Posts Tagged ‘MEE’

Education needs multi-disciplinary approach

By Mike Broad - 31st March 2011 9:09 am

Proposed reforms to medical education and training have received a mixed reaction from doctors’ representatives.

Under the Liberating the NHS: Developing the Healthcare Workforce proposals, a new body - Health Education England - would hold funding for training centrally, and distribute it to local skills networks. Postgraduate medical deaneries would be abolished and local trusts would have more control.

The Royal College of Surgeons welcomed the principles for reform but questioned whether it would lead to a divergence in training programmes.

The BMA, however, described the reforms as rushed and ill-conceived in its consultation response. It fears ‘geographical inconsistencies in the quality of training’ and diminished focus on medical research and education.

JDC co-chair Dr Tom Dolphin said: “There is no reason to abolish deaneries and the idea that employers would want to take on their functions is not tenable.”

The RCS said a conflict of interest could be created by trusts quality assuring themselves, in its consultation submission. The college believes that the professional elements of training - selection, rotation, assessment of trainees and quality assurance of posts - should be dealt with by professional bodies such as the royal colleges.

The RCS supports the establishment of Health Education England however, and believes it offers an opportunity to better focus training on patients. Medical Education England, which oversees training for doctors, dentists and pharmacists, would be replaced with one body that controls the training for all healthcare workers.

It also suggests there should be a multi-disciplinary approach to training, with surgeons, anaesthetists, nurses and operating department practitioners all being managed by the same training programme.

Professor John Stanley, vice-president of the Royal College of Surgeons, said: “The principles of the government plans for reforming medical education are fully supported by the Royal College of Surgeons and provide a great opportunity to refocus training on safe delivery of patient care.

“Currently the focus on individual disciplines is too inward looking and the reality of medicine is that patients get the best results when teams of healthcare workers are strong, with mutual understanding and respect for one another’s roles. If the new system is to have confidence and consistency across the country then independent quality assurance is vital and medical royal colleges are perfectly placed to deliver this.”

The RCS does express concern over the responsibility for medical CPD, which is currently held by Medical Education England - it fears it could be handed employers with no oversight by Health Education England nor measures to protect it from local budgetary pressures.

Read the full proposals.

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Temple’s recommendations on medical training under the WTD

By Mike Broad - 23rd June 2010 2:29 pm

The Working Time Directive was fully implemented into the NHS in August 2009.

Widespread concern has emerged about the ability of the NHS to continue to deliver safe services and high quality training for all its staff.

The traditional experiential model of training in England relied on trainees spending long hours in their place of work delivering services, during which time they developed their skills and knowledge. Given the reduction in the time available necessitated by the WTD, the challenge now is to continue to deliver high quality training within the current service context.

The government requested that Medical Education England commission an independent review of the impact of the WTD on medical training.

The ensuing review, chaired by Sir John Temple, released its findings earlier this month; it acknowledged that a 48-hour week is compromising medical training but suggested the solution lies in developing a truly consultant-delivered service rather than extending the working week for juniors.

Key findings

1. Gaps in rotas result in lost training opportunities.

2. WTD impact is greatest in specialties with high emergency and/or out-of-hours commitments.

3. Consultant ways of working often support traditional training models.

4. WTD can be a catalyst to reconfigure or redesign service and training.

Key recommendations

1. Implement a consultant delivered service:

The review emphasises the need for a ‘consultant-delivered service’, rather than the more loosely defined ‘consultant-based’ or ‘consultant-led service’ to become a reality. A consultant delivered service is defined as consultant 24-hour presence, or ready availability, for direct patient care responsibility.

Consultants may be the most costly members of the workforce but they make better decisions more quickly and are critical to reducing the costs of patient care while maintaining quality. A consultant delivered service should be seen as part of the solution to funding pressures.

A consultant delivered service will necessitate more flexible consultant working and will require, in many cases, reconfiguration or redesign of the way that services are currently delivered. Where clinical need dictates, this may involve 24/7 consultant working involving shifts.

There needs to be further development of the consultant role: concepts such as team job planning and the pooling of PAs and SPAs among a team of consultants will enable flexibility within a team. Newly appointed consultants need mentoring and support.

Trainees will still provide services - they should not be supernumerary. Delivering direct patient care is an important part of training in both elective and emergency situations. With increased consultant presence out-of-hours, trainees will gain from the experience of working under supervision.

2. Service delivery must explicitly support training:

Services must be designed and configured to deliver high quality patient care and training in order to deliver safe and effective healthcare in a consultant delivered model.

Regional or national reconfiguration solutions may be required for smaller specialties.

Reconfiguration and redesign of elective and emergency services can benefit training and patient care.

