UK Shape of Training steering group: report

7. The Academy of Medical Royal Colleges Curricula Mapping Exercise

7.1 The UK Academy of Medical Royal Colleges supported by the GMC coordinated the curriculum mapping exercise. The Academy's constituent bodies (Colleges and Faculties, hereafter referred to as Colleges for simplicity) were asked to describe how their current curricula and training pathways could be modified to incorporate the following key recommendations arising from the SoTR:

• To describe how the College's current curriculum and training pathway could be amended to take account of, and meet, the current and anticipated needs of patients and service providers
• To describe how the College would ensure that the training within their discipline was sufficiently broad to fulfil the SoTR recommendation that patients and service providers require more generalists
• To describe how the College would make training more flexible
• To describe how training in appropriate areas would develop doctors who are better able to work at the interface between primary and secondary care and in the community
• To identify the components of the current curriculum that would be suitable for credentialing

7.2 In undertaking this exercise, the UKSTSG recognised that the extent to which current curricula and training pathways require to change varies within and between clinical disciplines. It was also stated in the guiding principles that the UKSTSG would not seek to change a current curriculum if it already meets the current and anticipated needs of patients.

7.3 The responses from individual Colleges were compiled by the GMC and presented to the UKSTSG in December 2015. That document is available in full in annex 5. While the UKSTSG welcomed these proposals, further work was required to ensure that the amended curricula adequately embraced the key recommendations of the SoTR. Follow up meetings involving a sub-group (Panel) of the UKSTSG and representatives from individual Colleges were arranged for this purpose.

7.4 The Panel discussions principally considered the extent to which the proposals fulfilled the key principles of the SoTR (were "Shape compliant"). Other factors discussed included the extent to which the proposal was aligned with the strategic objectives of the 4 UK Departments of Health and the practicality of implementing the proposed change. 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.

7.5 The Panel considered whether a submission was "Shape compliant" based on the following 5 mandatory components.

• Whether the proposed curriculum/training pathway had taken account of the type of doctor that patients and service providers across the UK will need in the future
• Whether the proposed curriculum/training pathway was broad enough to ensure that most doctors within that discipline will be able to treat acutely ill patients and to provide continuity of care thereafter. It was important that the proposal ensured that "generalists" and "sub-specialists" within that discipline will have equal status and that in the future most doctors will have and maintain the skills to manage the acute unselected take where that is appropriate. This included a discussion as to the relative proportions of generalists and specialists that will be required for each discipline based on patient and service need
• Whether the proposal demonstrated a commitment to make training more flexible by recognising a doctor's previous learning and facilitating transfer between disciplines or to facilitate out of programme learning such as the pursuit of research
• How the proposal within the scope of the discipline will facilitate and support the delivery of more care in the community
• A description of the components of the current curricula that will be suitable for credentialing. For the purpose of undertaking this exercise the Colleges were asked to assume that they would develop and assess credentials, the GMC would approve them and the UK statutory post-graduate medical education bodies would implement and deliver the credentialed training.

7.6 All Colleges participated in the mapping exercise and submitted responses. To date the UKSTSG has reviewed in detail the submissions from the following 11 Colleges (two are joint College submissions) and considers that these are broadly consistent with the principles of the SoTR. (Work is on-going with regard to aspects of detail and also to consider the submissions from the other Colleges).

• Royal Colleges of Physicians ( UK JRCPTB)
• Royal College of Surgeons ( JCST)
• Royal College of Obstetrics and Gynaecology
• Royal College of General Practitioners
• Royal College of Paediatrics and Child Health
• Royal College of Anaesthetists
• Royal College of Ophthalmologists

7.7 Although the submissions differed regarding the extent to which they propose change they all include common elements. They all take account of the needs of patients and service providers. They all commit to the principle that in the future learning will be competency rather than time based. Importantly all the curricula will include the GMC's "generic professional capabilities". This will explicitly describe for the first time the common skills and aptitudes required from doctors in all disciplines.

For an outline of the proposals from these Colleges see appendix 1. An overview of compliance with the key recommendations is given below.

7.8 Balance between generalists and specialists based upon patient/service needs

This question was particularly applicable to the disciplines of general medicine and general surgery because they have an important role in managing unscheduled admissions and have been subject to considerable specialisation. Both have described proposals to address this by increasing the "general" content in their curricula and by increasing the breadth of clinical experience for trainees. In both proposals doctors will have the opportunity to develop a "specialist interest" but in the future the expectation is that most doctors in both disciplines will require to have and maintain the skills to participate in the "acute take" and to deliver continuity of care thereafter. It is expected that this will be reflected in the type of posts that are advertised in the future.

