Unfinished Business: Proposals for Reform of the Senior House Officer Grade
A New Framework for Training
This section describes the principles on which it is proposed to base a new framework for training. It sets out a series of recommendations to reform basic specialist and general practice training.
Setting the scene
3.1 If reforms to the SHO grade are to be successful they will need to operate within the continuum of training, with clear and effective links to career posts and appointments and with explicit training pathways leading to clear training goals. A key element is flexibility - the ability to support and accommodate varying needs of trainees and to respond to changing and challenging service demands.
3.2 The components of the new system and the principal training pathways that link them are set out in the diagram at Annex E. They are also all addressed in this chapter.
Lessons from the reform of higher specialist training
3.3 It is useful to draw on experience of commissioning the most recent major change to medical training. Reform of higher specialist training began ten years ago. It represented a fundamental change not only for doctors in training but for supervising consultants, educational bodies and NHS organisations. It affected: career structure; professional development; employment; service delivery; planning of the medical workforce; assessment and research. The programme of reform was unprecedented and delivered successfully over a short period of time. It provides many important lessons 8 which can guide reform of the SHO grade. Key messages are:
to set out a clear set of principles to guide reform at the outset;
to publish programme curricula - geared to deliver clear standards and be understandable by supervisors, trainers and trainees;
to ensure a coherent approach to setting standards and managing the delivery of training. This should involve competent authorities, postgraduate deans, educational supervisors, medical Royal Colleges and the service;
to place strong emphasis on the quality assurance of training;
to ensure a consistent and valid approach to assessment;
to provide robust and reliable information systems to support the management of training;
to introduce a sound process for the selection of trainees;
to have robust and effective processes in place to provide career counselling and advice;
to manage training-service tensions. Specifically to ensure:
a strong 'apprentice-based' focus, especially in the craft specialties;
the 'knock-on' effects of change on other career and training grades and the local delivery of services are anticipated and understood;
flexibility in training arrangements;
that any increased consultant workload can be supported.
to ensure that medical research is not disadvantaged by the changes;
to prepare adequately for managing change, ensuring that doctors in training are able to influence and participate in implementing reforms.
Five principles for reform for SHOs
3.4 Key principles underpin the organisation and delivery of the proposed reforms.
Five Key Principles for reform of training for SHOs
training should be programme-based;
training should begin with broadly-based programmes pursued by all trainees;
programmes should be time-limited;
training should allow for individually tailored or personal programmes;
arrangements should facilitate movement into and out of training and between training programmes.
3.5 These principles should be underpinned by commitments to provide flexible training (less than full-time training) and early and regular career advice. Young doctors should get advice about career planning, recognising both the needs and competence of the individual and the likely demands of the service.
Proposals: 1. The five key principles should be the basis for reform of basic specialist or general practice training. 2. There should be sufficient opportunities for flexible (part-time) training. 3. There should be access to early and regular career advice. |
A programme-based approach to training
3.6 A programme-based approach to training would substantially address the problems of the SHO grade. The approach would ensure that as many doctors as practicable, wishing to enter specialist or general practice training, are able to do so.
Features of a programme-based approach to training: is accountable and closely managed; is curriculum-based; requires formal entry requirements; provides planned and structured training including assessment and appraisal; is time-capped to prevent post or programme-blocking.
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3.7 Two types of programme would apply during this first phase of postgraduate training:
broadly-based programmes pursued initially by all doctors seeking to enter higher specialist training or general practice;
more tightly-focused individual programmes entered subsequently by a limited number of trainees. These will provide a high degree of supervision to support those needing further development to meet agreed, individual training goals.
3.8 Trainees would follow a co-ordinated series of placements within a managed programme delivering defined training goals. The approach would:
support flexibility (enabling switching between specialties, including general practice);
enable common inter-programme training activity to be recognised and credited;
improve opportunities to re-enter training from, for example, doctors:
necessitate formal systems of appraisal and assessment (moving to competence-based assessment as practicable) which would also support General Medical Council revalidation;
introduce a training number system which would support workforce planning as well as educational and financial management;
provide for non-UK graduate entrants.
