Friday, 5 December 2014

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 levelsVerdict: 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."

1 comment:

Speedblue said...

Hi Ben,

Seen a lot of your comments re Shape on the BMA website. Good Work.

You may not know this unless you are a medical trainee/involved with medicine- but interestingly/alarmingly, the RCP has decided to blunder on ahead and produce draft proposals for initiating the disaster-in-waiting that is Shape. They are requesting (via email response)that juniors sound their opinions by the end of August 2015.

To sell the whole fiasco, Professor David Black, JRCPTB medical director, has produced a podcast explaining how the RCPs version of Shape is "A Good Thing".,3JCRA,JM1ZYW,COM8L,1

He talks in vague Shape-esque terms about "The future needs for patients" and "The challenges for juniors"; without any sensible elaboration on exactly what these needs and challenges actually are.

As you are someone closer to Shape than most, I just thought I'd let you know that it's implementation creeps closer.