Posts Tagged ‘Training’

Workforce planners warn of funding cuts for specialist training

By Francesca Robinson - 28th August 2010 8:30 am

Financial pressures on the NHS are likely to hit funding for specialist training warns a report from the Centre for Workforce Intelligence (CfWI), the new national authority for workforce planning.

The report, the first from the Centre, makes recommendations on how many specialist trainees will be needed for the 2011 intake.

It identifies which medical specialties are at risk of over or under supply and highlights where trainees are unequally spread around the UK, outlining how training posts should be redistributed.

The CfWI suggests a small reduction of less than 1% of current places is needed. In a few specialties improved recruitment to training posts could result in higher numbers of doctors in specialty training in 2011.

But it warns that trusts needing to cut costs may be tempted to employ trust doctors. This would force trainees to achieve Certificate of Completion of Training (CCT) via the Combined Entry Programme Specialist Register (CESR) route.

It also fears that if the Multi Professional Education and Training (MPET) levy is reduced, strategic health authorities and deans will want to modify the report’s recommendations.

A spokesman for the Royal College of Physicians said they too were concerned that the CfWI’s recommendations will not be matched by sufficient funding, either by hospital trusts in employing newly trained doctors or by deaneries funding the training places. “Without this financial support, the opportunities these recommendations give the NHS will be lost and patient care will suffer as a result.”

But he said the report was a big step in the right direction for medical workforce planning in England. The RCP was pleased that it supported the recommendations of Sir John Temple’s report on the effects of the European Working Time Directive on medical training.

“The CfWI recommendations for maintaining trainee numbers in the medical specialties will help the development of consultant delivered care which can only be a good thing for patient care. Furthermore the CfWI has taken a very considered view of the skewed distribution of trainees in some parts of the country by using ‘weighted capitation’. This imbalance of both trainees and consultants currently has a large adverse affect on patient services. Correction of these imbalances is crucial to providing a fair health service for all,” said the spokesman.

Bill McMillan, head of medical pay and workforce at NHS Employers, also welcomed the report. He said: “It is critical that the correct number of doctors are trained in the specialities and geographical areas where they are most needed to avoid the risk of either a shortage or significant over-supply, both of which can be expensive, demoralising for doctors and affect patient care.”

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Working Time Directive is “spectacular failure”

By Mike Broad - 1st August 2010 9:19 pm

Surgeons’ representatives have called the working time directive “a spectacular failure” following new research suggesting care has deteriorated since its introduction a year ago.

Eighty per cent of consultant surgeons and 66% of trainees say that patient care has deteriorated under the working time directive.

The Royal College of Surgeons, Association of Surgeons in Training and British Orthopaedic Trainees Association are all campaigning for a 65-hour week, which they believe offers the best balance between adequate training opportunities, good patient care and work-life balance.

The survey’s results - taken from 980 surgeons covering all nine surgical specialties in England as well as those based in Scotland, Northern Ireland and Wales - compare unfavourably to a similar research undertaken last year.

Sixty five per cent say their training time has decreased - a quarter more than in October 2009.

More than a quarter of senior surgeons are no longer able to be involved in all of the key stages of a patients’ care, compared to 18% in 2009.

Two thirds of trainees have reported a decline in training time in the operating theatre and 61% of consultants report that they are operating without trainee assistance more frequently since the directive was introduced in August 2009.

Forty one per cent of consultants and 37% of trainees reported ‘inadequate handovers’.

This follows Hospital Dr research which showed that shift working and multiple handovers top the list of problems doctors face in delivering good care.

Almost three quarters of trainees and two thirds of consultants are consistently working more than the permitted hours. Over half of trainees say they cover rota gaps which result in them working in excess of their contracted hours, compared to 44% in 2009.

One consultant surgeon, who responded to the survey, said: “The European Working Time Directive has been a training disaster. We are raising a generation of demotivated, demoralised and poorly trained surgeons. The UK will pay for this and regret it for at least 30 years.”

Mr John Black, president of the Royal College of Surgeons, said: “To say the European Working Time Regulations has failed spectacularly would be a massive understatement. Despite previous denial by the Department of Health that there was a problem, surgeons at all levels are telling us that not only is patient safety worse than it was before the directive, but their work and home lives are poorer for it.

