11. Progress towards implementation of the 19 recommendations
This section describes the UKSTSG's recommended response to the SoTR's 19 recommendations.
Appropriate organisations must make sure post-graduate medical education and training enhances its response to changing demographic and patient needs.
The UKSTSG noted that published evidence shows that the UK population is ageing leading to more patients with multiple chronic conditions who would be better and more appropriately treated in the community (Edwards, 2014). It also noted that the strategic aim in all four Countries is to deliver more care in multi-disciplinary teams in a community setting.
In response, as described above, the UKSTSG has worked with individual Colleges to develop their proposals for curricula change to meet this challenge; namely train doctors with more general skills and train doctors who can work better at the interface between primary and secondary care. Measures have also been proposed to enhance the training of general practitioners to meet the needs of patients with complex comorbidities. In addition to GPs, many more doctors will be equipped with the skills to work beyond the traditional hospital setting.
Appropriate organisations should identify more ways of involving patients in educating and training doctors.
In considering this recommendation the UKSTSG noted that at present most medical undergraduates undertake a component of their training in clinical settings that involves interaction with patients. Post-graduate trainees have an important role in the delivery of clinical services interacting with patients daily. Further many components of the assessments and examinations that trainees must complete either directly involve patients or are based upon specific clinical case discussions.
The UKSTSG included patient representatives in all 6 workshops and has included their views in responding to this recommendation. It was also noted that there are patient representatives on various groups at the GMC and the four UK statutory post-graduate medical education bodies. Individual Medical Royal Colleges also have to a varying extent patient representatives on their committees.
Nevertheless these groups will be encouraged to review membership to ensure that there is appropriate patient representation.
Appropriate organisations must provide clear advice to potential and current medical students about what they should expect from a medical career.
The Terms of Reference for the SoTR focused on postgraduate medical education. Two of the 19 recommendations however relate to aspects of undergraduate education. These are principally the responsibility of the university Medical Schools Council ( MSC) and the GMC with support from the UK statutory post-graduate medical education bodies.
A recent review has been undertaken by HEE and the MSC of the experience of medical students in making career choices, in particular why they chose primary or secondary care. The reasons were varied and included overall perceptions of the various disciplines within medicine, the site of student placements and morale of the current workforce. In response, recommendations have been made that are designed to inform career choice (Medical Schools Council and Health Education England, 2016).
Based on the changes that we are proposing to curricula it will be important that medical students understand the values and attitudes that will be expected of a doctor. This will include an understanding that a generalist and a specialist will have equal status and that most doctors will require to have and to maintain the skills to treat acutely ill patients in the emergency setting. There is also an expectation that general practitioners and hospital doctors will have equal status. A specific initiative to support this has been the proposal to combine the GP Register and Specialist Register. This now has GMC support.
This has been discussed at the Council meeting of the Medical Schools Council ( MSC). Medical Schools already undertake work with schools and in the community to explain the implications of choosing a medical career. This advice will be adapted to reflect the principles of the SoTR.
Medical schools, along with other appropriate organisations, must make sure medical graduates at the point of registration can work safely in a clinical role suitable to their competence level, and have experience of and insight into patient needs.
The overall responsibility for the regulation of the standards and quality of undergraduate education lies with the GMC. It is essential that doctors can work safely at a pre-determined level of competence at the point of Registration. The GMC are currently taking to public and stakeholder consultation a proposal for a Medical Licensing Assessment ( MLA) that aims to ensure that all undergraduates across the UK have achieved a common standard at the point of graduation.
Full registration should move to the point of graduation from medical school, subject to the necessary legislation being approved by Parliament and educational, legal and regulatory measures are in place to assure patients and employers that doctors are fit to practice.
The regulation of Health Professionals is a matter largely reserved to Westminster. There have been discussions between DH, HEE and GMC about the possibility of moving the point of registration but no conclusion has yet been reached. Any recommendation will be discussed at the UK Medical Education Reference Group. Consequently this has not been included in the work programme of the UKSTSG.
Appropriate organisations must introduce a generic capabilities framework for curricula for postgraduate training based on Good medical practice that covers, for example, communication, leadership, quality improvement and safety.