3.9 Following graduation and during the first four or five postgraduate years (encompassing what are the current pre-registration house officer and SHO grades), all doctors require:
Both are essential and should be delivered through training programmes providing a breadth of clinical experience. This balance, however, may differ between different specialties or specialty groups.
3.10 This phase of training would have two main building blocks or programmes:
Foundation programmes
3.11 All doctors would undertake an integrated, planned two-year foundation programme of general training:
the first year would equate to the current pre-registration year leading to Full Registration;
t he second year would be post-registration and build on the first year by providing further generic training.
3.12 Foundation programmes would have two key purposes:
to develop core or generic skills essential for all doctors. Training would extend and consolidate the knowledge, skills, values and attitudes acquired in medical school and set out in the General Medical Council's Good Medical Practice 9. They would also provide skills in those essential requisites of modern medical practice: for example, the ability to form effective partnerships with patients, the ability to work towards high standards in clinical governance and patient safety, skills in the use of evidence and data, competence in communication, team-working and multi-professional practice, as well as capability in time management and decision-making;
to provide direct experience of different specialties (especially those disciplines that do not form a significant part of the medical school curriculum) and to gain experience in dealing with seriously ill patients.
The first year would form part of basic medical education, shaped by existing requirements for pre-registration house officers. The second would count towards meeting the requirements for specialty or general practice training and would be the responsibility of the relevant competent authority. 10 A shared arrangement between the General Medical Council and the proposed Postgraduate Medical Education and Training Board would be required to supervise foundation programmes.
3.13 An objective of the foundation programme would be to give new graduates broader experience of medicine and of the career options available to them. Such experience would strengthen insights into the essential links between different specialties and between primary and secondary care, and in the roles of other health professionals and how to work within them in teams. It is not proposed that foundation programmes be any more 'classroom-based' than existing arrangements for pre-registration house officers and first year SHOs. As now, the major portion of time would be spent in service settings - although those settings are envisaged as having more variety than at present. During the second year of a foundation programme the trainees would be much better equipped to provide flexible service cover than current first-year SHOs.
Basic specialist training programmes
3.14 By the second year of the foundation programme the doctor would have had an opportunity to sample a range of practice. It is during this second year that all trainees would compete to enter one of a number of broadly-based basic specialist training programmes. These would allow them:
to gain experience and develop their clinical skills in a broad specialty grouping;
to prepare for competitive entry to higher specialist training in their chosen specialty; or
to enter general practice and undertake further post-certification education.
3.15 There should be enough places in these programmes for all SHOs who have completed foundation programmes and also to accommodate some EEA and overseas-qualified doctors coming to the UK for further training. However, trainees entering basic specialist training programmes will not necessarily be successful in obtaining a place in the programme of their first choice. It will be important to incorporate support structures into the new system.
3.16 These programmes would provide a breadth of education and training but would focus increasingly on basic specialist or discipline-based skills. As far as practicable, career flexibility would be encouraged with the option of switching career paths. There should be provision for relevant training to be 'credited' to any new programme which the doctor might seek to follow.
3.17 The composition and number of these basic specialist training programmes should be decided during the implementation phase of the reform programme and take into account:
links to programmes of higher specialist training;
general practice training requirements;
workforce requirements;
the needs of patients and the service.
However, the model tested by the Working Group, which was generally accepted by those submitting evidence, envisaged eight programmes as follows:
3.18 These programmes will differ. Their exact composition and duration will require further discussion but they should provide for the needs of general practice and most specialties. However, the requirements of other specialties such as public health, radiology, and occupational medicine would require specific consideration.
