2. The Shape of Training Review Report
2.1 The Shape of Training Review Report described in detail how the review was undertaken and emphasized the fact that wide engagement took place with key stakeholders. The rationale for undertaking the review was that patient and service needs are rapidly changing. Average life expectancy is increasing leading to more patients with co-morbidities and in particular dementia. It has been estimated that the population aged over 75 in Scotland will increase by 60% by 2033 requiring a 70% increase in health and social care spending ( NHS Scotland, 2011). There is broad agreement that an important component of the response will be to deliver more care for patients with multiple chronic conditions in the community.
2.2 Other factors that will drive change include new medical technology, new pharmaceuticals and developments in information technology and medical science that will lead to new treatment options and make current treatments (and potentially medical careers) obsolete. In order to meet this challenge it will be necessary for the doctors of the future to have the flexibility to acquire new skills, change careers, participate in career long learning and to be able to adapt to changing patient and service needs.
2.3 These factors led the review group to conclude that "to ensure that the doctors of tomorrow have the appropriate skills, competencies and aptitudes to meet the changing needs, we have to rethink current arrangements for post graduate education and training".
2.4 The Terms of Reference for the Review defined 5 key themes that were to be explored and form the basis for the recommendations that arise from the Report. These are:
Theme one: Patient needs drive how we must train doctors in the future
Under this theme it was concluded that the type of doctor we train in the future must first and foremost be responsive to patient needs, reflect the changing patient population demographics and anticipate that more care will be delivered in the community. Training should facilitate blurring of the current distinct interface between primary and secondary care. Training must also recognize that patients are better informed than ever before and expect to be fully involved in the decision making about their care.
Theme two: Changing the balance between specialists and generalists
This theme considered the impact of increasing sub-specialisation in hospitals on career choices and the ability of service providers to deliver emergency care. The SoTR concluded that more doctors require to be trained who have generalist rather than specialist skills. The status of the generalist also requires to be raised. The review emphasised that training doctors with generalist clinical and professional capabilities that can be adapted and enhanced will respond to the demand from service provider organisations for doctors who can provide care in different settings depending on local service needs.
Theme three: A broader approach to post graduate training
This theme dealt with the practical aspects of the delivery of teaching and training. It advocated a return to a more apprentice style of training based on the attainment of competencies and generic capabilities rather than solely time based. This will need longer clinical placements and more focused supervision and support. The Review also recommended that "postgraduate training must recognise and value doctors who are well grounded in the broad areas of their specialty" with the important caveat that this should not lead to a sub-consultant. Any specialisation beyond this should be determined by patient and service needs. Finally there is recognition that doctors require more support at the transition points during their careers when they are new to carrying a higher level of responsibility such as when they first take up a post in the consultant grade.
Theme four: Tension between service and training
Under this theme delivering the emergency service is highlighted as one of the major challenges currently facing service providers. The report recognised that doctors in training will continue to make an important contribution to emergency and acute care but should be better supported by trainers and supervisors. Importantly it also recommended that most trained doctors in the future must continue to deliver general emergency care in their broad clinical area throughout their careers.
Theme five: More flexibility in training
The SoTR noted that current training structures are unnecessarily rigid. There is limited recognition of previous learning making it difficult for doctors to change careers or to take career breaks. Increased flexibility in training is also required to allow service providers to plan for and to deliver medical innovation and other services for patients in the future. Finally it was recommended that this flexibility should allow doctors to pursue an academic career or to undertake research.
The SoTR concluded by making 19 recommendations that are available in full in appendix 1. A summary of the key messages is as follows:
- Patients and the public need more doctors who can provide general care in broad specialties across a range of different settings.
- Local workforce and patient needs should drive opportunities to train in new specialties or to credential in specific areas that would still be approved, regulated and quality assured by the GMC.
- We will continue to need doctors who are trained in more specialized areas to meet local patient and workforce needs.
- Medicine must be a sustainable career with opportunities for doctors to change roles and specialties throughout their careers.
- Doctors in academic training pathways need a training structure that is flexible enough to allow them to move in and out of clinical training while meeting the competencies and standards of that training.
- Full registration should move to the point of graduation from medical school, provided there are measures in place to demonstrate graduates are fit to practice at the end of medical school. Patients' interests must be considered first and foremost as part of this change.
- Implementation of the recommendations must be carefully planned on a UK-wide basis and phased in. This transition period will allow the stability of the overall system to be maintained while reforms are being made.
Professor Greenaway summarised the report's findings 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"
Email: Dave McLeod, Dave.McLeod@gov.scot
Phone: 0300 244 4000 – Central Enquiry Unit
The Scottish Government
St Andrew's House