Securing the future of excellent patient care. Final report of the independent review Led by Professor David Greenaway

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1 Securing the future of exceent patient care Fina report of the independent review Led by Professor David Greenaway

2

3 Contents Foreword 3 Executive summary 4 Training structure for the future 6 Recommendations 10 The review s purpose 12 What was earned from previous education and training reviews? 13 How the Review was structured 16 What did the Terms of Reference set out? 17 Methodoogy 18 What was our review process? 19 Discussion of findings within themes 20 Theme One: Patient needs drive how we must train doctors in the future 21 Changing popuation needs 21 Burring the boundary between primary and secondary care 23 Patients want to be more invoved in training doctors 24 Theme Two: Changing the baance between speciaists and generaists 26 Pipeine into medicine 26 The current medica workforce 26 The medica workforce in the future 28 Theme Three: A broader approach to postgraduate training 29 Supporting transitions in the medica career 29 Variation between medica schoos 30 Impications of the Foundation Programme on postgraduate training 31 A case for moving fu registration 32 Generic capabiities 33 Training based on competence and capabiity measures 34 Making supervision and support centra to training and service deivery 34 Doctors shoud have onger pacements 35 Doctors and their trainers shoud have an apprenticeship based reationship 36 The outcome of postgraduate training 37 Leves of competence 37 Training in genera areas of broad based speciaties 38 Theme Four: Tension between service and training 40 Time to earn 40 Doctors wi have to provide emergency and acute care 41 Vauing a trained medica workforce 42 Training and education driven by service needs 42 1

4 Theme Five: More fexibiity in training 43 Changing work patterns 43 More fexibiity to support cinica academic training 44 A more structured approach to CPD 45 Staff grade Associate Speciaist doctors and ocum doctors 47 Reforms to postgraduate medica education and training 50 Characteristics of a new structure of training 51 New approach to postgraduate training 52 Deivery of recommendations 56 2

5 Foreword Across the four countries of the UK, we are we served by our medica profession. Our doctors undergo rigorous training and deveopment and deiver both primary and secondary care to a high standard. It is a workforce that makes a fundamenta contribution to the effectiveness of our heath service. So why was it necessary to undertake this review of the way in which we educate and train our doctors? Put simpy, our doctors are trained for a purpose, to care for patients. However, the needs of patients in the UK are changing fast. Doctors have to care for many more patients with chronic iness and with mutipe co-morbidities. This is party driven by our ageing popuation, is party driven by the success of earier intervention, which has owered mortaity rates in many diseases, and is party driven by ifestye. To ensure our doctors have the appropriate skis, competencies and aptitudes to meet our changing needs, we have to re-think current arrangements for postgraduate medica education and training. In particuar, we need a better baance between doctors who are trained to provide care across a genera speciaty area, and those prepared to deiver more speciaised care. In undertaking this review, I competed an extensive consutation across the four countries of the UK. I discovered a wide recognition of the need for change among doctors in training, trainers, empoyers, reguators and patients. There was aso a cear consensus about what change shoud deiver: greater fexibiity, better preparation for working in mutiprofessiona teams and more generaists. This report sets out a framework for deivering change and for doing so with minimum disruption to the service. It offers an approach that wi ensure doctors are trained to the highest standards and are prepared to meet changing patient needs. It aso offers an approach that wi be fit for purpose for many years to come. During the consutation, anaysis and preparation of this report, I have received outstanding support and advice from a speciay assembed Expert Advisory Group and a dedicated executive team. My sincere thanks go to both. Professor David Greenaway Chair, Shape of Training Review 3

6 Executive summary The Shape of Training Review aims to make sure we continue to train effective doctors who are fit to practise in the UK, provide high quaity care and meet the needs of patients and the pubic. As part of this review, we ooked at the desired outcome of training what kinds of doctors are needed, and the means by which we get there. 4

