UK Shape of Training steering group: report

Narrative summary

Background

The Shape of Medical Training Review ( SoTR) was established to consider how medical training could better meet the needs of patients and service providers over the next 30 years.

The resulting report made 19 recommendations and was received by UK Ministers in November 2013. Although the report was accepted in principle it described a broad framework for change that was open to interpretation and did not consider the practical implications of implementation. In response, Ministers convened a UK Group ( UK Shape of Training Steering Group) to consider the report and to provide policy advice.

This report outlines the work that has been undertaken by the UK Shape of Training Steering Group ( UKSTSG). It offers policy advice and describes a structure and process for the implementation of the key recommendations arising from the SoTR that is practical, proportionate and will cause a minimum of service disruption.

Why was a review of medical education and training necessary?

A review was necessary because the needs of patients and service providers are changing. Life expectancy is increasing. Whilst this is welcome it will lead to more patients with multiple comorbidities and dementia. It has been estimated that the number of over 75's will increase by 60% by 2033 requiring a 70% increase in health spending if current approaches to the provision of healthcare remain unchanged.

Other factors driving change include the rapid development of new technologies (such as gene therapy), new pharmaceuticals and sophisticated IT systems. These have the potential to lead to new treatments making current therapies (and potentially some medical careers) redundant. Indeed such is the rate of change that elements of the information gained during undergraduate training have been superseded by the time doctors commence work.

In the future doctors must be able to adapt to this rate of change by having the flexibility to acquire new skills, change careers and participate in career long learning. Medical training must also respond to the changing aspirations of doctors for part-time working, portfolio careers and to have the opportunity to take career breaks. Current training regulations and pathways are too inflexible to respond to these challenges.

There have also been changes to the configuration of medical services and working practices that have inadvertently had adverse implications for patients. These include a focus on care in hospital arguably at the expense of care in the community. Within hospitals there has been a focus on the specialist at the expense of the generalist. As a consequence service providers report that it is challenging to deliver the emergency service and that the continuity of patient care has been diminished. This is aptly characterised in the Royal College of Physicians of London Future Hospital 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"

"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 round the system like parcels".

What did the SoTR say requires to be done?

The SoTR report recommended that first and foremost the type of doctor that is trained in the future must reflect the needs of patients and service providers, taking into account the changing demographic of the population and the fact that more care will require to be delivered in the community. This means that more doctors will be required who have general rather than specialist skills. The report was clear that the need for specialists will remain but the number and type of specialists should be determined by patient need and sub-specialist training should be dealt with as a post- CCT credential.

The report also stated that in the future most trained doctors will require to contribute to the acute unselected take within their broad clinical discipline.

The review also dealt with the practical aspects of the delivery of teaching and training advocating a return to a more apprenticeship style based on the attainment of competencies and generic capabilities rather than being time based. Current medical training was also noted to be inflexible with limited capacity for doctors to change careers or to take career breaks. Measures are required to increase flexibility within and between training pathways.

Finally the SoTR recommended that action was required to develop and support the delivery of more patient care in community settings. One such action was to blur the current distinct "interface between primary and secondary" care.

The 19 recommendations are available in full in annex 1 of this report.

The Review stated:

"in order to ensure that the doctors of tomorrow have the appropriate skills, competencies and aptitudes to meet changing needs requires a rethink of the current arrangements for post graduate education and training".

The chair of the SoTR, Professor Sir David Greenaway, summarised the findings of the review as follows:

"in undertaking this review I discovered a wide recognition of the need for change" and a "clear consensus about what change should deliver: greater flexibility, better preparation for working in multi-professional teams and more generalists"

The UK Shape of Training Steering Group ( UKSTSG)

The UKSTSG was convened by Ministers to review the SoTR report and to provide policy advice. The purpose of the Group (see terms of reference annex 2) was to oversee implementation activities arising from the SoTR, providing policy advice and recommendations to UK Ministers as necessary. The group was chaired by Professor Ian G Finlay and had administrative support from both the Scottish Governments Health Workforce Directorate and the General Medical Council. In considering the report the UKSTSG was also required to work within the following parameters:

• To ensure that any recommendations that are made apply to all four Countries of the UK and are consistent with and facilitative to the strategic priorities in any individual Country.
• To ensure that any change will be proportionate and capable of implementation while minimising service disruption.