“The new government have indicated they share our concerns, but there is not a moment to lose in implementing a better system which would enable surgeons to work in teams, with fewer handovers and with the backup of senior colleagues.”

Mr Charlie Giddings, president of the Association of Surgeons in Training, said: “The survey shows that 12 months after the full implementation of the WTD there has been little progress with improvements to quality of training or to the quality of life of trainees and the subsequent impact on patient safety.

“New innovative solutions are required rather than the minor short-term tweaks that artificially produce compliance at the expense of training and patient care, which trusts have attempted so far.”

A spokesman for the Department of Health said: “The health secretary will support the business secretary in taking a robust approach to future negotiations on the revision of the European Working Time Directive, including maintenance of the opt-out.

“We will not go back to the past with tired doctors working excessive hours, but the way the directive now applies is clearly unsatisfactory and is causing great problems for health services across Europe.”

Meanwhile, additional RCS research suggests that the proportion of NHS patients having to wait longer than the 18-week target for non-emergency surgery had almost doubled from 1.5% 18 months ago to nearly 3% in March 2010. It blames the WTD.

Commenting on the findings, Royal College of Physicians president Sir Richard Thompson said: “We are not providing the service or the training that we require. I cannot over-emphasise the damage to service provision and to training.”

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Agreement over exams from non-approved roles

By Francesca Robinson - 13th July 2010 11:38 am

A breakthrough statement clarifying the rules about when professional exams can be taken has been agreed by the GMC, trainees’ representatives and the royal colleges.

It states that doctors who are already in specialty training or who enter by 31 October 2011 will be able to have any passes in previously approved national professional exams counted towards a CCT (certificate of completion of training), even if they were obtained outside approved training.

Guidance on the recognition of exams for doctors who enter a CCT programme after 31 October 2011 will be published in October.

Juniors say the statement allays concerns raised by a legal opinion obtained by the GMC which suggested exams taken out of recognised training programmes would not count towards CCTs. It should reassure doctors who may have made plans or have sat exams already.

The GMC says the furore over this issue has brought to light a number of misconceptions about the routes to the specialist and GP registers and about the recognition of specialties outside the UK. It has announced that later this year it will review equivalence routes and its standards for curricula and assessment systems.

The BMA’s junior doctors chair Dr Shree Datta said: “The statement should allay the fears of many juniors in or about to enter specialty and GP training. However, it is clear that discussions in the next six months will be crucial to iron out the role of exams in postgraduate training.

“There is no doubt that the input of junior doctors in the forthcoming review will be key to ensuring any proposed changes are relevant and beneficial to those who will be affected.”

Richard Marks, Remedy’s head of policy, said they were pleased that the GMC had listened to the views of the trainees. “This represents a major breakthrough for those doctors who had been caught out by the regulations.” But he warned that there were still some issues to be resolved later in the year.

GMC chief executive Niall Dickson said: “The new legal opinion that the GMC has obtained has given us the flexibility we need. I believe all the organisations share a determination to understand and respond to the needs of trainees while ensuring that the coherence and integrity of training programmes are maintained.”

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Specialist training should offer more flexibility

By Mike Broad - 7th July 2010 9:10 pm

Specialist medical training programmes should retain some flexibility to help trainee doctors make the right career choices, a study claims.

Researchers from the University of Oxford set out to compare doctors’ early career choices with their eventual career destinations.

They compared the extent to which doctors’ choices of specialties at one, three, and five years after graduation corresponded to career destinations 10 years after graduation.

They found that, 10 years after graduating, almost half of doctors were working in a specialty different from the one chosen in their first year after graduation and about a quarter were working in a specialty different from their year three choice.

The study, on bmj.com, also suggests that changes to postgraduate medical training mean that junior doctors are making their career choices sooner than in the past.

This concern was first highlighted by the Tooke report in 2008, which suggested that medical education and Modernising Medical Careers encourages foundation trainees to make career choices when many are not ready to make such commitments.

