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We all know the population is ageing and the patients who come to see us have increasingly complex conditions, often with multiple morbidities. You cannot argue with demographic data. However, what we need to debate is how we, the medical profession, respond to changing trends and requirements for patient care.
A key proposal in the Shape of Training review, published today and sponsored by the GMC and four health departments, is for the introduction of more broad-based specialty training ‘themes’ in postgraduate curricula.
According to the independent review, chaired by Nottingham University vice-chancellor David Greenaway, these themes would include areas such as women’s health or children’s health. There would also be a requirement for doctors in training to acquire and maintain generic capabilities.
The BMA junior doctors committee does not disagree with the principles behind the suggestion of obtaining more generic competencies, which is to allow trainees greater flexibility to move between specialties and respond to the changing needs of the population. In fact, we have been arguing for increased flexibility in the training system for years.
However, we don’t think a complete overhaul of the training structure is necessary to achieve the desired aims.
So, what do we want? The review only mentions a ‘delivery group’, which suggests there is to be no more consultation on the 19 recommendations.
We want the opportunity to input, via a steering group, ideas for improving our training and patient care, with the support of other interested groups. As you may be aware, high-quality training is one of the issues the BMA junior doctors committee is currently discussing in its contract negotiations with employer representatives.
And as doctors currently in the training system, we believe our views are vital.
We also want assurances that the suggestion to replace the current end point of our training — the certificate of completion of training — with a certificate of specialty training will not open the door to a sub-consultant grade.
The BMA has successfully fought off such suggestions in the past and will continue to oppose vehemently any moves to create a two-tier structure for senior doctors.
Another area of concern is the suggestion that the point of full registration with the GMC is moved to the end of medical school. We were surprised to read this in the report of a review whose scope, we thought, was limited to postgraduate training. We are not convinced by the idea of removing a whole year of education and experiential training by bringing forward the point of full registration.
However, there are recommendations that we do support, such as ensuring training posts are limited to GMC-approved and supervised placements of at least six months.
There is also good news for doctors outside the training grades who want to find a way in — the report calls for a review of the barriers facing those who want to enter formal training or credentialed programmes. The BMA also supports the idea for more flexible academic training.
Most of all we hope the publication of this report is not the end of the debate about postgraduate medical training. We would like a little flexibility to enable further discussion to ensure the future of our training is in the very best shape.
Kitty Mohan is BMA junior doctors committee co-chair
I believe many GPs and other medical professionals could benefit from reading about my experiences in caring for my mother who had vascular dementia. The account is contained in my book, 'Dementia and Mum-Who Really Cares?' Chapter 15 (Unlearning), Chapter 20 (Training to be a Nurse) and Chapter 23 (Home Care) would be particularly useful. There is information about the book on the michaelfassio.co.uk website and donations from sales have been given to Age UK, Dementia UK, The Carers Trust and Alzheimer's Society.
You are correct: a complete overhaul of post-graduate training is not needed to achieve the welcome changes put forward in this report.
However, you would have to be remarkably naive to think that the aims stated in the report were the true drivers of the proposed changes. This report has a very simple set of aims - to shift the cost of postgraduate education from deaneries and employers onto trainees, to reduce the cost of medical staffing, to make it easier to move doctors into unpopular posts, to create a need for contract negotiation (for the CST grade into which most non-GPs will spend most of their careers, with poorer terms and conditions than consultants), to increase the number of medical graduates without the cost of having to employ them all and to increase competition between doctors for jobs, weaknening their position as professionals with a set of desired skills that can demand comensurate remuneration.
This is a white paper for the final stage of preparing the nhs for privatisation. Make it appear cheaper before you flog it off, the blueprint for every privatisation of public services for the past 40 years.
'Working with' and 'engaging positively', 'shaping the implementation' are acknowledgments that we have already lost and that you are a powerless and pointless organisation.
I came to the NHS in 1991 after a career in the Royal Air Force during which I became responsible for training. At that time I was appalled at what passed for specialist training but did my best for my own registrars. I have also worked in Europe and have some familiarity of what happens in other EU nations. After a local public meeting in Crickhowell last June consulting on options for hospital planning I wrote a response which included the comments pasted below.
In the Consultation Document there is an implication that hospital programmes are being driven by considerations of medical specialist training and career structures. The relevance of these has to be qualified by consideration of what happens in Europe and the EU Directives on specialist training and recognition. The UK concept of the independent Consultant derives from the visiting consultant of pre-NHS days and provides those so appointed with a junior staff of assistants who may or may not receive good training. The pattern in other nations is that doctors can become specialists after some five years of post-graduate training and thenceforward follow a career during which increased responsibilities such as becoming a head of department or training juniors may accrue. Our system whereby every hospital Consultant is independent of others and must be able to train new specialists is comfortable for those in post, but this independent structure has no inbuilt quality control and provides apprenticeship training with variable standards. Undergraduate training of medical students was centralised by the Medical Act of 1850!
The classic planning sequence is to establish the function, devise the structure and then provide manning which also implies the necessary training. To permit requirements for medical specialist training to dictate the structure is perverse planning, especially when our national training pattern is out of line with other nations and potentially subject to European Directives. The prime purpose of health planning is to provide services to the population, training is incidental. After fifty years, reconfiguration is necessary but this will affect all specialities.
Following undergraduate medical training, post graduate specialist training has to be better organised and concentrated in fewer hospitals, although as with medical students all clinical opportunities can be utilised. NHS Wales is in a good position to pioneer change and this applies to more than the subject of this programme. The Royal Colleges in London should not be the only driver for change; they have their own vested interests.
Retired Consultant in Public Health Medicine
We also need to look again at selection:-
and we need to consider the whole person seeking such a career:-
Thank you for this piece Kitty - very well written.
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