7 The main thrust of the Review is to put in pace a structure that wi produce doctors who are abe to work in genera areas of their speciaties (the approach is described beow). The report s recommendations wi hep doctors to continue to meet patient and service demands now and in the future. Key messages in the report: Patients and the pubic need more doctors who are capabe of providing genera care in broad speciaties across a range of different settings. This is being driven by a growing number of peope with mutipe co-morbidities, an ageing popuation, heath inequaities and increasing patient expectations. We wi continue to need doctors who are trained in more speciaised areas to meet oca patient and workforce needs. Postgraduate training needs to adapt to prepare medica graduates to deiver safe and effective genera care in broad speciaties. Doctors in academic training pathways need a training structure that is fexibe enough to aow them to move in and out of cinica training whie meeting the competencies and standards of that training. Fu registration shoud move to the point of graduation from medica schoo, provided there are measures in pace to demonstrate graduates are fit to practise at the end of medica schoo. Patients interests must be considered first and foremost as part of this change. Impementation of the recommendations must be carefuy panned on a UK-wide basis and phased in. This transition period wi aow the stabiity of the overa system to be maintained whie reforms are being made. A UK-wide Deivery Group shoud be formed immediatey to oversee the impementation of the recommendations. Medicine has to be a sustainabe career with opportunities for doctors to change roes and speciaties throughout their careers. Loca workforce and patient needs shoud drive opportunities to train in new speciaties or to credentia in specific areas. 5

8 Training structure for the future In the report, we describe an approach to training in the future that wi deveop more broady trained speciaists. The key miestones in this mode are outined beow: Fu registration shoud happen at the point of graduation from medica schoo. Measures wi need to be put in pace to make sure graduates are fit to work as fuy registered doctors. They wi aso be restricted to working in approved training environments. Foowing graduation, doctors wi undertake the two-year Foundation Programme. Doctors must have opportunities to support and foow patients through their entire care pathway, both during medica schoo and in the Foundation Programme. After the Foundation Programme, doctors wi enter broad based speciaty training. Speciaties or areas of practice wi be grouped together. These groupings wi be characterised by patient care themes (such as women s heath, chid heath and menta heath), and wi be defined by the dynamic and interconnected reationships between the speciaties. They wi have common cinica objectives, set out in the speciaty curricua. How these patient care themes wi bridge the boundary between hospita and community care needs to be considered by the UK-wide Deivery Group. Across a speciaty training, doctors wi deveop generic capabiities that reinforce professionaism in their medica practice. Broad based speciaty training, after Foundation Programme, wi ast between four and six years depending on speciaty requirements (and depending on how individuas progress through the curricua). During postgraduate training, doctors shoud be given opportunities to spend up to a year working in a reated speciaty or undertaking education, eadership or management work (simiar to speciaty feowships). This year, which can be taken at any time during training, wi aow them to gain wider experiences that wi hep them become more rounded professionas. It wi be incuded in the timeframe of between four and six years. When doctors want to change speciaties, either within or between speciaty groups, they wi be abe to transfer reevant competencies they have acquired in one speciaty to their new area of practice, without having to repeat the same earning in the new speciaty. This wi incude earning during the optiona year and generic capabiities. By recognising previous earning and experiences, retraining in new areas shoud be shorter. 6

9 Nationay funded cinica academic training wi be a fexibe training pathway. Doctors on this pathway woud be abe to focus their academic training in their academic or research area, whie aso undertaking broad based training. Time spent in academic experiences wi be counted within training, but these doctors may occasionay take onger to reach the exit point of postgraduate training, if for instance they spend further time undertaking doctora research studies. In exceptiona circumstances, doctors in cinica academic training may be abe to restrict their cinica practice to narrow speciaty, specia interest or subspeciaty areas. Most doctors wi work in the genera area of their broad speciaty, based on patient and workforce needs, throughout their careers. They wi be expected to maintain and deveop their skis in their speciaty area and their generic capabiities through continuing professiona deveopment (CPD), and to meet the requirements of revaidation. Learning through experience and refection on their practice and patient outcomes wi hep to give them the depth of knowedge and skis necessary to master their speciaty area. Doctors wi aso have options at any point in their careers to deveop their education, management and eadership roes. The exit point of postgraduate training wi be the Certificate of Speciaty Training. It marks the point at which doctors are abe to practise in their identified scope of practice, with no cinica supervision, whie working in muti-professiona teams. Doctors may want to enhance their career by gaining additiona expertise in specia interest areas and subspeciaty training through forma and quaity assured training programmes, eading to a credentia in that area (credentiaing). These programmes wi be driven by patient and workforce needs and may be commissioned by empoyers as we as current postgraduate education organisers. These areas need to be approved and quaity assured by the reguator to ensure appropriate standards and portabiity. 7