A further challenge to the work of the UKSTSG was that the service delivery landscape has changed since the publication of the SoTR because the UK Health Departments have published their strategic plans. These differ in detail but share the common theme that more health care requires to be delivered by integrated multi-disciplinary teams in the community. Other key partners have also published or are progressing work that is relevant to the implementation of the Shape of Training Review. These are as outlined in the main report.

Work of the UKSTSG

The SoTR report described a broad framework for change. The challenge for the UKSTSG was to determine how these broad concepts could be applied in practice given the complexity of medical education and training and the parameters within which it was required to work. It was also necessary to interpret and define fundamental components of the recommendations such as the meaning of the terms "generalist and specialist".

This was progressed by sponsoring 6 workshops involving a range of stakeholders who were tasked to consider the practical implications and anticipated tangible benefits of implementing the recommendations. Informed by this work the UKSTSG developed guiding principles. These included a commitment by the 4 Health Department to work collaboratively to develop implementation actions based on the principles of the SoTR but to retain those elements of medical training that are currently fit for purpose.

The UKSTSG interpretation of key aspects of the report

It was necessary for the UKSTSG to interpret and develop a practical meaning for several of the broad concepts outlined in the SoTR. For example, the review emphasised the need for more generalists. This was expressed as follows:

"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"

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

The report also recognised that the requirement for specialists to work within narrow competencies would continue. The UKSTSG identified that understanding the correct balance between the generalist and the specialist in each area of medicine as determined by patient and service need would be the key to implementing the Review's recommendations.

For the purpose of progressing their work the UKSTSG identified the following three areas where there is a clear patient need for more generalists.

• To provide care for unscheduled patients in hospitals; particularly those with multiple co ‑morbidities.
• To provide continuity of clinical care in hospitals.
• The development of more doctors who can work at the boundary between primary and secondary care and doctors who can support more care in the community

The practical definition of "generalist" adopted by the UKSTSG when considering whether a College proposal fulfilled the SoTR recommendation for "more generalists" was whether it met those three areas of patient need. The report also stated that;

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

The challenge for the UKSTSG was to identify areas where patients would benefit from specialisation without diluting the proposal that most doctors in the future must retain sufficient breadth of practice to provide unscheduled care. This was an important aspect of the engagement exercise that was undertaken with the Medical Royal Colleges.

Credentialing was another area where further clarity was required. This is a new concept that could be interpreted in a number of ways. For the purpose of undertaking the mapping exercise the Colleges were asked to assume that they would develop credentials, the GMC would approve and regulate them and the UK statutory postgraduate medical education bodies would deliver and quality manage the credentialed training in the same way that they deliver pre- CCT training.

The Academy of Medical Royal Colleges Curriculum Mapping Exercise

The UKSTSG identified that the route to implementing many of the SoTR's recommendations would be to revise the current postgraduate curricula and training pathways. Consequently the Academy of Medical Royal Colleges was asked to coordinate a review of current curricula and to describe how these could be amended to incorporate the key principles of the SoTR. The output from this exercise was compiled by the GMC and submitted to the UKSTSG. A series of meetings followed involving representatives of individual Colleges and a sub group (Panel) of the UKSTSG who were tasked to ensure that the submissions embraced the principles of the SoTR. The Panel considered whether a submission was "shape compliant" on the basis of the following 5 broad principles.

• Whether the proposal had taken account of the type of doctor that patients and service providers across the UK will need in the future.
• Whether the proposal was broad enough to ensure that most doctors within that discipline will have and maintain the skills to manage acutely ill patients including those admitted via the acute unselected take and to be able to provide continuity of care thereafter. This included an assessment of the relative requirement of generalists and specialists within the discipline.
• Whether the proposal demonstrated a commitment to make training more flexible by recognising a doctor's previous learning, by facilitating transfer between disciplines or to permit out of programme learning such as the pursuit of research.
• Whether the proposal will better facilitate and support the delivery of more care in the community.
• Whether the proposal included a description of the components of the current curricula that may be suitable for credentialing.

The UKSTSG accepted that the extent to which current curricula and training pathways required to change varied between clinical disciplines. The Panel was also mindful of the need to ensure that medical careers remain sustainable, attractive, fulfilling and consider the needs of an increasingly diverse workforce.