MDT working must be used to support training. Working efficiently in reduced hours will require a co-ordinated multidisciplinary approach of the relevant professions to ensure suitable alignment of roles and utilisation of their available skills, coupled with interdisciplinary learning. There must be a national strategy with clarity on the service responsibilities and cost efficiencies for the development of roles such as physician assistants, specialist nurses, advanced nurse practitioners and surgical care assistants, as these professionals can reduce unnecessary demands on junior trainees.

Service requirements and training quality may mean that it is no longer feasible to train in all hospitals.

Rotas require organisation and effective management. General recommendations include: formalising a collaborative approach to rota design by actively involving trainees; an educational supervisor or person with responsibility and understanding of trainee education should assess and sign off the overall educational value offered in a rota; use appropriate, available software tools to assist with the design of busy, complex rotas; and, enable trainees to have some flexibility when planning annual and study leave.

There must also be a reappraisal of current employment contracts for doctors to better support training.

3. Make every moment count:

Training must be planned, focused and individualised. There needs to be an increased awareness by trainers and trainees of the learning opportunities in each and every clinical setting and training must be targeted and well planned in the 48-hour week.

Handovers must be effective, safe and supervised and represent an opportunity for learning. There must be improved mentorship and support of trainees.

We must accelerate learning by using simulation and technology in a safe, controlled environment.

Sir John says we must implement better ways of training, combining current best practice and innovation. Many consultant trainers’ perceptions are aligned to traditional models of training that they experienced, which involved long hours, personal sacrifices and less formalised support and supervision.

To meet the challenges of the developing environment an alteration is now required in the way training is delivered.

4. Recognise, reward and develop trainers:

Consultant educators need to be identified, trained, accredited and supported in their job plans, through mechanisms similar to those that currently exist for GP educators.

There should be flexibility for consultants to be training or non-training. The principles of the model used in general practice, in which not all principals are trainers and the trainer and trainee roles are clearly defined, should be adapted for hospital practice.

Training must be recognised in consultant job plans. Trainers must be developed, supported and accredited learning new approaches to medical education. Trainer excellence must be recognised and rewarded.

5. Training excellence requires regular training and planning, and commissioners’ levers should be strengthened to incentivise training.

6. Prioritise training at trust level:

The quality of training must be monitored. The absence of definitive evidence on the impact of the outputs and outcomes of training highlights the need for a rational, realistic system for monitoring the effects of reduced working hours, and other system changes. This must result in actions being taken where deficiencies are found.

Read the full review.

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Will the WTD review get to the truth?

By Mike Broad - 6th January 2010 5:23 pm

As far as the government is concerned, the implementation of the 48-hour for juniors has had no impact on either clinical care or the training of juniors. When the Working Time Directive (WTD) is criticised, the stock response is that there’s no evidence to suggest they’ve been compromised.

They have, however, acknowledged juniors’ concerns about their training and, back in July, at the eleventh hour, asked Medical Education England (MEE) to conduct a review.

It’s been a long time coming but, just before Christmas, MEE announced the review was underway. MEE has appointed Professor Sir John Temple, former president of the Royal College of Surgeons of Edinburgh and chair of the Specialist Training Authority, as review chair.

Sir John and his expert group will soon be listening to oral evidence, and this will include focus groups and face-to-face meetings. A final report is due to be presented to the health secretary by April.

Evidence is now the big issue. The government believes the PMETB Survey of Trainees for 2009 supports its current position. There is, however, a growing body of evidence which contradicts this just not from ‘official’ sources. 

A survey by Remedy showed a high level of rota non compliance among juniors. Then a large survey among surgical trainees showed that two thirds felt training was being compromised. And then there’s the small matter of record numbers of junior doctor vacancies as more people are required to fill rotas. Are you telling me this isn’t compromising care?

Sir John needs to cast far and wide in his search for evidence. Often ignored, frontline doctors have important stories to tell. Mr Peter Mahaffey, consultant surgeon in Bedford, recently dropped me a line. He said: “There can barely be a senior consultant surgeon anywhere who hasn’t witnessed the extraordinary reduction in practical skills amongst trainees and more frighteningly the relative helplessness of new consultant colleagues fresh from this neutered training.”

He was responding to an article by Mr Munchi Choksey, consultant neurosurgeon at University Hospitals Coventry and Warwickshire NHS Trust, which criticised the Royal College of Surgeons for not having done more to resist the implementation of the WTD.

Sir John has to get beyond the usual suspects and canvass frontline opinion. The acquiescence of many of the profession’s representatives, including many of the royal colleges and the BMA, has brought the profession to this crisis point.

He also needs to park the knighthood, retain his independence and be prepared to tell the health secretary some hard truths about the impact of the 48-hour week, as I’m sure a rigorous evidence search will reveal.

Will this review simply re-arrange the deck-chairs on the Titanic? I hope not. Tomorrow’s patients also deserve confident, highly trained and experienced hospital doctors. 

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