10 Undergraduate degree Postgraduate medica training Professiona practice FOUNDATION PROGRAMME BROAD-BASED SPECIALTY TRAINING Cinica academic training Academic training focused on a particuar research area combined with broad-based speciaty training. Doctors can move in and out of academic training at any point. A doctors deveop generic capabiities in key areas, incuding: Optiona year spent working in a reated speciaty or undertaking eadership or management work this can be taken at any time during broad-based training. Doctors are abe to practise with no cinica supervision within mutiprofessiona teams and networks. They are abe to make safe and competent judgements in broad speciaty areas. With further opportunities to: Graduation Fu registration at the point of graduation Wide range of training opportunities provided across different speciaty areas. Incudes severa 4 6-month pacements, in both acute and community settings. CARE THEME CARE THEME CARE THEME CARE THEME Speciaties or areas of practice grouped by patient care themes, such as: women's heath chid heath menta heath CARE THEME CARE THEME CARE THEME CARE THEME CARE THEME CARE THEME patient safety communication with coeagues and patients teamwork, management and eadership evauation and cinica appication of research. Certificate of Speciaty Training maintain capabiities and deveop practice through CPD enhance career and gain additiona expertise through credentiaing in specia interest areas deveop depth of knowedge by earning through experience and refecting on their practice move into education, management and eadership roes. Training duration 2 years 4 6 years (depending on speciaty requirements) Within broad-based speciaty training, doctors can: train across the breadth of speciaties: theme their training within particuar patient groups at any point in the training change speciaties by transferring competences within or between groups of speciaties combine speciaty training with academic research. Rest of career 8 9

11 Recommendations 1. Appropriate organisations * must make sure postgraduate medica education and training enhances its response to changing demographic and patient needs. 2. Appropriate organisations shoud identify more ways of invoving patients in educating and training doctors. 3. Appropriate organisations must provide cear advice to potentia and current medica students about what they shoud expect from a medica career. 4. Medica schoos, aong with other appropriate organisations, must make sure medica graduates at the point of registration can work safey in a cinica roe suitabe to their competence eve, and have experience of and insight into patient needs. 5. Fu registration shoud move to the point of graduation from medica schoo, subject to the necessary egisation being approved by Pariament and educationa, ega and reguatory measures are in pace to assure patients and empoyers that doctors are fit to practise. 6. Appropriate organisations must introduce a generic capabiities framework for curricua for postgraduate training based on Good medica practice that covers, for exampe, communication, eadership, quaity improvement and safety. 7. Appropriate organisations must introduce processes, incuding assessments, that aow doctors to progress at an appropriate pace through training within the overa timeframe of the training programme. * In the recommendations, appropriate organisations must incude the Sponsoring Board organisations, the four UK departments of heath, empoyers, and both patient and professiona interests. 10

12 8. Appropriate organisations, incuding empoyers must introduce onger pacements for doctors in training to work in teams and with supervisors incuding putting in pace apprenticeship based arrangements. 9. Training shoud be imited to paces that provide high quaity training and supervision, and that are approved and quaity assured by the GMC. 10. Postgraduate training must be structured within broad speciaty areas based on patient care themes and defined by common cinica objectives. 11. Appropriate organisations, working with empoyers, must review the content of postgraduate curricua, how doctors are assessed and how they progress through training to make sure the postgraduate training structure is fit to deiver broader speciaty training that incudes generic capabiities, transferabe competencies and more patient and empoyer invovement 12. A doctors must be abe to manage acutey i patients with mutipe co-morbidities within their broad speciaty areas, and most doctors wi continue to maintain these skis in their future careers. 15. Appropriate organisations, incuding empoyers, must structure CPD within a professiona framework to meet patient and service needs, incuding mechanisms for a doctors to have access, opportunity and time to carry out the CPD agreed through job panning and appraisa. 16. Appropriate organisations, incuding empoyers, shoud deveop credentiaed programmes for some speciaty and a subspeciaty training, which wi be approved, reguated and quaity assured by the GMC. 17. Appropriate organisations shoud review barriers faced by doctors outside of training who want to enter a forma training programme or access credentiaed programmes. 18. Appropriate organisations shoud put in pace broad based speciaty training (described in the mode). 19. There shoud be immediate consideration to set up a UK-wide Deivery Group to take forward the recommendations in this report and to identify which organisations shoud ead on specific actions. 13. Appropriate organisations, incuding empoyers, must consider how training arrangements wi be coordinated to meet oca needs whie maintaining UK-wide standards. 14. Appropriate organisations, incuding postgraduate research and funding bodies, must support a fexibe approach to cinica academic training. 11