Proposals resulting from the Academy Curriculum mapping exercise

All Colleges submitted proposals. At the time of writing, the UKSTSG had engaged in detail with 11 Medical Royal Colleges and (subject to further discussion with regard to aspects of detail) has agreed that their proposals broadly fulfil (or could be amended to fulfil) the principles of the SoTR. These submissions are described in appendix 1 of this report. Work is on-going to review the submitted proposals from the other Colleges.

Although the submissions differ regarding the extent to which change was required they all include common elements. They are all based on the anticipated needs of patients and service providers. They all commit to the principle that in the future learning will be competency rather than time based. They all include the GMC's "generic professional capabilities" which will explicitly describe for the first time the common skills and aptitudes required from doctors in all disciplines. Turning to the key criteria:

Balance between generalists and specialists based upon patient/service needs

All proposals ensure that, where appropriate, doctors will be equipped with the skills to participate in the acute unselected take for their discipline and to provide continuity of care thereafter. It is expected that this will be reflected in the type of posts that are advertised in the future. The opportunity to develop a "specialty interest" will remain in several of the current proposals.

Flexibility within and between training pathways

All submissions include a commitment to increase flexibility for trainees who wish to move between disciplines predominantly based on the GMC's generic professional capabilities. All Colleges have committed to support trainees to gain experience "out of programme", to undertake research or a higher degree and to provide training experience for doctors from other disciplines. The UKSTSG welcomes these commitments but believes that more flexibility can be achieved beyond this.

Current regulation dictates that previous learning can only be recognised for CCT purposes if it has taken place in a formal regulated training post. Increasingly doctors are choosing not to progress directly from Foundation to a specialty training post, or from core into a higher specialist training post but are gaining experience in non-recognised posts. At present this learning cannot easily be recognised for CCT purposes unnecessarily prolonging the training pathway.

Supporting the delivery of care in the community

All submissions included proposals to support the delivery of more care in the community. Several Colleges proposed links with the RCGP to offer post CCT modules or fellowships and to better support GPs in community settings. General practitioners have a key role in the delivery of care in the community by leading multidisciplinary teams. The UKSTSG agrees that there is a requirement to enhance the training of general practitioners to support this. This could be achieved in a number of ways such as the development of the current model of post- CCT fellowships that are being delivered in some parts of the UK.

Credentialing

The Colleges were asked to describe components of their current curricula that would be suitable for credentialing. This assumed that Colleges would develop these credentials. Areas within current curricula such as the optional specialty and sub-specialty components that are not undertaken by all trainees have been identified as suitable for credentialing. The UKSTSG believes that developing credentialing as described in this report will allow the training and deployment of specialists to be more responsive to patient and service needs. They may also provide opportunities for lifelong learning.

UKSTSG response to the 19 recommendations arising from the SoTR

In addition to undertaking the curricula mapping exercise the UKSTSG has carefully considered and responded to each of the SoTR's 19 recommendations. These are outlined in section 11 of this report.

The Group also considered the benefits that it is anticipated would accrue for patients, service providers and doctors if the SoTR's recommendations were implemented. Indeed achieving these benefits will serve as the test of success of this work. These are listed in full in annex 6 and summarised below.

Anticipated benefits

For patients:

• Will improve patient care in hospitals and in the community
• Will improve the continuity of patient care which would allow for the implementation of the proposal for a named clinician for patients
• Will support the delivery of more care in the community
• Will allow patients to influence medical education and training
• Will better equip doctors with the skills to meet the needs of the population
• Will allow patients access to specialist doctors when that is appropriate

For service providers:

• Will support the sustainability of acute hospital services by equipping more doctors with the skills to manage and provide continuity of care for unscheduled admissions
• Will support and enhance the delivery of more care in the community in integrated multi-disciplinary teams emphasizing the provision of care closer to the patient's home
• Will allow future service providers to influence the design and number of training opportunities
• Will develop the workforce to support the transformation of services as described in the strategic plans of the UK Departments of Health
• Will provide for the appropriate specialisation of doctors to meet patient need

For doctors:

• Will improve the quality of training
• Will increase the flexibility for doctors to change career pathways and take career breaks
• Will support the recognition of previous learning
• Will make training competency rather than time based
• Will build upon the concept of life long support and learning
• Will enhance the training and careers of general practitioners
• Will improve the provision of mentoring support for doctors and safeguard patients at transition points such as when consultants are appointed

Other benefits:

• Will support the development of academic careers and give doctors the flexibility to undertake research

Summary and UKSTSG recommendations

In summary the UKSTSG was tasked to consider the recommendations arising from the SoTR and to make policy proposals to UK Ministers. For the past 2 years the Group has worked collaboratively with stakeholders to understand and interpret the recommendations and to develop a strategy for implementation.

