Guest article - the real motives behind Shape?

I’d be careful not to go off on the tangents about the sadistic medical narcissists of the 1970s or to blame “The Trendy Educationalists” for these policies. This is driven, top-down, by the government, hence the involvement of lay folk (plus a few of the usual suspect Quisling collaborators from the ranks of the medical politicians). It is driven by the interests of the corporates, who have the politicians in their back pocket. We all dislike the bullying tyrannical consultants of the 1970s & the patient-averse oafs pushing Mickey Mouse reflective learning, but they are not the enemy here.

The aim is to have a very large pool of medics, who have no job security, self-confidence or professional self-respect. They needed to smash the old UK medical firm model to create US/EU-style 'attendings'. The old UK consultant grade had its faults & was by no means perfect. It was suited to the days of “generalism” in the truest (i.e. non-corrupt) sense of the term. Bottle necks & folk, lying in wait for uber-specialised tertiary centre posts, meant that, perversely, it took longer for folks to become sub-specialists, doing a very narrow range of repetitive tasks, than it took people to become generalist consultants. The consultant model was better suited to medicine than some other specialities, it did a lot for my speciality (anaesthetics), raising standards big time. But, it has had its day. The one size fits all MMC approach confused public health training with clinical training. You can randomly allocate a mixed bunch of medics & non-medics to random sequences of QUANGO placements & give them a chit saying they are trained PH specialists after 3 years, you cannot do the same with surgeons. Yet, this is precisely what is being proposed.

The stuff about generalists is despicable. They have realised that subspeciality–ologists don’t do acute medicine & they reckon that scrapping current training pathways to create a pool of accredited generalists will make it easier to staff the few remaining major acutes that will be left when cold sites are sold to private companies, who’ll run them to rake it in from elective surgery. A few doctors will get work in these privatised units, the rest will just end up doing shifts in the major acutes. This is about herding doctors to do skivvy work instead of the work we aspire to.

Expect the medical establishment to make it as difficult as possible for generalists (and existing consultants) to acquire the essential credentials to do any meaningful elective surgery/-ology. Such restrictive practices will suit the corporate subcontractors, who’ll have no problem recruiting medics, with huge student debts & mortgages, who’ll be desperate for scraps of work. Doctors are like scouts, they love acquiring silly badges, without realising how tacky it looks & how their egos are being massaged. It is a con trick. Credentials are barriers, limiting people in what they can do. Fools think they'll do an online course & get the leadership credential, enabling them to lord it over others. Dream on! Things like Breast Surgery will get credentialed, which means that generalist cst-holders wont be able to do it, so they'll have to continue doing shifts at the local major acute, doing back-to-back abscesses & laparotomies. The "Sell" is that this system will enable you to show what you can do. In reality, it will prohibit what you can do & you'll be at the mercy of employers, who'll offer you jobs doing stuff you'd rather not do (shifts in acute surgery) rather than training for the stuff you want to do (major cancer work, bariatrics etc). Create cst oversupply & then limit what cst-holders can do [most elective work]. Suddenly, acute surgery gets a whole lot cheaper!

Remember, the DH know that doctors will always happily kick the ladder away from their younger colleagues. They figure that we'll figure that a new SR grade would be in our interests. It is classic divide & rule. Naturally, the guys doing their PhD in the cell biology of Ca Oesophagus will figure that they will effortlessly become credentialed in upper GI surgery, whilst their younger colleagues will simply become shift-working acute surgeons, doing the "low level" stuff. Please lets not fall for this. They are not redesigning medical careers to cater for some indescribably brilliant doctors, who are head & shoulders above their peers. They are doing this to undermine the profession & make it easier to errode our pay & T&Cs to suit their corporate cronies, who'll end up hiring (and firing) doctors. Wake up!

We need to oppose this & that means jettisoning the traitors in the medical establishment, who’ll try to stifle proper resistance.

The Shape of Training - first do no harm Prof Reid?

 

I have been doing a fair bit of thinking about medical training reform in recent days, things appear to steaming ahead at full speed despite a rather large number of valid concerns that remain totally unaddressed by those pushing Shape through.  I stumbled upon an interview with HEE chief Wendy Reid and it is worth reading.

I think this brief interview succinctly demonstrates a number of crucial problems with those railroading through the review.  Firstly there is a lot of talk of doing good things:

“We’re really pushing forwards saying, ‘Here are explicit ways in which you can become this,’ and that’s where I think we will make a big difference.”

The meaning of such statements is debatable, it is actions that matter as cynics like myself have come to realise after years of seeing harmful reforms being packaged in a sheep's clothing.  Wendy Reid says we need major structural reform to meet the expectation of patients:

Reid says the structure of doctors’ training, which has remained the same for decades, needs to change to keep up with patients’ expectations. “We have doctors training in a system that is pretty much the same as it was in the 1980s when I trained”

This is a total straw man argument.  It is strange to say that our training system has not been changed since the 1980s, perhaps Wendy failed to notice the structural reform of MMC, I do not know.  Anyhow the argument that we need major structural change because we have not had it for a while is incoherent and sloppy.  In medicine 'first do no harm' is a fantastic motto by which to practice which serves one well in many different aspects of life.