13 The review s purpose My hope is that any doctors who treat me do so with competence and kindness and aways professionay. I want to be treated as a thinking person and not to be taked down to or over. I woud ike to be treated hoisticay and humaney and not just as a representative of a particuar compaint. Patient 12

14 1. The purpose of the Shape of Training Review is to make sure that over the next 30 years, we continue to train doctors who are fit to practise in the UK, are abe to meet patient and service needs, and provide safe and high quaity care. 2. We were asked to focus on postgraduate medica education and training across the UK from the transition from medica schoo to the Foundation Programme and through to speciaty training and CPD. We aso considered doctors expectations and opportunities when they begin a medica career, and their decisions about what they want to speciaise in during postgraduate training. 3. Our recommendations appy to a four UK countries. It is crucia that reforms to medica education and training produce doctors who have reached standards common across the four countries and are abe to address the rapidy changing heath needs of the UK popuation. We recognise that the four UK governments are taking forward the deivery of heath services differenty and we need to educate and train doctors fexiby to respond to these chaenges. 4. The image * on the next page shows the career structure of most doctors and you can read more about how medica education and training is organised currenty in the UK in annex A. We have aso incuded a gossary of key medica education and training terms in this annex. 5. Cinica academic medicine fits within the current career pathways. Annex B describes the current arrangements for cinica academic medicine in the four UK countries and how the recommendations in this report wi fit with this. What was earned from previous education and training reviews? 6. Over the past decade, there have been six major inquiries considering aspects of the structure, function and effectiveness of medica education and training in the UK. These reviews, as a whoe, concuded the current system is sow to adapt to patient and service needs. The training structure imits opportunities for doctors to change speciaties, deveop knowedge and skis outside their speciaty curricua, or move in and out of training. A recurrent theme in a the reviews was a ca for more fexibiity in the way we train doctors. Annex C sets out a summary of some of these reviews. 7. The Sponsoring Board asked us to consider these previous reports recommendations, and give particuar attention to Aspiring to Exceence Fina Report of the Independent Inquiry into Modernising Medica Careers. Sir John Tooke caed for a more fexibe and broad based approach to training, integrating both training and service into workforce panning. Tooke aso said there must be more carity about the contribution of doctors in training to service deivery and how doctors work in muti-professiona teams. These eements featured strongy within our review s themes. * Genera Medica Counci (2012), The State of Medica Education and Practice. The chart on the next page shows GP training is between 3 and 4 years. GP training is currenty 3 years athough a number of 4-year programmes exist, but the additiona experiences is not a requirement for a Certificate of Competion of Training. Tooke, J. (2008) Aspiring To Exceence: Fina Report of the Independent Inquiry into Modernising Medica Careers, ed by Sir John Tooke. 13

15 The medica career path Speciaist route * 4 6 years 2 years 5 8 years Newy appointed Consutant post Consutant for 10 years Consutant for 20 years Consutant for 30 years Consutant for 40 years Newy appointed Consutant post Consutant for 10 years Time since PMQ (years) Consutant for 20 years Consutant for 30 years * 7 10 Consutant for 40 years wy ified P GP route 4 6 years Time since PMQ (years) years 3 4 years Newy quaified * GP GP for 10 years GP for 20 years GP for 30 years GP for 40 years GP for 10 years GP for 20 years GP for 30 years GP for 40 years * Providing service ade doctor or speciaty doctor Providing service Associate speciaist, staff grade doctor or speciaty doctor * The current NHS retirement age is 65 years od * The current NHS retirement age is 65 years od Descriptions Descriptions Undergraduate medica education Primary medica quaification (PMQ) Foundation training GP training Speciaty training Appointment to post Undergraduate medica education Foundation training Speciaty training These timings are indicative so can vary. For exampe, extensions to training, ess than fu-time training and periods of absence wi a extend this. Primary medica quaification (PMQ) GP training Appointment to post These timings are indicative so can vary. For exampe, extensions to training, ess than fu-time training and periods of absence wi a extend this