Proposals: 4. After graduating doctors should undertake an integrated, planned two- year foundation programme of general training: 5. After completing their foundation programme, doctors should enter a basic specialist training programme providing a breadth of education and training within certain broad clinical disciplines. |
3.19 An important feature of this process is that programmes should be time-capped. It will not be acceptable for individual trainees to spend significant periods as SHOs beyond that necessary to complete this stage of training. Trainees will be expected to make reasonable progress through to completion of training and then to move on. This will generally be into higher specialist or general practitioner training but may, for example, be into an individual programme (see below) or temporarily into a service post outside the training structure.
Individual training programmes
3.20 A limited number of placements on more tightly-focused individual programmes designed to meet the specific training needs of individual doctors will be required.
3.21 Individual programmes would:
be managed closely with clear criteria for assessing eligibility for entry and regular assessment of trainees' progress within the programmes;
provide a strictly limited number of placements;
not provide a temporary 'sanctuary' for those requiring more time to study for Royal College examinations.
3.22 An individual programme would be suitable for:
re-direction of training: For most doctors seeking to change career path, the expected route will be to apply in competition for a new basic specialist training programme. Wherever practicable they should enjoy recognition of equivalent or accepted training already undertaken. 'Transferable credits' in areas of education and training common to the new and old programmes should ease transfer. However, for some doctors the additional training needed to meet the requirements for a switch of career path could be met instead through an individual programme;
return to training: Many doctors seeking to re-enter training from non-consultant career grades, research or wishing to move to or from general practice could find the support of an individual programme useful. It should help them prepare for competitive entry to advanced or higher levels of specialist training or for general practice training;
doctors entering training from elsewhere in the EEA and from overseas: Individual programmes might provide one route for preparing some of these doctors for competitive entry to training or short periods of specific training to meet individual needs before returning home;
remedial training: For those who have not made the necessary progress through basic specialist training programmes.
Proposal: 6. A limited number of placements on individual training programmes should be provided for those doctors requiring: remedial help; support in changing career direction; or who wish to re-enter training to prepare for competitive entry to higher specialist or general practice training. |
Time-capping programmes
3.23 All programmes will be time-capped but this must be flexible enough to reflect, for example, the requirements of those doctors whose training is part-time or whose training is interrupted. Time taken to complete a programme will be governed by the needs of the particular programme but must also take the needs of the individual trainee into account.
3.24 Time-capping:
is an inherent part of sound programme management;
helps trainees to move through programmes designed to meet their requirements;
enables trainees to make decisions about future career directions;
reduces uncertainty for trainees.
3.25 Trainees cannot remain in a training programme for extended periods of time but they should have reasonable opportunities to complete the programme. For sound educational reasons some may take longer to complete a programme than the time agreed for the programme. In such special circumstances:
the time-capped period for the programme may be extended to meet their particular needs, subject to an upper limit beyond which further extensions cannot be made; or
the doctor, after counselling, may seek:
3.26 These arrangements are separate from circumstances where:
the programme is extended to accommodate an agreed career break or leave of absence due to illness;
a time-capped 'period of grace' is granted to a doctor at the end of a programme to enable her or him to make arrangements to move to the next stage of professional development. For example, those doctors who have completed basic specialist or individual programmes, but who have not been successful in securing a place on a higher specialist or general practice training programme, should benefit from a time capped ' period of grace'. Although in-grade but out-of-programme, the postgraduate medical dean remains responsible for their development. This ' period of grace' would allow the doctor:
to prepare for the next phase of training;
to gain further managed, assessed and supervised service experience;
to consolidate skills;
to complete medical Royal College examination requirements.
3.27 Time spent in placements or posts during the ' period of grace' would be limited, but could vary depending on the needs of both doctor and service. To some degree this reflects the present situation where doctors can consolidate experience by spending a further period in the SHO grade. As a consequence there are service benefits which may help to meet the increasing demands of the European Working Time Directive.
Leaving training
3.28 Time-capping basic specialist and individual training programmes will mean that there will be a group of doctors who will not have been able to progress to higher specialist training or to general practice. For example, at the end of a ' period of grace' doctors would have to move on and, if they were not moving into higher specialist training or general practice training, leave the training grades. This could mean taking a post in a non-consultant career grade. This subject is discussed again later in the report.
