UK Shape of Training steering group: report

5. The UKSTSG interpretation of key aspects of the report

5.1 In order to provide guidance as to the extent and nature of change that would constitute "Shape compliance", the UKSTSG needed to develop clear and practical definitions. The most important was the practical interpretation of the terms "generalist" and "specialist". The UKSTSG interpreted these as follows:

Generalists

5.2 The report strongly emphasized (in recommendations 10, 11, 12 and 18) that medical training must become structured to deliver a more generic, competency based training and that doctors in the future must be able to manage acutely ill patients within their broad specialty area and to maintain these skills throughout their future careers. These were expressed in the report 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"

5.3 The report also recognized that there would be a continuing requirement for specialist doctors to work within narrow competencies. 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 fundamental in implementing the Review's recommendations.

5.4 On this basis, the UKSTSG identified three areas where there is a clear requirement for more "generalists". These are:

• The provision of care for unscheduled patients in hospitals
  
  Over the past 25 years, hospital doctors have become increasingly specialised and sub-specialised. The Shape of Training review recognised that this has weakened the provision of generic/holistic care to patients and challenged the sustainability of services for unselected, unscheduled admissions to hospitals because fewer doctors contribute to the "unselected take" or contribute appropriate specialist skills to the initial assessment of patients.
  
  Since more than 50% of hospital admissions in some clinical disciplines are unscheduled this is an important area of patient need that requires to be addressed (Comptroller and Auditor General, 2013). In this context, the UKSTSG has interpreted the SoTR recommendation that patients need more "generalists" to mean that doctors must have and maintain the skills to provide emergency care to acutely ill patients. Further that there is an expectation that most doctors in the future will have and maintain the skills to be able to contribute to the emergency unselected "take" within their broad area of clinical practice.
• The provision of continuity of clinical care in Acute Hospitals
  
  The Group were told that specialisation in hospitals has contributed to a loss of continuity of care for patients. This occurs because if "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 patients having several responsible doctors over a short time period. This practice was described in the Royal College of Physicians London Future Hospital document as follows:
  
  "older patients with an ill-defined acute illness and multiple comorbidities is 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)
  
  Independent reviews of poorly performing hospitals have also identified this is an important contributory factor in the delivery of poor patient care that requires urgent action (Francis, 2013). In response, it has been recommended that all hospital patients should have a single named consultant who is responsible for their care throughout their hospital admission
  (Royal College of Physicians London, 2013).
  
  In considering the role of the generalist the UKSTSG concluded that in the future doctors should have the breadth of training that ensures that they can provide continuity of patient care within their broad area of clinical practice and can meet the needs of the increasing number of patients with multiple chronic conditions.
• 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
  
  There has been rapid growth in the numbers of patients admitted to hospital. For the past decade, unscheduled hospital admissions have been rising at 5-6% per annum (Purdy, 2010) with an increase of 124% in short stay admissions between 1998 and 2013 (Comptroller and Auditor General, 2013). Further, approximately one-fifth of hospital admissions involve conditions that could have been managed as well or better in the community (Health Foundation, 2013). In response all UK Governments have policies/strategic plans to transform health and social care delivery and to provide more care in the community. It will be necessary to ensure that doctors are equipped with the skills to deliver this.

5.5 General practitioners already undertake "general training" and treat patients with all conditions at all ages. To facilitate more care in community-based settings, GPs will require appropriate support and resource, and to have the opportunities to enhance their skills in a range of areas including the management of patients with complex co-morbidities. This was described in the Shape of Training Workshops as a "community physician" or an enhanced "expert medical generalist" GP role. Other suggestions included the training of a new kind of doctor to work at the "interface" with commitments in both primary and secondary care.

There is also a requirement for disciplines that are currently predominantly hospital based to consider how they might support the delivery of more care in the community.

Specialists and sub-specialists

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".

5.6 It has been reported that specialisation in specific clinical areas improves patient outcome. As such, the UKSTSG wishes to identify and support specialisation (and sub-specialisation) where that is consistent with patient need. In doing so, the UKSTSG is mindful that no study, of which they are aware, has been published that was designed to measure any detrimental consequences of specialisation. These may include the failure to recognise and treat clinical conditions out with the narrow expertise of the specialist or the fragmentation of care that occurs from multiple handovers when expert specialist input is seen as the sole approach.

The UKSTSG Panel identified a further potential unintended consequence of the ad-hoc development of sub-specialisation over the past two decades. In several instances the academic and experiential requirements expected from a sub-specialist have not been described, do not form part of current assessment processes and lack governance. Consequently, there is the potential for variability in the quality and standards of the delivery of these services. The recommendation within the SoTR for the development of credentials to deal with specialisation offers a solution.

The UKSTSG also noted that there are more specialties and sub-specialties in the UK than in comparable western Countries ( GMC, 2017). The challenge for the UKSTSG was to identify areas where patients would benefit from specialisation without diluting the importance of the proposal that most doctors in 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.