with age related diabetes and macular degeneration. There is a requirement to take this into account in a review of training.

In addition to providing the general service many ophthalmologists also undertake more focused work as a "special interest". At present there is no formal training pathway or recognition for these "specialty skills" although in many cases the doctors who perform this work have undertaken additional ad-hoc post- CCT fellowship training.

The current training programme

At present training is of seven years duration. This was considered necessary because trainees enter the specialty with few pre-existing skills that are relevant to ophthalmology. There are opportunities for sub-specialty "tasters" in years 6 and 7 but there is no formal academic recognition for these sub-specialties. The College submission also recognised that some registrars lose generalist skills before the time of CCT because they are concentrating on a specific sub-specialty area.

The proposed training programme

The College proposal designed to meet changing patient needs is innovative. The current training pathway is focused towards the surgical aspects of ophthalmology and the acquisition of practical skills. In the future there will be a requirement for ophthalmologists who have a more medically based focus to their work. On the basis of current knowledge it is estimated that the future requirement will be for approximately 70% of staff to have a surgery focus and 30% to have a medical focus.

It is proposed that this will be achieved by having a common stem to ophthalmology training for two years and will include an enhanced component of simulation-based training. Thereafter trainees will enter one of two higher training programs that will be capability rather than time based but will have an indicative length of 5 years. These will have a "surgical" or a "medical" emphasis. An advantage of this proposal (which is not available at present) is that there will be the opportunity for trainees pursuing the surgery-focused pathway to transfer to the more medically based pathway.

The College envisages that the current opportunities for trainees to undertake "taster periods" in a sub-specialty in years 6 and 7 would continue.

The UKSTSG response

The UKSTSG broadly welcomes these proposals. In particular, the proposal to have surgical and medical focused pathways provides an innovative solution to the anticipated future needs of patients. The Group also supports the proposal to enhance the simulation component of technical skills training. It was also noted that ophthalmologists had embraced the development of "new working" arrangements with increasing roles for allied health professionals ( AHPs) and advanced nurse practitioners.

The proposal was considered against the following four key SoTR principals.

General Training

The current training pathway equips all doctors with the skills to participate in the appropriate general unselected on call rotas. Further, most ophthalmologists currently participate in the emergency service and undertake "general clinics". In this respect the current curriculum fulfils this principle of the SoTR.

Whilst the UKSTSG are broadly supportive of the development of a new medically focused pathway it will be essential that this does not compromise the ability of service providers to deliver emergency care. The UKSTSG require further reassurance that "medically focused" trainees will have the skills to manage conditions that require immediate care such as retinal detachment. Alternatively the UKSTSG would be interested to understand how emergency services in the future might be configured to accommodate this change in training.

Flexibility

The College representatives highlighted the fact that most trainees who enter the specialty have only a rudimentary understanding of the "eye". As such there is little scope to recognise previous learning with regard to practicing clinical ophthalmology. The College will however recognise previous experience based on generic professional capabilities as described by the GMC. The College is also supportive of flexibility in relation to supporting academic work and for doctors who wish to pursue an academic career. The UKSTSG broadly accepts that there is specificity to training in ophthalmology but recommends that the College review the options for flexibility beyond generic professional capabilities.

Supporting Care in the community

At present ophthalmology has strong links with community care with an important role for optometrists. Indeed many referrals to ophthalmologists currently come from optometrists who are taking an increasing role in patient care. The College representatives did not envisage that more ophthalmology would be undertaken in general practice principally due to the time that it takes to acquire the requisite skills and the costs of setting up ophthalmology suits. Consequently it is not envisaged that this is an area for extended role GPs. The UKSTSG broadly accepts this view.

Credentialing

The College had not considered the role of credentialing in their proposal predominantly because of the lack of clarity as to how it would be configured. The representatives however accepted that components of the current curriculum may be suitable for credentialing; in particular the "taster elements" that are not undertaken by all trainees in years 6 and 7. Credentialing would also provide a solution to the current lack of objective recognition and governance of "sub specialisation" within ophthalmology.

Conclusions

The UKSTSG broadly welcomes this proposal. In the most part it fulfils the principles of the SoTR. The proposal to develop a new training pathway that is "medically focused" appears to address a specific patient need. This will require the development of a new CCT. While being broadly supportive of this aspect reassurance will be required that it will not adversely affect the delivery of emergency services.

The UKSTSG recommends the following actions:

• The College makes a submission to the UK Reference Group seeking support for a new "medically focused" curriculum/ CCT.
• The College identifies those components of the current curriculum that will be suitable for credentialing.