Proposal: 7. Following completion of a basic specialist or individual training programme, those trainees unable to progress directly to higher specialist or general practice training should be allowed a period of grace before leaving training. |
Assessment and examination
3.29 The proposals support a greater emphasis on competency-based assessment throughout training and as evidence of successful completion of training. This will take time to achieve. Thus, progress through training will continue to be informed by success in medical Royal College examinations and increasingly, by the Record of In Training Assessment (RITA) process as it is introduced for SHOs.
3.30 There is striking variation in examination practice across medical Royal Colleges and Faculties and in the arrangements for setting and quality assuring the standards of examination practice. In their present form, Royal College examinations are not clear indicators of satisfactory progress through specialist medical training.
3.31 It is proposed that a new Postgraduate Medical Education and Training Board will be required to ensure that, throughout training, all assessments and examinations (with the consequent classification of trainees) are appropriate, valid and reliable. 11
3.32 Royal College examinations will remain an important component in the assessment of trainees complementing in-course assessments and appraisal. However, no comprehensive and fundamental review has been undertaken of Royal College examinations in the round. Nor are they subject to any external quality assurance, which is unusual compared to other fields of education and training. Examinations should be "fit for purpose", supporting evidence that a doctor has reached a required standard for clinical practice. There needs to be greater co-ordination of the timing of examinations with trainees' progress through programmes. The amount of 'marking time' by trainees waiting to achieve the entry requirements of the next phase of training could be reduced by ensuring that the examinations take place before trainees are due to complete their programme and that the standards of the examination are linked to the programme objectives. A review of the medical Royal College examinations by them would be very valuable and it is understood that the Academy of Medical Royal Colleges has already started work on this.
Proposals: 8. Progress through programmes should be determined by assessment. 9. In the longer-term assessment should move towards a competence-based system. 10. The purpose of the Royal College examinations should be reviewed and a system of external accreditation introduced. |
Managing training
3.33 Postgraduate medical deans are responsible for managing the delivery of postgraduate training to standards set by the competent authorities. The medical Royal Colleges and their faculties work through the competent authorities and have a key role in supporting postgraduate training.
3.34 In recent years there has been significant change driven by reform of higher specialist and pre-registration training and better management of training for general practice. In England postgraduate deans now work closely with Workforce Development Confederations, universities, medical Royal Colleges, NHS employers, supervising consultants and general practitioners to ensure effective delivery of postgraduate training. There are equivalent arrangements in the other UK countries.
3.35 The SHO grade, with multiple stand-alone NHS trust appointments, has proved difficult to manage. A programme-based approach to training will enable postgraduate deans to extend the same level of supervision and management as presently apply elsewhere in the training continuum. Under the proposals the postgraduate dean would be responsible for:
ensuring that the doctor in training receives, in advance, information relating to her or his intended training programme;
the appointment of trainees to programmes;
managing the delivery of the new programme-based training arrangements. These should become the responsibility of programme directors rather than individual NHS trusts. Programme directors should be part of the postgraduate deanery, accountable to and appointed by the postgraduate medical dean after consultation with the relevant Royal College or Faculty;
ensuring that trainers are adequately supported and trained. The introduction of programme-based training will mean greater emphasis on both the quality of the training placements within programmes and therefore on the skills of trainers.
Proposals: 11. Programmes should be managed by programme directors appointed by, and accountable to, postgraduate medical deans. 12. Trainers should be supported and trained. 13. Key information on programmes: the arrangements for appointment and induction; the curriculum to be followed and the procedures for assessment must be made available to all trainees. |
Recruitment and appointment to training programmes
3.36 Postgraduate deans should be responsible for the recruitment arrangements to all programmes: foundation; basic and higher specialist and individual programmes, as they are now for specialist registrar posts. They and employers will need to ensure that NHS equal opportunities and sound employment practice prevail. In particular:
a national system of matching may suit appointment to foundation programmes;
doctors will compete for entry to basic specialist programmes during the second year of their foundation programme and, as not all will be admitted to their first-choice programme, there will need to be provision to enable alternative applications. Equally, there will need to be provision for those seeking to switch programme and who seek credit for training undertaken.
the arrangements for appointment to the limited placements on individual programmes will need particular consideration. It will be necessary to reconcile different interests: those seeking further time in basic specialist training, those returning to training and the possible placement of some
non-UK graduates entering the country for the first time.