During that time the 4 UK Health departments described their strategic plans for the future configuration and delivery of clinical services. It became evident that these plans and the recommendations outlined in the SoTR were complementary and should be taken forward in tandem.

The UKSTSG recommends that the principles of the SoTR as interpreted in this report should underpin future developments in medical education and training to meet the current and future needs of patients within an evolving service landscape.

The UKSTSG considers that the following recommendations are a proportionate and practical response to the SoTR and will not disrupt services. It is also anticipated that successful implementation of these recommendations would deliver clear and tangible benefits for patients, doctors and service providers.

UKSTSG Recommendations

The UKSTSG recommends that the following activity should commence.

In relation to curricula and training pathways:

• The curricula and training pathways outlined in this document should be further developed by the appropriate Medical Royal Colleges in collaboration with educational commissioners and other stakeholders and submitted to the GMC for approval.
• The Panel of the UKSTSG should consider the submissions from the remaining Colleges to ensure that they fulfil the principles of the SoTR aiming to complete this element of the work by July 2017.
• The 4 UK statutory post-graduate medical education bodies should continue work to prepare for implementation of the new curricula and training pathways described in this document.

In relation to credentialing:

• The UKSTSG identified the development of regulated credentialing as described in this report as an important element of the strategy to ensure that medical education and training responds to the needs of patients and the service and provides flexibility for doctor's career developments.
• The UKSTSG has identified a simple method whereby the process of developing post CCT credentials could begin. Namely; Medical Royal Colleges develop the educational content based on the sub-specialty components of their current curricula, the GMC as the regulator approve and quality assure them (subject to any legislative change that may be required), and the four UK statuary post-graduate medical education bodies implement and quality manage them in the same way that they deliver pre- CCT training.
• On this basis the GMC should bring forward proposals to further develop credentialing as soon as it is reasonable to do so.
• The UK Medical Royal Colleges and others should work collaboratively with the GMC to agree the components of their curricula that will be credentialed.
• The determination of the number and type of credentials should be informed by local patient and service needs.

In relation to responding to patient and service needs:

• Any other implementation activity should be undertaken by the Implementation Steering Groups or other appropriate organisations in each Country taking account of local strategic plans and patient needs but based on UK agreed standards and curricula.

Other:

• Medical Royal Colleges and employers should work collaboratively with others to deliver a more formalised system of supportive mentoring for doctors at the transition points of their careers and particularly for newly appointed consultants.

In relation to future curricula submissions and oversight:

The UK Medical Education Reference Group ( UKMERG) is currently the forum for the discussion and approval of matters relating to medical education and training with representation from the four UK health departments and the four statutory post graduate medical education bodies. At present applications for the recognition of new specialties are considered by this group in the first instance. Since in the future it will be necessary to ensure that curricula fulfil the principles of the SoTR the UKSTSG recommends that the following protocol be adopted.

• Submissions of new curricula or major revisions of existing curricula will be submitted to the UKMERG in the first instance and thereafter to the GMC for Regulatory approval. It is anticipated that in the future given the rapidly changing healthcare landscape it will be necessary to refresh curricula more frequently than has happened in the past.
• Submissions will be assessed to ensure that they fulfil the following 5 key principles of the SoTR:
  
  (i) Take account of and describe how the proposal will better support the needs of patients and service providers
  (ii) Ensures that the proposed curriculum to CCT equips doctors with the generic skills to participate in the acute unselected take and to provide continuity of care thereafter.
  (iii) Where appropriate describes how the proposal would better support the delivery of care in the community.
  (iv) Describes how the proposal will support a more flexible approach to training.
  (v) Describes the role that credentialing will play in delivering the specialist and sub-specialist components of the curriculum.
• The UKMERG should engage with and seek regular reports from Colleges and others as necessary to monitor progress in implementing any agreed changes.