Since the SoTR was published the GMC has published proposals for the development of generic professional capabilities that include communication, leadership and quality improvement ( GMC, 2016). These will become common components of all training programmes permitting objective recognition of learning between programmes allowing trainees the flexibility to move between disciplines. This responds to the following statement within the SoTR:
"Medicine has to be a sustainable career with opportunities for doctors to change roles and specialties throughout their careers".
Colleges have been asked to describe how they will ensure that their training pathways recognise previous learning and can accommodate trainees who wish to transfer between disciplines without the necessity for these trainees to complete the entirety of the new training pathway. This may involve the development of bespoke "bridging" components to current curricula.
Appropriate organisations must introduce processes, including assessments, which allow doctors to progress at an appropriate pace through training within the overall timeframe of the training programme.
The UKSTSG is especially supportive of the recommendation that training should be competency rather than time based. This will be an important component of the assessment of trainees pursing all the proposed new curricula described above and will be implemented by the 4 UK statutory post graduate medical education bodies. As an example, it is anticipated that the measures that are proposed to support the new general surgery curriculum including high quality clinical placements, protected training time and simulation based training may allow some trainees to achieve the required competencies more quickly than at present.
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.
Based on the proposed changes to curricula it will be the responsibility of the 4 UK statutory post graduate medical education bodies in conjunction with employers (who are represented on the UKSTSG through the NHS Employers organisation) to structure training to permit longer placements that are more apprenticeship based. In England HEE are already working to achieve this.
In the context of apprenticeships, the UKSTSG was told during the workshops that there is a requirement to support doctors at the points of transition in their careers and in particular when they are first appointed as consultants. It was proposed that this could be achieved by introducing more formalised mentoring. This is discussed in section 10 of this report.
Training should be limited to places that provide high quality training and supervision, and that are approved and quality assured by the GMC.
This recommendation has been implemented in that the GMC carries out annual surveys of training making recommendations for improvement where necessary and has the power to remove the recognition of training places. The quality of training is also currently assessed and quality managed by the four UK statutory postgraduate medical education bodies via their Deaneries and associated structures.
The new curricula proposals such as those for general surgery include a commitment to improving the quality of training by protecting training time and developing simulation based training (see proposals for General Surgery appendix 1).
It will be the responsibility of the 4 UK statutory postgraduate medical education bodies to ensure that trainees are placed in units that provide training that meets GMC quality standards.
Postgraduate training must be structured within broad specialty areas based on patient care themes and defined by common clinical objectives.
This recommendation was considered in the workshops. Concern was expressed by several stakeholders as to the practical implications of implementing this given that it would require a "root and branch" restructuring of medical education. The UKSTSG was required to ensure that the implementation of any of the 19 recommendations could be achieved with the minimum of disruption. It was concluded that this was unlikely for this recommendation and that the anticipated benefits would be met by implementing the other recommendations.
The UKSTSG however wishes to add caveats to this decision. The SoTR stated that the Foundation programme as currently configured was fit for purpose. In the event of the point of registration being moved to graduation, with the required changes made to the structure of undergraduate medical education to enable such a change, it may be appropriate to review the foundation programme. This would provide an opportunity to align undergraduate and postgraduate education to meet strategic priorities, especially in terms of creating more doctors with generalist skills.
An alternative proposal that the UKSTSG supports was to develop "clusters" or "families" of related clinical disciplines such as "surgical" or "medical" based specialties. It may be easier to develop apprentice based training with cross-recognition of skills within and across such clusters.
Appropriate organisations, working with employers, must review the content of postgraduate curricula, how doctors are assessed and how they progress through training to make sure the postgraduate training structure is fit to deliver broader specialty training that includes generic capabilities, transferable competencies and more patient and employer involvement.
A review of postgraduate curricula has been undertaken as described above. These reflect the anticipated needs of patients and the Service. NHS Employers are represented on the UKSTSG and have been involved in developing the response to the SoTR recommendations. Employers in the NHS have requested that they be given notice of curricula and training changes in a timely fashion in order that they can co-ordinate these with their plans for transformation of local services.
The GMC has described and are implementing transferable generic professional capabilities that are expected to improve identification of transferable elements of curricula ( GMC, 2016). It is envisaged that detailed implementation of the proposals will be undertaken by implementation groups across the UK who will liaise with and involve local service providers and employers. The GMC are also committed to removing barriers to, and encouraging greater use of, existing opportunities for recognising transferable competences in existing curricula.
