Why was there a review?
The Shape of Training review was commissioned in early 2012 to look at the structure of postgraduate medical education and training. Workforce planners and employers have been saying for some time that there is a need for greater flexibility in training, and a need for a higher number of doctors with more generalist skills as opposed to specialists in narrow areas.
The review led by Sir John Tooke, Aspiring to Excellence, called for a more flexible and broad based approach to training. Other reviews over the last decade have identified that medical training is slow to adapt to patient and service needs, limits the chance to change specialties or retrain, limits the chance to move in and out of training, and is inflexible.
A number of factors including an ageing population, success in lowering mortality rates, and lifestyle changes, and the fact that more patients in the future will have multiple conditions, mean the health service in the future will have to deal with more than ever before. Doctors will therefore need to be trained in a way that gives them the skills and competencies, and in the right numbers, to deal with the current and future patient need.
Key messages at a glance
- Doctors should work in more general areas of their specialty, and training will need to adapt to deliver this.
- Doctors in specialised areas and new specialties will still be needed, but opportunities to train in these areas should be driven by patient needs.
- Careers in medicine must be sustainable, and give the opportunity to change roles and specialties. Training pathways need to be more flexible, to encourage moving in an out of training.
- Full registration with the GMC should move to the point of graduation from medical school. Measures will ensure graduates are fit to practice, and they will need to work in approved training environments.
- The report recommendations will be planned and phased-in to allow stability. A UK-wide Delivery Group should be established to take forward recommendations. This will have to be sanctioned by the four health departments.
How will the new training structure look?
The structure of training will have to change if this new vision is to be achieved. Graduates leaving medical school will leave with full GMC registration, and will still participate in the two year Foundation Programme as they do now. Medical students and Foundation trainees should have as much clinical contact with patients as possible.
On leaving the Foundation Programme, doctors will enter “Broad Based specialty training”. Doctors will study in an area of practice defined by patient themes (such as child health, metal health etc), that will share common clinical objectives. All specialty training will include generic capabilities reinforcing professionalism in medical practice.
Broad based specialty training will last between four and six years depending on the specialty area and the progress of the individual (individuals could progress at different rates). To encourage the development of more rounded professional, an optional period of up to a year in a related specialty or in education, leadership or management should be offered, which could be taken at any time during the planned 4 to 6 year timeframe. Placements towards the end of training should also be longer to improve trainee engagement.
Switching specialties should be made easier as generic competencies will be recognised and therefore training will not have to begin from scratch. This will also make retraining shorter. The impact of this should be that the workforce can be more responsive to patient needs and trends. Workforce planning can play a part but it can never be 100 per cent accurate, so more flexibility in the workforce will help meet short term service needs.
Nationally funded clinical academic training will be a new flexible pathway enabling doctors to focus on academia or research while undertaking broad based training. This work will count towards training, but it may take longer for the doctor to complete the programme, if they spend further time in research for example. In rare cases these doctors may be able to restrict clinical practice to their narrow specialty or special interest.
On completion of postgraduate training the doctor will receive a Certificate of Specialty Training, which similar to the current Certificate of Completion of Training (CCT), will enable them to practice in their identified area with no clinical supervision. Most doctors will work in the general area of their broad specialty, and maintain and develop their skills through CPD, as well as having the option to develop education, management and leadership skills.
“Credentialing” will allow a doctor to build up more knowledge of a specific specialty or subspecialty, so they can further specialise in this area. Training for a credential however will be subject to there being a patient and workforce need, so we are not training for roles where there is no demand for them. Credentialing programmes could be commissioned by employers where there is a local need, as well as by postgraduate education organisers.
If care in the future is to be delivered more in the community, having more doctors trained in more broad specialties, including general practice, will help achieve this goal. Evidence suggests that having specialists coordinating hospital and community care with GPs improves outcomes and patient satisfaction, and reduces hospital stays and emergency readmissions. Postgraduate training should therefore include providing care in community and acute settings.
For all the recommendations at a glance see our page 'Recommendations and employer impact'.
Taking forward the recommendations will fall to a UK-wide delivery group sponsored by the four health departments. Greenaway suggests that work should begin immediately on all the different strands needed to implement the changes. He estimates that it will take two to five years for all curricula will be shifted to the new broad based training system with generic competencies, and to make the relevant legal and regulatory changes. It will also take two to five years to put in place longer placements and supervision arrangements, and local structures to support specialty training and credentialing. It is thought that within five to ten years there will be a measurable way of making sure the new postgraduate training structure is meeting patient and service needs.