Proposal: 14. The appointment arrangements to all programmes should be the responsibility of the postgraduate medical dean. They should meet published nationally agreed standards and practice. |
Funding training
3.37 At present in England, 50% of the basic salary of SHOs is funded from an education levy. The remainder of the salary including additional costs falls to the employing NHS trust. Currently 100% of the basic salary of pre-registration house officers and specialist registrars is funded from the levy. In Scotland funding now provides 100% of basic salary costs of all trainees. This raises the question of whether 100% of SHO salaries should be met by this method in England. There are arguments in favour. For example, it may be easier to fund less attractive posts, it may help fund cross-Trust placements and the development of programmes and it should aid integrated planning. There are counter-arguments. The balance of arguments will have to be weighed carefully following consultation.
Specific training requirements
General Practice
3.38 General practice should be regarded as a specialty equivalent to other specialties for the purposes set out in this report.
3.39 All doctors, whatever their career choice, should follow a similar model of training beginning with a two-year generic foundation programme, followed by competitive entry to one of eight or so time-capped basic specialist training programmes. Where practicable, all doctors on foundation or basic specialist training programmes should benefit from some training in general practice.
3.40 One of the basic specialist training programmes will provide specific training leading to certification in general practice. The principles applying to foundation or basic specialist programmes must apply equally to general practice programmes. For example, it must be possible for doctors at this stage of training to switch between hospital specialist and general practice programmes in the same way as they may switch between different specialist programmes.
3.41 The minimum period of vocational training is determined by statute and is currently three years. This requirement might be met by:
the second year of the two-year foundation programme in which some time could be spent in general practice; and
a two-year general practice programme. Trainees would follow, as now, a mixture of hospital and general practice-based training with a period of not less than 12 months training in general practice. Doctors would compete to enter this programme. The programme must ensure that the hospital components of the training programme take into account the needs of trainee general practitioners.
Proposal: 15 The SHO element of general practice training programmes should follow a similar model to those for hospital disciplines. |
Dentistry
3.42 High standards of practice in dentistry are based upon sound training and clearly defined educational programmes which broadly parallel those in medicine. There are many core skills which are held in common with medicine with considerable overlap of the educational and training processes. However, there are areas of difference. Specific recommendations for the future of the house officer and the senior house officer grades in dentistry are at Annex F.
Doctors qualifying outside the United Kingdom
3.43 Doctors who qualified outside the UK currently make up over a third of the SHOs in England. They are an important group who should have fair and equal access to high quality training programmes. They are not a homogeneous group. Some may already have extensive clinical experience in the UK while others will have recently come to this country.
3.44 The requirements for each doctor would best be met by:
appreciating their career aspirations;
recognising and assessing training already received outside the UK;
providing career advice where sought;
identifying clear and achievable training goals;
advising points of entry into training;
ensuring equality of opportunity in recruitment practice;
delivering effective induction arrangements.
3.45 As a consequence of the reforms proposed here, the role of direct placement schemes ( otherwise known as sponsorship) will require review. These provide for non-competitive placement of non-UK graduates into posts or programmes, which do not lead directly to certification. A particular issue is whether these doctors should be eligible for 'direct placement' into individual programmes.