A feature of the proposal for general surgery is that it will include mandatory simulation based training and protected training time for trainers and trainees. It is anticipated that this will accelerate the development of craft skills particularly in the early years. The UKSTSG are especially supportive of this proposal because it fulfils the principles of the SoTR and has the potential to improve general surgical training in the UK.

In contrast, doctors in anaesthetics and obstetrics & gynaecology already undergo broad based training. Further, most of these doctors contribute to the acute take. Consequently, the UKSTSG accepted that in this respect these curricula were largely fit for purpose.

The situation for paediatrics is more complex. The current pathway allows for both general and sub-specialist training within the CCT programme. This is contrary to the principles of the SoTR that stated that specialist elements of training may be better undertaken as credentials. The UKSTSG has accepted that a specialist approach to training is appropriate for some of the 17 sub-specialties within paediatrics based on patient need but has not accepted that this approach should necessarily apply to all 17 sub-specialties. It has recommended that further work be undertaken to determine the correct proportion of generalists and specialists that are required to meet patient needs in this discipline.

The UKSTSG was particularly supportive of proposals that had considered the future needs of patients. For example, the Royal College of Ophthalmologists has identified a rapidly rising demand based on demographic change for the care of patients with age related diabetes and macular degeneration. The College has proposed that a new CCT should be created with a more "medical focus". The UKSTSG broadly supports this proposal and has suggested that the College make the appropriate submission to the UK reference group.

7.9 Flexibility within and between training pathways

All submissions included a commitment to increasing flexibility for trainees within and between disciplines and in this respect were broadly "Shape compliant". This will be predominantly based on the incorporation of the GMC's generic professional capabilities that will allow the recognition of prior learning. All Colleges are committed to supporting trainees to gain experience out of programme, to undertake research or a higher degree and to provide training experience for doctors from other disciplines.

Several Colleges during the Panel engagement exercise highlighted that the principle impediment to extending the recognition of previous learning is the inflexibility of the current Regulations. These mandate that only learning obtained in a regulated training post is eligible for this purpose. Many current trainees however are choosing not to enter a formal higher training programme immediately after foundation training (The Foundation Programme, 2016).

The UKSTSG welcomes these commitments but believes that further flexibility needs to be achieved beyond simply recognising generic professional capabilities.

7.10 Supporting the delivery of care in the community

All submissions to a varying degree included proposals to support the delivery of more care in the community. Some are particularly innovative. The UKSTSG heard of projects using telemedicine to support care to rural communities. Other examples included the published proposal from the RCoA to undertake pre-operative assessments 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. These included aspects of general medicine and care of the elderly, obstetrics & gynaecology and paediatric services. The UKSTSG was also told that pilot initiatives are taking place across the UK to develop and /or to support multi-discipline community hubs and/or practice clusters.

General practitioners have a key role in the delivery of care in the community by leading multidisciplinary teams. The RCGP believes that there is a requirement to enhance the training of general practitioners to support the delivery of more care in the community. The College proposed that the current 3-year programme to CCT be extended to four years with the fourth year taking place within general practice. The UKSTSG supports the proposal to enhance the training of GPs but believes that there are alternative ways to achieve this that would more closely fulfil the principles of the SoTR such as building on the current model of post CCT fellowships that are now being delivered in some parts of the UK. This is explained in appendix 1 under the proposal from RCGP. Further work is required to identify the best way to achieve this end.

7.11 Credentialing

The Colleges were asked to describe areas within their current curricula that would be suitable for credentialing in the future. This assumed that Colleges would develop and assess these credentials and that the GMC would approve and regulate them. RCOG and RCoA have identified areas that are not undertaken by all trainees and are currently considered to be "sub-specialties". The UKSTSG identified these as potential areas for credentialing in the future.

The proposals from the Royal Colleges of Physicians and Surgeons include the opportunity for doctors to pursue a "specialist interest" alongside general training. Any further optional specialisation in these disciplines should be dealt with by credentialing. Work is on-going to identify the components within the RCPCH curriculum that would be suitable for credentialing.

The development of credentialing is considered by the UKSTSG to be an important element in the delivery of the recommendations arising from the SoTR. It will allow the training of specialists to be more responsive to patient and service needs and will provide quality and governance to the delivery of these services. When credentialing has been fully developed, it will be necessary to review both curricula and training pathways.