The Future of Medical Training in the UK
Professor Sir John Temple
The meeting started at 7pm with a welcome from the LMI President, Mr Roy Farquharson, to members of the LSA. He then handed over to Dr John Chambers. Dr Chambers reported the sad news of the death on December 9th 2006 of Dr Julie Nash, Consultant Anaesthetist at Whiston Hospital and LSA member. There was a minute’s silence in her memory. After the signing off the minutes of the last meeting, Dr Chambers introduced the speaker, Professor Sir John Temple.
Professor Temple began by describing his background. Having qualified and worked as a trainee in Liverpool, he was appointed as a consultant surgeon in Birmingham in 1979 and was given a personal chair in 1994. In education, he was the Post-Graduate Dean for the West Midlands Deanery 1991-2000 and was special adviser to the previous CMO, Dr Kenneth Calman and current CMO, Sir Liam Donaldson. In recent years he has been President of the Royal College of Surgeons of Edinburgh and Chairman of the Specialist Training Authority of the Medical Royal Colleges (predecessor of PMETB).
Professor Temple continued with the background to the current educational reforms. Following Bristol and other medical ‘scandals’, there had been both a public and professional crisis of confidence in standards of medical practice. Error is inevitable but many errors from one individual is not acceptable. There came an understanding that service should be delivered by trained doctors and doctors in training should be properly supervised and act within their competencies. The NHS employs 1.3m people, the third largest employer after the Chinese army and the Indian railways. Over the last 10 years, there has been an increase in numbers employed by the NHS by 38,000 every year. This is where the additional monies have been spent. Consultant numbers have increased from 17,900 to 29,600, a 45% increase with an additional 58% increase in trainee numbers.
Professor Temple saw the current problems in medicine as the following. Firstly, despite the increased numbers, the UK was still chronically short of doctors, training was still too long, the gender shift in doctors meant that still more were needed to compensate for the rise in flexible working and the overseas supply was now drying up. To illustrate his points, he showed the doctor:patient ratio in France was 300:1 with a total medical workforce of about 200,000. This compared to England and Wales where the ratio was 600:1 with a workforce of 130,000. In comparison the ratio in India was 3000:1 from where the UK had been trying to recruit. 9% of the NHS workforce were doctors, 30% nurses, 45% other supporting workers and only 3% were managers. Undergraduate intake had increased by ~50% over the last 10 years but 70% were now female and there was general agreement that approximately 1ψ women were equivalent to 1 man to compensate for increased flexible working. There were also other constraints on the workforce such as work-life balance and the EWTD.
Professor Temple said that there was no doubt that performance declines with fatigue. The fundamental problem was that there were too many small and medium sized hospitals which needed ever more doctors to staff them out of hours because of the EWTD. However because of their size, there was often inadequate numbers of patients for training purposes and trainees were not gaining the necessary experience in these posts. Prior to 1995, the average trainee spent 10 years in training doing 80 hour weeks and had a clinical exposure of about 36,800. This compares currently with 8 years of training doing a 48 hour week totalling about 17,600 hours. Professor Temple argued that this would be beneficial as a lot of the work that trainees did, were repetitive tasks of little training or educational benefit. He said that there were several solutions to this problem. These were producing or importing more doctors, passing on tasks traditionally performed by doctors to others and reconfiguring services.
Professor Temple said that medical education had been unchanged for many years until recently. It had been based on an apprenticeship and was repetitive, experiential and unsupervised. It had been education by random opportunity but trainees had had a large exposure because of their long hours of work. This was no longer acceptable. Now there were major constraints on time not only for the trainees but also the inpatient population was dramatically decreasing with the increasing emphasis on daycase work. The public also expect to be treated by competent professionals. He then went onto describe the changes initially started with the Calman reforms going onto the new system of Modernising Medical Careers.
Professor Temple stated that the aim of training was to produce independent practitioners. Service would be delivered by trained doctors and doctors in training will only deliver service they need for training. Clinical practice is constantly changing and some of the skills learned in training may no longer be needed when trained. But with life long learning, new skills can be acquired during a professional lifetime. Robust assessment is always important because this drives learning and maintains standards. The role of simulators should be increased which were now relatively sophisticated but few in number. He stated his 5 key principles of education as firstly competitive entry, programme based training, limited numbers by discipline to prevent over-production, programmes to be time capped and a clear exit point. Programmes should be curriculum based with robust formal assessment.
The new curricula were presently being submitted to PMETB and there would be a greater emphasis on the acquisition of competencies. There were real question marks about the future role of formal examinations. There would be 3 principle stages of assessment, firstly at entry level to training after the foundation years, then at completion of training and finally with regular revalidation. There were several things still missing such as academic opportunities, a defined role for the Colleges and a time cap for each discipline so exit is prescribed.
Professor Temple finished his talk by saying that he felt that with the reforms in medical training, the public could be assured that only competent doctors would be produced, trainees could be assured that only the incompetent will fail and the wider profession could be assured that standards would be maintained.
Dr Chambers thanked him for speaking and asked for questions from the floor. He started by asking whether MMC had been given such a bad press because it was perceived as a threat to the Royal Colleges or that the profession found it difficult to deal with change. Professor Temple answered by saying that he certainly thought that change was perceived to be very difficult and that consultants were, at times, too independent and sometimes slow to change working practices. The Colleges were also too numerous, there being 3 for both surgery and medicine and were all saying different things ultimately making it easier for them to be sidelined. The Academy of Royal Colleges may help with this allowing the profession to speak with one voice.
Other comments and questions from the floor included one from Dr Simon Ridler who said that general training can improve experience and deferment of career choice may help to make this more committed in those that are initially uncertain. Professor Temple commented that there should be opportunities for crossing over to alternative training schemes if the initial choice was felt to be wrong but there was likely to be stiff competition. Eoin Young asked what the career prospects for those in training expecting CCT around 2011 after press reports about potential medical unemployment among CCT holders at this time. Professor Temple said that predicting manpower so far ahead was always fraught with difficulty and more than likely the changes under the EWTD would mop up excess numbers. The only real problem he could foresee was if practice changed, as was currently the case in cardiac surgery where increasing medical advances were sidelining surgery. Dr David Gray asked why deanery budgets were being reduced for study leave when both trainees and consultants need more time for education. Professor Temple said that the Department of Health needed to understand that a quality service cannot be maintained without quality education.
Professor Jenny Hunter gave the vote of thanks and the meeting ended at 20.45.