Some respondents commented about an increasing lack of flexibility, as they saw it, in applying for specialty training, while some expressed concerns about having only one lifetime opportunity to succeed in getting on to a training programme for their chosen specialty.

The authors conclude that a two point entry to specialty training programmes would alleviate this problem by allowing those who have made early, definite choices to progress quickly into their chosen specialty, while recognising the need for flexibility for those who choose later.

Commenting on the research, Jeremy Brown, a senior lecturer at Edge Hill University in Lancashire, said: “Specialty programmes need to identify ways of supporting those trainees who need time and experience in the postgraduate setting to make a firm commitment that will match their eventual career destination.”

Read the full study.

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Stepping up to the mic at the BMA conference

By Mike Broad - 30th June 2010 4:25 pm

A lot of voices get heard at the BMA’s annual representatives meeting but, when it comes to the media, only the GPs and consultants tend to get any coverage.

So, in the interests of balance, it’s worth giving some of the views of juniors’ and the SAS doctors an airing.

Dr Shree Datta, chair of the JDC, stuck to her line that the problem with the working time regulations is their implementation rather than a restricted working week per se.

“Half-hearted compliance leads to half-filled rotas,” she insisted in her conference address.

She added: “It is time for employers to take up Temple’s challenge, and engage with junior doctors to create realistic rota solutions that balance training and service to our patients.”

Where all the additional ‘manpower’ will come from to fill these rotas she didn’t say. Maybe she feels, like Sir John, it’s up to consultants to fill the gap.

Training will clearly continue to be this year’s hot potato.

She said: “The many streams and rivers of NHS money are being diverted and dammed. The NHS prides itself on its highly trained workforce. But the quality of senior doctors in future depends on the quality of training now. The whole profession must unite against any suggestion of haphazard cuts to our training budgets.”

Dr Radhakrishna Shanbhag concurred. The chair of the SAS committee told the conference: “My job is not an easy one. It is no secret that the SAS grades include many varied and sometimes challenging needs and aspirations. We are a diverse group but that should be our strength. We need to improve access to training (for those that want it), provide some formal recognition of our competencies and skills and ensure that with this, the SAS grades are seen as a positive career choice for highly skilled and motivated specialists.”

But it’s not just about money, Shanbhag is after a bit of respect too. He complained about the slow implementation of the ‘new’ SAS contract. “Two years since it was introduced, I’m shocked that there are still many SAS doctors waiting for assimilation. I believe that this is a damning indictment of the lack of respect that employers have for our grade. We have continually pressed NHS Employers and devolved administrations to move things along and will continue to do so.”

And did I detect a desire for a bit more respect from within the ranks of the BMA?

In summation, he asked the conference to “take ownership of this grade, celebrate their achievements, acknowledge their vital role and let them be spoken to and about in the same breath as other senior medical professionals. Let us stand up for SAS doctors.”

While the slogan of the conference might have been ‘standing up for doctors’ - a line that the chairman of BMA council repeated at least 742 times - the real message was more one of ‘sticking together’, possibly alongside other public sector unions, to see out the gathering storm.

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Juniors enraged by escalating college fees

By Francesca Robinson - 25th June 2010 8:18 am

Trainees are calling for a say in royal college fee setting procedures following a spate of escalating charges which are being enforced on them without consultation.

The JRCPTB (Joint Royal College of Physicians Training Board) recently put up its enrolment fees by 22%; the Royal College of Obstetricians and Gynaecologists has raised its annual subscription to the trainees’ register from £75 to £120 and the Royal College of Surgeons recently raised its exam fees.

Junior doctors, who will have no pay rise for the next two years following the Emergency Budget, say this unfair as college fees are compulsory.

Dr Shree Datta, chair of the BMA’s junior doctors’ committee, said: “We have heard of increases in three different colleges it’s not just the college fees but also the exam fees that are going up so much. I’ve no doubt that in the next few months we will see a couple more following suit.

“You can’t just squeeze more and more money out of people.”

The JDC and the Academy of Royal Colleges Trainee Doctors Group are both calling for college trainee committees to be consulted on fee setting procedures.