16 8. The Scottish Medica and Scientific Advisory Committee in the September 2008 report Promoting Professionaism and Exceence in Scottish Medicine set out pans to improve the quaity of patient care in Scotand. It focused on training doctors to work in an integrated and mutiprofessiona team in both primary and secondary care settings. Like Tooke, the report caed for a more genera approach to training with fewer speciaties and subspeciaties. It aso highighted the need for doctors to gain broader training experiences and to work in genera areas of their speciaties for onger before deciding to speciaise further. Together for Heath - the five-year vision for the NHS in Waes by the Wesh Government identified a simiar need for a medica workforce with more generaist skis to meet their expected demographic changes. 9. In 2011, the report Transforming Your Care: A review of heath and socia care in Northern Ireand again caed for heathcare to take pace near to peope s homes with more reiance on mutiprofessiona teams. The report particuary caed for doctors to have more training in community settings and in providing acute care. 10. The NHS Future Forum (Engand), in its report to the Government on education and training in January 2012, re-emphasised the need to deveop a more fexibe career pathway for doctors and a means of fostering generaism in the community and the hospita. These issues were core to the Shape of Training Review. How the Review was structured 11. The Review was aunched through an agreement between the foowing organisations responsibe for the reguation, commissioning and deivery of medica education and training: Medica Education Engand (MEE) whose function was subsumed into Heath Education Engand (HEE) the Academy of Medica Roya Coeges (AoMRC) the Genera Medica Counci (GMC) the Medica Schoos Counci (MSC) the Conference of Postgraduate Medica Deans of the UK (COPMeD) NHS Education Scotand (NES) the Northern Ireand Medica and Denta Training Agency (NIMDTA) Waes Deanery 12. Coectivey these organisations formed the Shape of Training Sponsoring Board. It was responsibe for setting the Review s strategic direction incuding its scope, timeines and outputs. These were agreed in the Review s Terms of Reference on 22 March Professor David Greenaway, Vice-Chanceor of the University of Nottingham, was appointed by the Sponsoring Board to ead this independent review. He assembed an Expert Advisory Group (EAG) to hep him identify issues and potentia options for changes to postgraduate training. Members of the group were seected for their independent expertise and advice rather than as representatives of their organisations. 14. More information about the Review s governance can be found in annex D. 16

17 What did the Terms of Reference set out? 15. Buiding on earier work ed by Medica Education Engand, and invoving key groups incuding the four UK departments of heath, the Terms of Reference identified five themes as we as some cross-theme issues for the review to consider. Box 1 summarises the key issues in each theme and area we considered. You can read the Terms of Reference in annex D. In addition, the UK Scrutiny Group asked the Review to consider the needs of academic training and the transition from medica schoo to the Foundation Programme 16. We considered this review against the backdrop of rapidy changing medica and scientific advances, evoving heathcare and popuation needs, changes to heathcare systems and the information and communications technoogy (ICT) revoution. Doctors roes and responsibiities wi have to accommodate new technoogies, systems and professions. 17. We recognise that the medica profession does not exist in isoation and other heath and socia care professionas are fundamenta in deivering a safe and high quaity service. But we were commissioned to review medica education and training. There is no doubt that doctors must be trained to work in muti-professiona teams and respect the roes and responsibiities of their coeagues. Box 1: A summary of the key issues in the themes and areas set out in the Terms of Reference Baance between sufficient exposure to acutey i patients and emergency interventions and care in the community. Patient needs Carity about the competencies attained by doctors at different stages of their careers. Roes and responsibiities of a doctors. Workforce needs: speciaists or generaists Baance between generaists and speciaists needed to deiver care and impications for medica training. Timing of the CCT, the content and ength of training, exit points, the timing of subspeciaty training, recognition of competencies. Roe for CPD and credentiaing. Breadth and scope of training Support needed for right mix of knowedge, skis and behaviours to prepare doctors for the different contexts in which they work. Time to refect on practice and earn from experiences. Training and service needs Roe of doctors in training in the service and competing needs of the service and training. Fexibiity of training More fexibe training to aow doctors to move more easiy between speciaties and into and out of training. Support for doctors pursuing academic or management careers. Transitions throughout medica career Advice about medica career. Support for doctors through transitions. 17

