A joint position statement has been released by the Royal Colleges of Physicians (Edinburgh, Glasgow and London), and JRCPTB on the Shape of Training report (ShOT). Since the publication of Professor Greenaway’s report late last year there has been a considerable amount of concern that the recommendations contained within would lead to the decimation of postgraduate medical training in the UK, resulting in a sub-consultant level and inadequately trained doctors. I previously blogged about this in November 2013.
Somewhat unusually there has been no method for concerned parties to comments on or respond to ShOT, and it is still not fully clear which organisations or governing bodies will be responsible for the redesign and implementation of training pathways. The Future Hospital Commission remains a current document in England, but it is not apparent whether the training and restructuring recommendations contained within the FHC will be incorporated into ShOT implementation – or ignored, despite the level of expertise behind them. Discussions have been held between the specialist medical societies who have broadly agreed on a number of pertinent points, and it is reassuring to see these points of concord reflected in the Colleges’ statement. In an opinion piece published in the British Medical Journal this week, the Presidents of the Association of British Neurologists and the British Cardiovascular Society also make this point, and state that ShOT should be a green paper for discussion and debate, and not a bill for implementation. They warn of a likely repeat of the mistakes and damage that occurred in 2007 at the time of Modernising Medical Careers (MMC).
There is agreement with the exploration of the balance between internal medicine and specialist medical care, and training in settings outside of the hospital, however emphasis that there is also a need to maintain excellent specialist care. I feel that this statement supports the way that many of geriatricians already work, and that this is an opportunity to show other specialities how doing it ‘our way’ leads to effective, high quality, patient care. Support is also given to the plan to support life-long development for all doctors, and reintroduce support and consistency for junior doctors, much of which was lost in the MMC debacle. It is imperative that we continue to stress that geriatric medicine is a speciality in its own right, and not just a branch of generalism. Although an improvement in the care of older people by doctors is to be welcomed, there are a group of patients who specifically need to be under our care.
The position statement puts forward a number of challenges to be addressed. These are more complex than the points of agreement, but summarise the pertinent ShOT issues which have caused most concern to the profession. Pertinent themes include:
- The length of higher specialist training. Any reduction in time would lead to the risk of compromising the quality of care that a CCT holder is able to deliver, so the Colleges are maintaining their position that a minimum of 7 years post foundation training is essential. There is also welcome acknowledgement that people develop and become competent at different rates. The proposal to allow junior doctors to spend a year of an already shortened training programme gaining experience in a different area is criticised, and the suggestion is made that broadening of experience should be encouraged but taken as an additional year.
- Dual accreditation for all bed-based specialities is welcomed If progressed, this could have positive effects for our speciality. If more doctors dual-accredit, then there will be more people taking the part in the medical registrar rota. This will ease the burden on those specialities who are currently performing most of the work (geriatrics and diabetes, and general improve conditions. This could have a direct impact on recruitment of junior doctors wanting to pursue geriatric medicine as a career, there are clearly some who would make excellent consultants but are put off by the internal medicine part of the medical registrar role.
- Credentialing and post-CCT training.This is one of the areas of greatest discomfort and concern. Some specialities, for example gastroenterology, welcome the opportunity to deliver their higher training in this way. Others (geriatrics, cardiology, rheumatology) are not able to package their speciality up into ‘modules’ which can be learnt at different times because while a minority of super-speciality areas or procedures could be dealt with in this way, there is a level of broad based knowledge that is needed for all CCT holders within a specific field. The position statement emphasises that any post-CCT programmes that are developed must be “planned, competency based, supervised, quality assured, funded and managed to consistent and high standards on a national basis.”
We still don’t know where ShOT is going, who is managing it, and what the outcomes are going to be. This joint statement, together with the BMJ piece, imply that the bodies we are professionally dependent on may be listening to the opinions put forward to them, and also that there is a sense of agreement between the medical specialist societies.
Unfortunately “watch this space….” Is probably still the main message