Transcript Document

How does the regulator
plan to cope with change in
the medical workforce?
Dr John Jenkins CBE
Chair, Postgraduate Board
The current model of education and training of doctors,
for which the GMC has overall regulatory responsibility, is
seen as high quality but has limited flexibility
Provisional
registration
Medical School
(4-6 years)
Certificate of
completion of
training (CCT)
Full
registration
F1 year
(1 year)
F2 year
(1 year)
Specialty/GP
training
(3-8 years)
Specialist/GP
register (to
retirement)
SASG (specialty doctors)
Cowboys and Pit Crews
Atul Gawande
“The rapid growth in medicine’s capacities is not just a
difference in degree but a difference in kind.
… medicine’s complexity has exceeded our individual
capabilities as doctors.
The public’s experience is that we have amazing
clinicians and technologies but little consistent sense that
they come together to provide an actual system of care,
from start to finish, for people. We train, hire, and pay
doctors to be cowboys. But it’s pit crews people need.”
Context for the debate

GMC assuming responsibility for regulating all stages of
medical education and training including undergraduate, foundation, specialty
(including GP), continuing professional development

Increasing recognition of importance of increasing
flexibility whilst maintaining standards throughout
medical education and training

Implementation of Quality Improvement Framework
GMC Quality Improvement Framework
Quality Improvement Framework:
Four elements
Approva
l
against
Standar
ds
Education strategy 2011-2013
Setting and assuring standards,
and valuing education and training:
Ensure that the standards we set
provide a framework for excellence and
that we are proactive in maintaining
compliance
Defining outcomes for education and
training:
Define clear outcomes which must be
met by students and trainees on
completion of different stages of training
Education strategy 2011-2013
Working with partners and promoting
feedback and learning:
We will work with all those
organisations, groups and individuals
who have a stake in medical education
and training. We will develop
mechanisms to feedback what we have
learned to encourage learning and
improvement
Promoting effective selection,
transition and progression:
Ensure there are clearer progressions
between the stages of medical
education and that risks associated
with transitions are better managed
Cowboys and Pit Crews
“You are the generation on the precipice of a
transformation medicine has no choice but to
undergo, the riders in the front car of the roller
coaster clack-clack-clacking its way up to the
drop.”
3 apprenticeships of learning
The cognitive apprenticeship, where the learner develops
knowledge and understanding
The practical apprenticeship, where the learner develops skills and
competencies
The moral apprenticeship, where the learner develops the ability to
practise medicine with integrity and respectability
Shulman described these as the habits of
the head, the hands and the heart
which need to continue as long as we practise medicine
Framework for Appraisal and Revalidation
4 domains
Knowledge, Skills and Performance
Safety and Quality
Communication, Partnership and Teamwork
Maintaining Trust
Professionalism - the doctor as:
Practitioner
Partner
Leader
Foreword to TD 2009
“It is not enough for a
clinician to act as a practitioner in their own discipline.
They must act as partners to their colleagues, accepting
shared accountability for the service provided to patients.
They are also expected to offer leadership, and to work
with others to change systems when it is necessary for the
benefit of patients.”
A flexible model - for the future
Competencies are necessary but not in themselves sufficient
for safe and effective practice as they are limited to visible
behaviour and its measurement. This overlooks the subtleties
of sensitivity, imagination, wisdom, judgement and moral
awareness that are the mark of a wise doctor.
Competence (a holistic understanding of practice and all-round
ability to carry it out) is a better goal than competencies (a
series of discrete skills that are learnt and assessed
separately).
Developing the wise doctor – Fish & De Cossart
Environment unfamiliar
CAPABILITY
Task familiar
Task unfamiliar
COMPETENCE
Environment familiar
Martin Talbot
Professionalism
“A set of values, behaviours, and relationships that underpins
the trust the public has in doctors.”
It is important to balance the need for increased specialisation
WITH
the need for a holistic approach to health which takes account
of physical, mental, emotional and spiritual aspects.
Good Practice in
Prescribing
Personal Beliefs
In
Medical Practice
Acting as an
Expert Witness
Reporting
Convictions
Raising
Concerns
The wise doctor
“… brings together the context, professionalism, knowledge,
clinical thinking and professional judgement for the best
interests of the individual patient.”
This can only be achieved through a continuum (spiral) of
lifelong learning, based on solid foundations established during
undergraduate and postgraduate education and training, and
with clear connections to continuing professional development.
Professionalism in Action
‘A set of values, behaviours, and relationships that underpins
the trust the public has in doctors.’
For each of us and throughout our career this requires –
Competence, capability and confidence
Preparation for practice as individual and team member
Reflection, mentoring and leadership
Regulatory systems (professional and systems) must
promote and underpin these values and behaviours,
including through appraisal, clinical governance and
revalidation
Patient-centred partnership
Capability
Communication
Conscience
Care
The hospital is dead, long live the hospital
“NHS hospitals currently try to be all things to all people
and deliver every healthcare service to everyone.
This is no longer clinically or financially sustainable and it
holds the NHS back from delivering better, safer and
higher quality care.”
Professor Paul Corrigan CBE, Caroline Mitchell
Reform, September 2011
Context of care delivery - Telehealth
A flexible model - for the future
The state of medical education and practice in the UK 2011
“Doctors need to be equipped to deal with changing
healthcare needs. We believe postgraduate training should be
reviewed to ensure it is flexible enough to allow doctors to
move between specialties.
Doctors also need a higher level of core competence than
training programmes currently allow.”
A flexible model - for the future
“The major demand on healthcare over the next 20 years will
be the ageing population and with it increasing prevalence of
long-term conditions and multiple pathologies and a need for
high quality end of life care.
There will remain a huge demand for elective and acute care