18 18 Methodoogy

19 What was our review process? 18. The Terms of Reference defined the key themes and areas and we undertook a comprehensive process of consutation and evidence gathering to address these. Box 2: Our engagement activities Monthy web and e-updates Nine site-visits Five arge seminars 19. We engaged with patients, medica students, doctors in training, trainers, empoyers and organisations invoved in deivering training. We consuted in Engand, Northern Ireand, Scotand and Waes, incuding rura and urban settings. Box 2 describes some of our engagement activities. 16 targeted workshops Over 65 meetings and discussions 54 ora evidence sessions Ca for ideas and evidence (written responses) 20. In the first phase, we did a iterature review, deskbased research and site-visits, and hed five arge seminars. These activities heped us scope out the key issues. 21. In the second phase, we expored key issues through a written ca for ideas and evidence, which resuted in amost 400 submissions. We used this information to deveop principes and possibe approaches to medica education and training. 22. Finay we tested these principes and frameworks through workshops, discussions and 54 ora evidence sessions. 23. This extensive consutation process provided opportunities for individuas and organisations to express ideas, judgements and experiences. Responses were not formay weighted or quantified, but we acknowegded that some organisationa responses represented the views of a arge number of individuas. 24. We received feedback from over 1,500 individuas and organisations in Engand, Northern Ireand, Scotand and Waes. You can read more about our engagement activities, who we engaged with and the evidence coected in annex E as we as summaries of the activities in the appendices. 19

20 20 Discussion of findings within themes

21 Theme One: Patient needs drive how we must train doctors in the future Changing popuation needs 25. Our assumptions are based on what experts currenty beieve wi happen to the UK popuation and future heathcare structures. Some of these trends are unpredictabe. * We need to create a training structure that makes sure the medica workforce can respond to this uncertainty. Reports from the four UK countries show a move towards more integrated care across primary and secondary care boundaries in response to changing popuation demographics. For exampe, the Scottish Government s 2020 Vision for Heath sets out a strategy to deiver integrated heath and socia care with the majority of care taking pace in the community. The popuation over 75 years od in Scotand is expected to increase by 60% by 2033, resuting in a 70% increase in heath expenditure. 26. We examined the impact of changing demographics as a means of understanding how patient needs may change and how doctors training wi be shaped by this. 27. Drivers of change that wi impact on medica training and practice incude the foowing: More peope in a age groups are iving with mutipe inesses. A recent report found 42% of the popuation in Scotand had at east one ong term condition and 23% had two or more. There is a growing number of oder peope across the UK, many with mutipe conditions incuding dementia. Even though they make up a reativey sma group compared with the popuation as a whoe, many oder peope require more medica interventions. Oder peope wi make up a high percentage of rura popuations in the UK. The onset of co-morbidities occurs years earier for those iving in deprived areas. They are more ikey to experience menta heath probems aongside their physica conditions than more affuent groups. ** * A scenario-based report that forecasts possibe demographic trends based on changes in socioeconomic conditions in the UK is avaiabe in appendix 6. NHS Scotand (September 2011) Vision: Strategic Narrative, Achieving Sustainabe Quaity in Scotand s Heathcare. Barnett K et a. (2012) Epidemioogy of mutimorbidity and impications for heath care, research, and medica education: a cross-sectiona study. The Lancet onine. Oder peope are defined differenty across the UK. The British Society of Gerontoogy and Age UK prefer a broad term rather than a specific age cut off. Barnett K et a. Epidemioogy of mutimorbidity and impications for heath care, research, and medica education: a cross-sectiona study. The Lancet onine, ** Office for Nationa Statistics 21

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