All doctors must be able to manage acutely ill patients with multiple co-morbidities within their broad specialty areas, and most doctors will continue to maintain these skills in their future careers.
The SoTR also stated that:
"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".
This is similar to recommendation one. All Colleges have been asked to review their curricula to ensure that they are more generic and will equip doctors with the skills to treat acutely ill patients in the emergency setting and patients with multiple co-morbidities. This will provide the doctors who have the requisite skills to meet this need.
Employers recognise that if this recommendation is to be fulfilled in the future it will be necessary to configure jobs to ensure that doctors are able to utilise these skills. This means that more consultant posts will require to be advertised as general with a special interest (rather than a free-standing specialist post) with a clear requirement that the doctor contributes to the unselected unscheduled "take".
Appropriate organisations, including employers, must consider how training arrangements will be coordinated to meet local needs while maintaining UK-wide standards.
The UKSTSG undertook a workshop to understand the needs of employers. In addition to meeting the local needs of patients, employers are required to configure their services to meet the strategic aims of the four UK Health Departments. It is inevitable that this will lead to a difference in emphasis regarding service provision across the UK.
Arguably the most important aspect of the UKSTSG's work therefore has been to maintain a UK consensus on the key aspects of medical education and training while recognising these regional differences. The proposals that are outlined in this document have been agreed in principle on a UK wide basis.
Standards however are determined and assured by the GMC on a UK wide basis. The 4 UK statutory post-graduate education bodies implement and oversee training programmes that accord with these standards. The planning and coordination to meet local needs and strategic aims will be led in the first instance by the Shape of Training Implementation Boards in the devolved nations and by Health Education England ( HEE) in England.
Appropriate organisations, including postgraduate research and funding bodies, must support a flexible approach to clinical academic training.
It is important for patients that medical training equips doctors with the skills to teach and to undertake clinical and scientific research. The current training pathways are considered not to be flexible enough to permit the acquisition of both clinical and research skills or to allow trainees to undertake a period of research without jeopardising their clinical training.
The UKSTSG support the recommendation that a more flexible approach would better support clinical academic training. In the first instance a workshop was initiated to consider how this could be achieved. A challenge that was identified is to ensure that academic trainees attain both the required clinical and research competencies. This will be more readily facilitated by competency rather than time based training and the inclusion of specific generic professional capabilities in curricula. Further, Colleges in their proposals to amend current training curricula and pathways to meet the principles of the SoTR have committed to the adoption of a more flexible approach to academic training.
The UKSTSG received a document from key stakeholders proposing the adoption of principles to underpin the future development of medical academic careers (see annex 7). These were broadly supported by the Group with the caveat that it was out with the remit of the UKSTSG to comment on the terms and conditions of employment of doctors.
Appropriate organisations, including employers, must structure continuing professional development ( CPD) within a professional framework to meet patient and service needs, including mechanisms for all doctors to have access, opportunity and time to carry out the CPD agreed through job planning and appraisal.
The UKSTSG agree that career long learning will be important in ensuring that doctors remain up to date, fit to practice and able to respond to changes that arise from innovation. Job plans for employed doctors should therefore include provision for CPD.
The UKSTSG has identified the appraisal and revalidation process as an appropriate vehicle for the governance of CPD. Appraisal identifies individual development needs and reviews the extent to which they are addressed on an annual basis. It also itemises the extent to which CPD and other learning has occurred. It will continue to be necessary in the future for employers to ensure that time is included in job plans to facilitate this and that doctors are able to use this time as intended. The failure to do so should be raised by doctors through their local workplace structures and will then be highlighted on an individual basis at appraisal and on an institutional basis by the local governance of appraisal and revalidation.
The UKSTSG also suggest that organisations such as the statutory education Bodies, Universities and/or Medical Royal Colleges consider developing career long CPD packages and learning programmes.
Appropriate organisations, including employers, should develop credentialed programmes for some specialty and all subspecialty training, which will be approved, regulated and quality assured by the GMC.