Dr Ollie White, SpR in child and adolescent forensic psychiatry, Oxford, co-chair of the Academy Trainee Doctors Group, said: “The issue has increased in profile recently due to a sharp increase in the JRCPTB trainee fees and the fact that trainee fees are now compulsory due to the mandatory requirement for all trainees to be registered with their college under Modernising Medical Careers.”

He said the Academy Trainee Doctors Group were keen to ensure there was trainee involvement within each colleges’ fee setting procedures, for there to be transparency of fees to ensure that they were cost neutral, and for there to be no more sharp increases in fees in the future.

JDC joint deputy chair Johann Malawana said: “With the introduction of these compulsory fees, we see the introduction of a tax on juniors by royal colleges without any democratic accountability.”

The JDC has written to the Academy of Royal Colleges, NHS Education Scotland and Bill Burr, medical director of the JRCTB but have not yet received any replies.

The JRCPTB and the RCOG both blame a withdrawal of Department of Health support for college training and increased costs involved with developing new aspects of the curricula, particularly workplace based assessments and e-portfolios provided by NHS Education Scotland.

A spokeswoman for NHS Education for Scotland (NES) rejected the accusation that their e-portfolio service was expensive.  “We currently charge the colleges who use the NES e-portfolio system £18/trainee/year. Until this year NES have not made a charge for specialist trainees. This charge has been initiated to cover the costs of hosting the portfolio, security checks and ongoing technical support. Deaneries meet the costs of the Foundation e-portfolio.”

She added that the e-portfolios had made a “very significant” improvement in the way in which trainees can record and demonstrate achievement of competences and progression against a curriculum.

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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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“48-hour week is compromising O&G training”

By Mike Broad - 12:09 am

Nine out of ten O&G trainees have had to cover daytime rota gaps since the Working Time Directive was introduced, a survey reveals.

The rise in unfilled posts, following the implementation of a 48-hour week, also resulted in 49% of trainees covering gaps during evenings and weekends and 36% at night.

Over 950 trainees responded to the Royal College of Obstetricians and Gynaecologists’ survey.

It also reveals that 16% of trainees believe their rotas were not WTD compliant at the time of the survey, and nearly all blamed insufficient staff numbers.

Nearly a third of O&G trainees felt that there had been an overall decrease in training sessions.

Respondents felt that achieving competence and the confidence to do independent 2nd on-call duties may be an issue at ST2/3 levels. More alarmingly, those on sub-specialty and advanced training felt that obstetric on-call cover impacted negatively on their training. ST5 trainees feel less confident to do independent out-of-hours acute gynaecology.

Dr Maggie Blott, the college’s vice president (education) said: “The results of this survey will help us to focus on the weak areas in specialty training. It has raised issues which we are particularly concerned about, such as the knowledge gaps and the lack of opportunities to train, which this survey has identified.

“What we need to remember is that O&G is a high-intensity discipline and long shifts where trainees have little rest will compromise safety. We must strike a balance between what trainees can achieve within the confines of a normal working day with the demands of work. We will work with the trainees and trusts to ensure that our trainees receive adequate training and don’t burn-out at the same time.”

On the positive side, trainees mentioned that it was because of the WTD that supervision by senior staff has improved. And it had also resulted in greater consultant presence in the labour ward.

The government-commissioned Temple review recently acknowledged that the WTD had damaged training but suggested the solution lay in truly consultant-delivered services rather than an extension to the 48-hour week for trainees.

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GMC U-turn over recognition of trainees’ exams

By Francesca Robinson - 18th June 2010 9:35 pm

The GMC has backtracked on a ruling about exams being taken within approved training posts that was threatening the validity of some trainees’ qualifications.

Juniors were up in arms in April when the GMC published a note clarifying legislation which stated that exams must be taken with an approved training programme in order to count towards a CCT (certificate of completion of training).

Now, following legal advice, the regulator has announced that it is able to take a more “flexible” approach over the timing of exams.

The GMC, which took over the regulation of postgraduate training in April this year, says it will allow all trainees already in approved CCT training programmes to obtain a CCT even if they passed one or more of their exams before entering the programme.

The same will apply to those already selected to enter CCT training programmes in August.