As I have summarised in more detail here, the case for major structural reform has not been made by the review and no solid evidence is put forward to justify this needless change for the sake of change.   The reason for 'first do no harm' is that change is expensive, time consuming, disruptive and results in many unintended negative consequences.  The straw man has been exposed, so what are the real motives behind this major structural change Wendy?

Wendy Reid tries to answer "What is the future doctor going to be doing?".  I would suggest that if Shape is implemented then the future will see many quit medicine and emigrate to work in health care systems in which they can be trained to the level of a proper consultant.  Also how does dumbing down the consultant grade meet the expectation of patients?  Do patients want a lower quality service delivered by sub consultants?  Do they want a system of care delivery that traps a large cohort in the sub consultant grade and forces much top talent abroad and out of medicine?  These are the questions I would like Wendy Reid to answer.

Contact your MP to protest against cuts to medical training........

The Shape of Training is a review of doctor training that is currently being forced through despite many significant safety concerns being expressed by the majority of doctors' professional bodies.  If you want your doctors to be trained properly then it is essential that you take the time to write to your MP to express your opinion on this matter, below is a template letter you may use:

https://www.writetothem.com/

"Dear <INSERT HERE>

I am writing regarding the ‘Shape of Training’ review of doctor training that recently reported and is currently in the process of implementation.  I have grave concerns about several specific recommendations made by the review. 

Firstly the recommendation to shorten the training time of hospital consultants and will create a ‘sub consultant’ grade.  Such a move is incompatible with maintaining high quality patient care and would have a significant negative impact on patient safety.  Secondly moving the point at which doctors register fully with the GMC to medical school graduation is unsafe.  

In addition to these significant concerns surrounding both short and long term harms relating to both doctors and patients, the review has ignored the majority of respondents to its consultation who felt the training of hospital consultants should not be shortened:

“most individuals and organisations argued that generalists would require a longer training period or reconstruction of training to capture the breadth of experiences needed to provide competent general care”

As things stand the Shape of Training review’s implementation is incompatible with maintaining high standards in medical education and patient care and as a result I would be very grateful if you could look into what can be done to halt this review's dangerous implementation,

Yours sincerely"

Write to your Royal College or Trainee Organisation

Here is a letter template that I have crafted for anyone to send to their Royal College or trainee organisation.  If you agree that Shape takes medical training in the wrong direction, please take the time to do this, we must hold these organisations to account and tell them what we think. Every little really does help.

"Dear <INSERT HERE>

I am writing regarding the ‘Shape of Training’ review that recently reported and is currently in the process of implementation.  I have grave concerns about several specific recommendations made by the review. 

Firstly the recommendation to shorten training time before CST that will inevitably lead to the creation of a ‘sub consultant’ grade.  Such a move is incompatible with maintaining high quality patient care and would have a significant negative impact on patient safety.  Secondly moving full GMC registration to medical school graduation is unsafe.  Thirdly the introduction of post-CST ‘credentialing’ is not based on any evidence base and it would lead to serious problems with workforce planning as local employers would be left in control.  Fourthly the combination of a ‘sub consultant’ grade with post CST credentialing controlled by employers would lead to significant staffing issues as a result of its negative impact on staff retention and recruitment.  It will become harder for medicine to attract high quality applicants when a large number of post CST ‘sub consultants’ become trapped in a non-training service delivering graveyard, while currently the recruitment environment is worryingly brittle in many areas.

In addition to these significant concerns surrounding both short and long term harms relating to both doctors and patients, the review has ignored the majority of respondents to its consultation who felt training should not be shortened:

““most individuals and organisations argued that generalists would require a longer training period or reconstruction of training to capture the breadth of experiences needed to provide competent general care”

As things stand the Shape of Training review’s implementation is incompatible with maintaining high standards in medical education and patient care and as a result I urge you to openly reject the review’s implementation.  The failure to withdraw from such a failed process will only be used to by those forcing it through as a signal of tacit approval and this must be avoided at all costs,

Yours sincerely"

The Shape of Training - the Key Issues

I am sure many of you are aware of the small details of the Shape of Training (ShoT) review, however many of you probably are not, therefore I though I would write a brief piece to summarise the key issues in training, how the review has gone about their business and the many issues that have been left completely unanswered.

Firstly medical training was subject to huge structural reform less than ten years ago in the form of Modernising Medical Careers (MMC).  It is worth remembering that history proved MMC was a covert and dishonest attempt by the Department of Health to force through a 'subconsultant grade' through the back door.  This was never admitted before or during MMC, I obtained documents after the event proving that the DH and senior medical leaders had misled doctors and patients by claiming the review was just about 'better training', it clearly was not, it was dressed up as something that it overtly was not.  This context of government dishonesty is hugely important.