in hospital settings, but it will be essential that the education
of doctors keeps pace with the shifts in healthcare design
and delivery and creates doctors who can work flexibly in
new environments.”
A flexible model - for the future
“There is an ongoing discussion about whether the structure
of training should allow greater flexibility for trainees to
transfer between specialties, for example, if trainees find that
they are better suited to another specialty or where
workforce requirements change.
The current architecture for training does not easily allow for
this.”
Generic outcomes for specialty curricula
“In 2011, we will begin to consider the scope for setting out generic
outcomes for postgraduate training (for example, key components
of the Good Medical Practice framework for appraisal and
assessment such as leadership, communicate effectively,
establish and maintain partnerships with patients, share information
with other healthcare professionals for safe and effective patient
care, put into effect systems to protect patients and improve care
and apply knowledge and experience to practice).”
A flexible model - for the future
We are working closely with the Academy of Medical
Royal Colleges, COPMeD and others in the development
of a number of initiatives designed to improve the
flexibility of postgraduate medical training whilst
protecting its quality.
These include transferable competences and a broadbased programme.
A flexible model - for the future
Training in remote & rural
placements
Remote & Rural training environment
“Regional General Hospitals are recognised as having
potential to be good training environments for trainee
doctors.
The trainee will work directly with consultant and other
senior staff and they are provided with the opportunity to
work autonomously (within their capabilities), within a
supervised and supportive environment.”
Training the right medical workforce
“If trainee doctors are not exposed to the remote and rural
environment as part of their training, it will put at risk the
sustainability of hospital services within remote and rural
areas.
One of the key deliverables identified within ‘Delivering for
Remote and Rural Healthcare’ therefore was the
sustainability of the flow of young doctors into rural
specific training in the core specialities of general
medicine, general surgery, anaesthesia and General
Practice.”
Recognition in current UK-wide curricula
Curriculum for CCT in Anaesthetics
One of the eight ‘optional higher units of training’ • Ophthalmic;
• Pain medicine;
• Plastics/burns;
• Pre-hospital care;
• Anaesthesia in developing countries;
• Conscious sedation in dentistry;
• Military anaesthesia;
and
• Remote and rural anaesthesia
Other core specialty training
Medicine – mixed economy of routes into remote and rural
medical practice, the main training pathway being via a CCT in
Acute Medicine with a special interest in Remote and Rural
Medicine. Whilst it is likely that the consultant led model will
continue, GPs appropriately trained are providing important
input in some areas.
Surgery – surgeons in remote and rural practice require a
broadened general training, including experience in some
aspects of Emergency Medicine (formerly A&E), Orthopaedic
Surgery, Urology, Obstetrics and Gynaecology, Neurosurgery,
otorhinolaryngology, ophthalmology and plastic surgery.
Reshaping the medical workforce
“a joint project between the Scottish Government and NHS
Scotland that is designed to increase the number of trained
doctors delivering front line services and reduce the reliance on
doctors in training. Transition to this revised model of service
requires difficult decisions about the distribution of training posts
across Scotland.
The future model for RGHs should always include a number of
trainee doctors exposed to R&R life and work in order to secure a
healthy supply of R&R trained doctors for the future. That these
trainee doctors also contribute to and gain from the R&R services
in which they are placed is important not only to these services,
but also to the development and career-direction of the trainees.”
Possible future developments?
Credentialing Steering Group Report
“The literature review report suggests that there is an urgent
need for recognition of competence attained in discrete
areas of practice, not covered by either CCTs or by PMETB
recognised subspecialty training, e.g. forensic and legal
medicine, breast disease management, remote and rural
medicine, cosmetic surgery etc.”
Three current pilots - forensic and legal medicine, breast
disease management, musculoskeletal medicine.
Shape of Training
“We believe there should be a fundamental review
of the shape of postgraduate training and we are in
discussion with the four departments of health, the
Academy of Medical Royal Colleges, the Medical
Schools Council and others about taking forward a
review of the shape of postgraduate training.
In our view, this work needs to be focused and time limited
with conclusions by the end of 2012.”
Principles of better regulation
Development of the QIF was guided by the five principles for
assessing and improving the quality of regulation:
• Proportionality - Regulators should only intervene when
necessary. Remedies should be appropriate to the risk posed, and
costs identified and minimised
• Accountability - Regulators must be able to justify decisions and
be subject to public scrutiny
• Consistency - Government rules and standards must be joined up
and implemented fairly
• Transparency - Regulators should be open, and keep regulations
simple and user-friendly
• Targeting - Regulation should be focused on the problem and
minimise side effects
Cowboys and Pit Crews
Atul Gawande
“Recently, you might be interested to know, I met an
actual cowboy. He described to me how cowboys do their
job today, herding thousands of cattle. They have tightly
organized teams, with everyone assigned specific
positions and communicating with each other constantly.
They have protocols and checklists for bad weather,
emergencies, the inoculations they must dispense. Even
the cowboys, it turns out, function like pit crews now. It
may be time for us to join them.”
What is the GMC doing to improve training?
 Clarifying the standards of training (for today’s healthcare) and
education (for the challenges of tomorrow, including complexities,
uncertainty and risk)
 Securing an identified individual responsible and accountable for the
quality of training delivered locally
 Maximising the value of training time, including the experiential and
environmental components
 Aiming for excellence (building on competence and including
confidence) in personal responsibility for the quality and safety of care,
delivered in the context of team-based approach to management