The GMC will now draw up proposals for discussion on the timing of examinations for future trainees. It says it is clear that there is scope for flexibility to benefit doctors not currently in or about to enter approved training.

A further meeting of key interests will be held in late summer or early autumn to discuss those proposals.

GMC chief executive Niall Dickson said: “This issue has caused a great deal of concern among trainees and we are determined to sort it out as quickly as possible. We have a duty to ensure that exams and other requirements for a CCT form a coherent programme of training but we also have a duty as a regulator to take account of the different ways in which young professionals today plan their careers.”

BMA junior doctor’s committee chair Dr Shree Datta, said: “This change in stance by the GMC will come as a relief to many junior doctors who feared that the retrospective application of an officious legal ruling would have denied the CCT award expected after many years of training.”

But she said they were still concerned about the impact of the GMC’s previous advice on doctors currently taking exams in non-training posts as many may have put off applying for a training programme next year. “It is simply unacceptable for decisions that affect trainees to be taken without prior consultation and with no notice. Medical training takes many years and changes to regulations must take place with the full consultation of all stakeholders so that doctors have the information necessary to plan their careers properly”

She also said there was still some uncertainty about the long term solution. “The BMA will not tolerate advice which leads to retrospective changes to the career paths of junior doctors,” she warned.

John Black, president of the Royal College of Surgeons, commented: “The original proposal would have severely disadvantaged many trainees undertaking academic research, serving in the armed forces, undertaking voluntary work overseas or having to pause standard training route for any number of personal or family reasons. In doing so a lot of excellent surgeons would have found their qualifications ineligible and would narrow down options for personal development.”

Professor Sir Ian Gilmore, president of the Royal College of Physicians, said the GMC’s announcement signalled a much more flexible and pragmatic approach. “Junior doctors in the UK have had more than their fair share of anxiety with regard to training issues in the last few years, and the RCP is committed to avoiding further unnecessary hurdles,” he said.

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“Political will exists to extend 48-hour week”

By Mike Broad - 17th June 2010 9:48 am

The president of the Royal College of Surgeons says there is now the “political will” to tackle the 48-hour week and its damaging effects on training.

Mr John Black said, in the college bulletin, that he had recently spoken to the new health secretary Andrew Lansley and suggested he was sympathetic to the college’s campaign against the WTD.

He said: “The Secretary of State for Health assured me that he has given sorting out the problems produced by the EWTR a very high priority. He is well aware of the current crisis it has produced in the NHS, with deteriorating patient care and seriously compromised training. He knows the massive cost to the NHS, with in one trust 15% of the medical staff budget going to pay for locums for rota gaps that would not exist with a sensible hours regime.

“I told him that there could be no better way for the new government to get surgeons (and I suspect many other doctors working in acute care) on their side than to remove the restrictions of the EWTR.”

Last week, the Temple review acknowledged there are problems with access to training but suggested they would not be eased by either increasing trainees’ work hours beyond 48 hours nor lengthening training programmes.

Instead, the review suggested that rota gaps can only be overcome with a fundamental change in the way training and services are delivered. It says that, despite a 60% increase in consultant numbers over the past 10 years, hospitals remain reliant on juniors to provide out-of-hours services.

Chair Sir John Temple recommended a move to a consultant delivered service, with seniors more directly responsible for the delivery of 24/7 care.

Black said the health secretary has several options to lengthen juniors’ training “including UK primary legislation, a formal sector opt-out within the current European law or a modification to the EU Social Chapter”.

He continued: “The new foreign secretary, William Hague, has indicated publicly that the EU should not set junior doctors’ hours of work. As I have said throughout what is needed is political will and this is now there.”

He said: “The key, given removal of the legal restrictions, is a contract for junior surgeons based on training, with hours worked becoming secondary. Proper hands-on training should become a contractual commitment from employer to trainee. Properly drafted new rules would stipulate team working (the old firm structure), which would restore continuity of care to patients.

“We look forward to working with Mr Lansley to achieve this and it is very good news that he understands the urgency. There are many difficulties to overcome but at last we are moving in the right direction.”

Earlier this year a BMA survey claimed that half of juniors were missing out on training opportunities following WTD implementation.

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