Proposal: 16 The provisions for basic specialist training should ensure that the needs of non-UK qualified doctors are properly and fairly taken into account and that they have equal access to high quality training programmes. |
A single training grade
3.46 Neither the EU Directive on mutual recognition of specialist medical qualifications nor the relevant UK legislation (the European Specialist Medical Qualifications Order 1995) make a distinction between basic and higher specialist training. Instead the period of specialist training begins in practice when the doctor achieves Full Registration with the General Medical Council. Despite this, the current arrangements are often, incorrectly, taken to mean that the Certificate of Completion of Specialist Training programme begins upon appointment to the specialist registrar grade.
3.47 The report of the Working Group on Specialist Medical Training (the 'Calman Report') 12 recommended a combined career registrar and senior registrar grade and that consideration be given to further integration of the training grades.
3.48 The introduction of a programme-based approach to basic specialist and general practice training will unify mechanisms for delivery, assessment and appraisal across the training continuum. A doctor's progress through the continuum may then best be defined by advancement through a programme or series of programmes, rather than through a grade or series of grades. Within a single grade, all programmes would have entry criteria, normally met through open competition, and exit criteria, determined by successful completion of the programme. Workforce planning mechanisms would continue to determine the estimated numbers for each programme. Such an approach would strengthen the role of:
the competent authorities and the medical Royal Colleges in determining the appropriate structure for training programmes leading to certification; and
the role of the postgraduate deans in managing training.
3.49 The proposal is not that the NHS generally moves immediately to a 'run-through' training grade in which all entrants to basic specialist training, subject to satisfactory progress, automatically obtain places at higher specialist level. There may always be a need for some competition in some specialties depending on the needs of the service. However, the concept of a 'run-through' grade should be actively explored for each specialty. Provided there are appropriately defined entry and exit points for each programme and means of assessing progress through the programme, it could become unnecessary to expect a doctor to change grade during a programme or to link a particular programme to a grade. In some specialties (e.g. some of the surgical disciplines) it may be desirable to create a more direct path to specialist qualification and these should be examined.
3.50 A ' programme-' rather than a ' grade-' based approach to training would:
allow greater flexibility in planning training providing, for example, opportunities for doctors to change career direction and for shorter programmes leading to a more 'general' Certificate of Completion of Specialist Training;
more readily enable progress to be linked to demonstration of competence;
allow for programmes of differing duration and structure determined by specialty need;
re-affirm the importance of basic specialist training within the overall requirements for the award of a Certificate of Completion of Specialist Training;
be consistent with moves to introduce shorter Certificate of Completion of Specialist Training programmes in some specialties;
promote greater flexibility for doctors outside formal training programmes to re-enter training.
Proposal: 17. It is proposed that urgent work is undertaken to explore, specialty by specialty, the appropriateness of creating a 'run-through' training grade in which doctors would move seamlessly through training with satisfactory progress checks. This could not be implemented immediately. Given the needs of the service and the availability of training places, the need for application and competition prior to progression should be explored. |
Links to higher specialist training
3.51 Reformed SHO training will improve the quality of early postgraduate training and provide a better platform for doctors wishing to progress to higher specialist training:
foundation programmes will provide a coherent and thorough grounding in general professional training with opportunities to gain experience in a range of different disciplines;
structured programmes of basic specialist training within broad specialty groupings will allow the development of skills and provide the appropriate experience for doctors to progress smoothly to higher specialist training in their chosen specialty.
3.52 The SHO period forms the initial phase of a doctor's specialist medical training, the end point of which is the Certificate of Completion of Specialist Training. Reform of the SHO grade consequently provides an ideal opportunity to consider the aims behind, and delivery of, UK specialist medical training as a whole. Both the trainees' educational goals and the needs of the service need to be considered.
