Wendy Reid: Postgraduate medical training in the NHS: complex and transforming

Wendy_Reid2Junior doctors’ anger and disillusionment during their recent dispute highlight the need for a new approach to ensure that they feel valued and able to work in supportive and accountable environments.

Rather than wait for the contractual dispute to be resolved, Health Education England (HEE) has been working with others, including postgraduate deans, the BMA’s Junior Doctors Committee, NHS Employers, and the Academy of Medical Royal Colleges (AoMRC), to address some of these challenges.

Doctors’ training has shifted from a time-served apprenticeship to complex, structured programmes with regulatory approval of posts, programmes, and trainers. There is detailed assessment at all stages using assessment tools. Doctors undergo the “Annual Review of Competence Progression (ARCP)” and for many the process has been reduced to a stressful “rite-of-passage” with progression or failure being the only perceived outcomes. 

HEE intends to strengthen assessment and appraisal for junior doctors with a review of the Annual Review of Competence Progression (ARCP) process to be launched in October 2016. A “tick-box’” culture does not support the professionalism or individualism that both the public and doctors aspire to. Revalidation provides an opportunity to embed appraisal as the focus of assessment (to progress), valuing diversity and nonclinical skills.

Postgraduate training does not consistently reward excellence or recognise that competence does not necessarily reflect capability or confidence. We need to challenge the system to respond to individual’s development needs; as professionals, and as people.

HEE is working to improve the employer-employee relationship by reducing unnecessary rotation between trusts allowing doctors to rekindle the element of local public service.

We are reviewing the application rules for doctors with caring responsibilities and doctors in relationships.

We need to address the fact that some units and clinical placements are more popular than others. Over the past twenty years, three reports (Calman 1995; Tooke 2008; Greenaway 2013) have proposed change in medical training, with little consideration  about the wider workforce. Changes to working hours and patterns have been vital for patient and doctor safety but have led to complex rotas. HEE has committed to improving the communication between deans and trusts to ensure that doctors beginning rotations know their schedule a month earlier than at present. There will be no fixed leave within rotations.

Nowadays many doctors want to work flexibly, more than 50% of graduates are women, and there are different expectations of a lifelong professional career. There are gaps in rotas and NHS pressures have affected service organisation and access to training. The Five Year Forward View provides an opportunity to develop new ways of ensuring all elements of care are delivered by the most appropriate staff and embrace the new roles such as Physician’s Associates. HEE strongly supports the involvement of doctors in training at all stages of the development of these models.

HEE is working with the Academy of Royal Medical Colleges to  prepare doctors using simulation training and “boot camps.” We have also extended whistleblowing protection for junior doctors, providing a new legal route directly against HEE, if required, for trainees who raise concerns and believe that HEE has caused them detriment as a consequence. There is an HEE guide that explains the main points of this new protection.

All doctors are members of the NHS family. We are concerned about the differential attainment of doctors from different ethnicities and backgrounds. We know that being a junior doctor is challenging and stressful without any extra pressures being imposed by poor rota planning, unsupportive senior colleagues, and lack of family time. We need all senior leaders in the medical profession to support trusts and others to deal with poor behaviours. This is a patient safety issue and a waste of human and economic resource if we fail to value every doctor and every member of the team.

Wendy Reid is Medical Director of Health Education England.

Competing interests: None declared.