The UKSTSG identified the development of credentials to be an important recommendation that will make medical training more responsive to patient needs. In response, the Medical Royal Colleges were asked to identify components of their current curricula that would be better undertaken within credentialed programmes. For this purpose, Colleges were asked to assume that they would develop curricula and assessment systems for credentials, the GMC would approve them and the 4 UK Post graduate statutory bodies would deliver them. It is of note that the GMC are piloting their approach to credentialing with the Royal College of Surgeons of England in relation to the accreditation of cosmetic surgeons. The further development of credentialing may require an amendment to the Medical Act.
The UKSTSG has identified in discussion with Colleges that components of their current curricula could be transferred to post CCT credentialed programmes without compromising the core components of training to CCT. These are principally the "optional components" that at present are undertaken by a relatively small proportion of trainees en-route to a CCT. It was also noted that at present many trainees undertake post CCT Fellowships that are similar in concept to credentials.
Although the development of credentialing had the potential to be complex the UKSTSG has identified a straightforward, pragmatic and incremental way to implement it. This involves transferring the components of current curricula that have been identified in this report as suitable for this purpose to post CCT credentials. The pre- CCT curriculum may then require to be reviewed. The GMC would approve the credential and the 4 UK postgraduate statuary bodies would deliver the post CCT credentialed training in the same way that they currently deliver pre CCT training.
The UK Shape of Training Implementation groups or other appropriate organisations working with the 4 UK statutory post-graduate medical education bodies will require to work with local service providers to identify the number and type of credentialed doctors that they will require in the future.
Appropriate organisations should review barriers faced by doctors outside of training who want to enter a formal training programme or access credentialed programmes.
The recommendation that SAS doctors should have access to credentialed programmes will be fulfilled when credentialing has been developed by the GMC. It has also been assumed that the current process that allows SAS doctors to gain access to the specialist register via Certificate of Eligibility for Specialist Registration ( CESR) or Certificate of Eligibility or GP registration ( CEGPR) will remain. The UKSTSG welcomes the expectation that this process should become simpler and less bureaucratic once the GMC implements its new standards requiring curricula to become "outcomes-based".
The UKSTSG undertook work to consider whether other measures could be developed to support SAS doctors in the interim. Under the auspices of the UKSTSG work was undertaken in Wales and Scotland to explore how the current skills of SAS doctors could be more formally recognised and how new skills could be developed.
It is clear that SAS doctors across the UK wish to develop their skills to better serve their patients. The UKSTSG was told that regarding the acquisition of new skills the current SAS doctor development programmes, where they exist, were working well and there was a desire for these to continue. The group was also told that there was demand from SAS doctors in areas where such programmes do not currently exist to be able to access this type of training.
In Scotland, a survey of SAS doctors was undertaken to determine their appetite for the development of an interim process to recognise their current extended skills. The results of this are shown in annex 9. In brief, approximately 75% of responders expressed support in principle for the development of a process to identify their extended skills and competencies particularly if these could subsequently be included in applications to gain access to the specialist register. In Wales a similar listening exercise was undertaken. In England, the BMA, Health Education England, the Academy of Medical Royal Colleges and NHS Employers have undertaken joint work to promote development opportunities for SAS doctors by extending their skills and competencies culminating in the publication of an SAS doctor development guide (see annex 10)
The UKSTSG also noted and commended the fact that SAS doctor "charters" had been published across the UK that embrace several key aspects of this recommendation.
In conclusion until and alongside the development of credentialing by the GMC the UKSTSG recommends that initiatives to support SAS doctors should be developed and progressed by appropriate bodies in the devolved nations and by HEE in England.
Appropriate organisations should put in place broad based specialty training as described.
The UKSTSG has responded to this recommendation by asking the Colleges to consider how their curricula can be more generic in content. Broad based training programmes have been developed to a varying degree across the UK and are popular with trainees who have not made a definitive career choice. The UKSTSG response is explained above at recommendation 10.
There should be immediate discussion about setting up a UK-wide Delivery Group to take forward the recommendations in this report and to identify which organizations should lead on specific actions.
Convening the UKSTSG fulfilled this recommendation.
Email: Dave McLeod, Dave.McLeod@gov.scot
Phone: 0300 244 4000 – Central Enquiry Unit
The Scottish Government
St Andrew's House