3.53 While the changes to higher specialist training introduced by the Calman reforms appear to have served both trainees and the NHS well, there are a number of emerging issues which need to be addressed. In particular:
the Government is committed to a service which is increasingly delivered by trained doctors rather than trainees;
the current pattern of training produces highly-skilled specialists at a time when there is a growing demand from the NHS for more 'generalist' consultants to provide safe and effective care to patients;
the period of training before reaching Certificate of Completion of Specialty Training level is comparatively long by European standards;
training is still heavily based on time in grade rather than on mastering the competencies required to progress;
training programmes are based on the assumption that all trainees will wish, and be able, to progress to consultant status;
it will be increasingly important to ensure that training arrangements (and career posts) provide for those who wish to train and work on a part-time basis;
the development of new roles for nurses and other members of the healthcare team will affect the way in which doctors will work in future.
3.54 There could be considerable advantages in introducing a new range of training programmes which would enable doctors in higher specialist training to be awarded a Certificate of Completion of Specialist Training earlier than at present (e.g. after three or four years). This would be followed by a period of more highly specialised training for those who wished to undertake it, and for which there was a service need.
3.55 Such a model would work best if at the point of completion of the shorter first phase period of higher specialist training, the doctor was eligible for a consultant level post in their chosen specialty. So they would become a consultant in for example: general internal medicine or general paediatrics. This would make a distinction between two categories of specialist: the 'generalist' consultant and what some have dubbed the 'ologists'.
3.56 Such a restructuring of specialist training and certification would have considerable advantages, for example:
shortening the path to a consultant post for some doctors;
meeting the needs of the many patients who do not require the skills of a highly specialised doctor;
opening up more opportunities for doctors in non-consultant career grades to re-enter training and become a consultant.
3.57 These ideas were not part of the original objectives of this Report, but inevitably arose as the 'knock-on' effects of a modernised SHO grade were thought through.
Proposal: 18. The arrangements for awarding a Certificate of Completion of Specialist Training (CCST) should be changed. New and shorter higher specialist training programmes should lead to the award of an earlier CCST for those satisfactorily completing training in the 'generalist' elements of a specialty. At that point a doctor should be able to apply for a consultant post in their chosen specialty - say general internal medicine or general paediatrics. |
Implications for the consultant and non-consultant career grades
3.58 These proposals relating to SHOs will have other important implications. In particular, for the consultant and non-consultant career grades.
3.59 There may be an impact on the number of doctors in the non-consultant career grades as:
more doctors may leave training on completion of basic specialist training and move into non-consultant career grade posts before entering higher specialist training;
implementation of the European Working Time Directive and changed patterns of training may reduce the service output of SHOs and increase the demand for non-consultant career grade doctors.
3.60 The non-consultant career grade has for a long time been a source of concern. Many doctors in non-consultant career grade posts undertake valuable roles for the NHS. However, they are not always valued. There are few opportunities to leave the grade and return to full time training. As a result the concept of the non-consultant career grade has come unfairly to carry a degree of stigma.
3.61 Although the NHS will continue to need non-consultant career grade doctors, there should not be a profligate expansion of this grade on grounds of expediency or perceived cost savings. An important goal of the NHS is still that more patients should be seen by a consultant.
3.62 The position of the non-consultant career grade post could and should be transformed. It should be a post in which a doctor gains valuable service experience but from which many will be able to move (or move back) into specialist training should they so wish.
3.63 A doctor who chose for whatever reason to remain in a non-consultant career grade should be able to do so with pride, knowing that their experience and expertise in an area of medicine (whether it be for example, emergency medicine, ultrasonography or breast cancer care) was something which the NHS valued and cherished.
3.64 Thus a necessary consequence of these proposed SHO reforms will be to undertake a comprehensive review of the non-consultant career grade and to complete this as quickly as possible.
Proposal: 19. A review of the role, educational support, professional development and career opportunities and pathways for non-consultant career grade doctors should begin in the autumn. |
Implications for service provision
3.65 With an apprenticeship model of training, service and training are inevitably linked. It is important to consider the possible implications of training reform on service provision. The principal effects of reform to address would be:
a greater focus on training might suggest the service output of individual SHOs will diminish; and
improved workforce planning and time-limiting of programmes will impact on the number of SHOs and doctors in the non-consultant career grades.