The ShoT review was led by a Professor of economics with no medical experience and supported by the GMC, it gathered 'evidence' over 2013 and released its final report at the end of 2013.  It is currently in the process of being implemented by Health Education England and others including the GMC, of note not a single trainee is involved in implementing this reform, ironic that.  Now let us consider the review from a series of angles that any sensible individual would see as vital, let us examine the need and rationale, the evidence, the consultation, the review's recommendations, the views of professional bodies and the future.

The rationale and evidence for major structural change. Firstly it is necessary to move forward and back, the review claimed from the start that it would not necessarily lead to major structural changes, but this is precisely what the review has recommended, major structural changes, and very soon after MMC.  It is clear from the evidence reviewed by the ShoT team that there was no solid evidence to justify major structural change, it is this simple.  Not only that but the evidence gathering appeared biased and the opinions on the evidence predetermined. The argument from some Shape proponents that 'reform is needed' is bogus, reform is always needed as reform is improvement, but this does not justify the negative destructive proposals of Shape.  The current system needs gentle tweaking in some areas, minimal change in others, what was not needed was blanket reform of a major structural nature.  Verdict: inadequate evidence to justify major structural change.

The consultation.  The consultation was poor in many ways.  Firstly the consultation was extremely biased and leading in the way in which questions were asked to respondents.  Shape deliberately tried to push people into certain boxes with their answers on the future of training, in a way that appeared they wanted a certain answer even before the evidence had been gathered.  The consultation was also extremely poor in terms of the total number of responses, less than 200 responses were gathered from doctors.  Interestingly the majority of opinion was also ignored on key issues such as time to train:

“most individuals and organisations argued that generalists would require a longer training period or reconstruction of training to capture the breadth of experiences needed to provide competent general care”

Verdict: poor quality consultation which ignored majority of opinion on key issues.

The review's key recommendations.  Much like MMC many of the vague comments of the review appear reasonable at first glance, more 'flexibility', 'quality training' and 'generalism'.  Sadly when one takes the time to analyse the practical reality of the review's key recommendations then not only are some of the ideas extremely vague, but some of the clear points are quite frankly unsafe for patients.  The two most reckless and harmful recommendations are to reduce training time for hospital specialities and to move full GMC registration to the end of medical school.  It is of key importance that these two dangerous ideas are not justified or even explained in any sufficient detail within the review's text.  It is also key that there was significant majority of opinion against shortening training time.  The reality of shortening training time is a less skilled consultant grade, this is to all intended purposes a 'sub-consultant grade', and something that many professional bodies have argued strongly against, based on some very strong evidence I should add. 

The review does not justify why it is necessary to dumb down the consultant grade, and it introduces the highly bureaucratic idea of post CST (completion of specialty training) 'credentialing'.  Hence 'sub-consultants' may well not be able to do some things unsupervised as they are not proper consultants as the public would understand, but they would also not be guaranteed training to the proper consultant level, this would be left up to individual employers via the 'credentialing' pathway.  Another problem with this development of responsibility of training to employers is the lack of ability to plan the shape of the workforce in the long term.  The RCP/RCS/BMA have all spoken eloquently about the dangers of these key recommendations.  The review also fails to address the really key problems in training today such as reducing experience levels.  Verdict: valid patient safety concerns from several professional bodies regarding key recommendations remain unaddressed and key recommendations inadequately justified. 

The future.  The one positive thing about the review is that it has not yet been implemented, it is currently in process.  If I briefly try to sum up the review, it would be that it's proposed aims are inconsistent with the practical reality of its recommendations.  Shape claims one thing but does another, much like MMC before it.  The reality of the review is that unless aborted it will reduce training standards, create a far less skilled and demoralised sub-consultant grade.  Not only will it have direct negative impacts on care quality and patient safety but it will likely lead to more recruitment crises, as intelligent able young doctors are not going to be keen at being trapped in a service providing sub-consultant grade for life.  Do not be conned by the eloquent claims Shape makes of 'excellent patient care', the reality is the opposite, and the highly cynical would see the changes as creating a compliant new service grade doctor to be putty in the hands of an ever expanding network of corporate NHS providers.  The Francis report highlighted huge problems with HCA training, something that has been left to employers, and Shape pushed the training of doctors further towards this disastrous position in which quality will be sacrificed for the artificial financial imperatives of employers.  I shall leave you with a quote that sums up the reality of Shape as things stand:

"The Shape of Training does not lead to 'generalism' as the public would understand it, a new 'generalist' will be trained in less time than currently it takes to train a specialist, essentially Shape's brave new 'generalist' will be a service providing middle grade, someone who is simply not trained to provide the high quality care that a properly trained consultant of today can deliver.  It would be more accurate to call Shape's new version of the consultant a 'registrar‘, essentially the review results in an Orwellian abuse of the English language in order to hide the truth from the public."