3.66 However, overall levels of service should be maintained as:
training reforms will deliver fully-trained - and better trained - doctors more quickly. This will be especially so if the reform of basic training is coupled with shorter, more generalist Certificates of Completion of Specialist Training. Reform, therefore, answers an important service need;
time-limiting basic specialist training programmes means doctors will not provide service within the SHO grade for long periods as they do now. The number of SHOs coming through the system will be more carefully identified through improved workforce planning. On completion of SHO training they will be encouraged to progress to higher specialist training or move to a non-consultant career grade post. Levels of service can be maintained through careful control of the relative numbers of trainees and doctors in the non-consultant career grades. Where less service is delivered by SHOs more will be provided by those who have completed training and by those who are following a non-consultant grade pathway.
3.67 SHO reform would take place against a background of rapid and significant expansion in the medical workforce. The planning model is not, therefore, a static one but one which will see important changes in the flows through training and in the relationships between doctors in training and service grades. Delivering doctors into the right specialties in the right numbers is a fundamental aim and better linkage between SHO training and specialist registrar training will enable the planning of a better-balanced workforce. There will be more grounding in primary care as a result and an accent on working across professional boundaries and in teams.
Impact of the European Working Time Directive
3.68 New training programmes would be introduced at a time when implementation of the European Working Time Directive for doctors in training will lead to major changes in working arrangements for these doctors and for other members of the healthcare team. Implementing the European Working Time Directive is an important challenge. However, it provides an opportunity to look critically at how service is delivered and the workforce is organised. It needs to be addressed by the service and by the health professions in a creative way. For example, making more effective use of available resources, by innovative service delivery, new ways of working and better skill-mixes.
3.69 Training reform has an important part to play. It is a necessary element in the response to the European Working Time Directive since the best use of the time available for educational benefit will have to be made. The way forward is to acknowledge that trainees will be available for shorter periods and will be engaged in new working patterns and then to build new approaches to training. Such approaches should increase its quality, the opportunities to learn and the ways in which skills and training are acquired in the most meaningful way from the experience available. A programme-based system proposed here offers a way to structure training and to monitor progress against clear goals achieved with a greater ability to make the most of the experiential component of training.
3.70 Simply maintaining the status quo is not an option in meeting European Working Time Directive implementation nor, indeed, in a rapidly changing and expanding NHS constantly faced with new challenges. It is not productive to see the solution to implementing the Directive simply as a matter of producing trainees and non-consultant career grade doctors in ever-greater numbers. This will add to, rather than solve, the problem.
3.71 The European Working Time Directive and training reform are mutually interdependent. The European Working Time Directive requires reform in training and this in turn can support implementation of the Directive. Together they can support the wider changes required in the NHS, increasing flexibility while maintaining a clear focus on providing safe, high quality services.
Implementation and timing
3.72 Implementation of these proposals for reform would represent a significant task for the service, postgraduate deaneries, the Royal Colleges and the proposed Postgraduate Medical Education and Training Board. For example:
the postgraduate deaneries, in concert with NHS Trusts and Workforce Development Confederations would need to identify and formalise training rotations at both foundation programme and basic specialist training programme level;
new appointment processes would be required giving access to programmes;
educational and training supervisors would need to be secured;
basic specialist training programmes would have to be designed and put in place;
the Royal Colleges with the proposed Postgraduate Medical Education and Training Board would need to develop new curricula for both foundation and basic specialist training programmes and to agree with the Departments of Health on the length and number of SHO programmes;
implementation might straddle the period when the European Working Time Directive is coming into force for doctors in training.
3.73 For these reasons, implementation would need to be planned and timed very carefully. There are a number of options available. These range from, for instance:
a staged, gradual introduction of the reforms for new trainees coming through the system over a period of years;
through to
a single, one off process through which all trainees at SHO and pre-registration house officer level were subject to a short transition period into the new structure.
3.74 The options will be subject to careful analysis but, clearly, views on the main issues which implementation will expose is a necessary component during the consultation process on this report.