Thursday, 5 February 2015

The straw men of the 'Shape of Training'

So many straw man have been put forward in an attempt to justify the potentially disastrous 'Shape of Training' (ShOT) review's recommendations, that it is slightly tricky to know where to start.  It is also important to acknowledge from the start that it is impossible to discuss these issues logically with some people, much in the same way that it is impossible to debate religion with someone who has a fundamentalist belief that they are right.  Anyway here we go:

Straw man 1: Training is not perfect, hence Shape is justified

Firstly everyone acknowledges that there are problems with training today, however Shape does nothing credible to address these and improve training quality, actually it promises to do rather the reverse by diluting down the quality of the consultant grade of trainers.  ShOT also threatens to worsen other problems with training today including an over reliance on box ticking competency based methods, a lack of employers valuing training and trainer time over short term service needs and the inadequate regulation of training exposure. For example >10% of FY1s get zero emergency exposure throughout their whole first year of work, a really worrying statistic ignored by the powers that be and ShOT.  Opposing SHoT is not the same as saying nothing can or should be done about training.

Straw man 2: Time is a useless measure of genuine clinical expertise, therefore shortening training time is of no consequence to training standards and patient safety

If one withdraws all context, no measure is useful.  In context of the hours worked, the training exposure of a job and the trainer quality, time is a very useful measure of clinical expertise.  For example in surgical training, reducing training time and not improving quality as Shape does, will reduce operative exposure which will have inevitable implications for the quality of the consultant grade.  Time is imperfect as a measure, but in context it is a very useful aspect of appreciating expertise levels and far more valid than many modern tick box assessments.  It is also ironic that Shape talks of valuing the apprenticeship model but seeks to ignore time served as an important factor.

Straw man 3: There needs to be more consultant involvement in our of hours care, this justifies Shape's plans

There are several aspects of this flawed argument in relation to Shape.  Firstly reducing the quality of the CCST/consultant grade has the inevitable safety implications, if consultant delivered care involves effectively re branding registrars as 'consultants' who need to continue training it is not entirely honest with patients and any gains of 'consultant delivered' care may well disappear.  For example one cannot re brand earth as chocolate and expect it to taste as good.  The implications of creating an less autonomous consultant grade who may be stuck at this level indefinitely could be extremely negative for recruitment and retention, meaning that rota problems could well be made worse in the long term by this short sighted strategy.  Also many young consultants are already extremely hands on in clinical terms, why do we need to restructure the whole training system to increase consultant involvement?  Simple, we don't.

Straw man 4: Other countries train consultants in a shorter period, therefore Shape's shortening of consultant training is justified

There are many differences between different countries' training system reflecting differences in factors such as service delivery, hours worked, training quality, training regulation and funding.  It is not apparent that any country currently trains most doctors in some sort of generic ‘generalism’ before then permitting a few to ‘top-up’ their training and become specialists. In much of Europe and North America doctors go straight into specialist training, which is shorter than that in “Commonwealth” countries, but usually has a narrower focus and does not involve much if any generic training, plus in many countries such as the US many more hours/week are worked. This is not the model which is proposed by SHoT, and indeed is not a solution which would work in the NHS as it is currently constituted or funded. The “Commonwealth countries”, excluding Canada but including Ireland i.e. “Commonwealth” is a bit of a misnomer, generally have a model of broad based training, leading to specialist training – but not truncating the majority of careers at the end of this broad based training.   The UK doesn't have a monopoly on excellence in medical training, although it is arguable that those who exit the UK CCST program have a broader and deeper experience than their equivalents at the point of certification from some other countries - in time this levels out, and indeed it may be that if one looks at case numbers and years spent practising it all comes out in the wash.

Straw man 5: Patient needs are changing, hence Shape is justified

The way in which the evidence was analysed to identify and assess the future needs of patients in ShOT was highly flawed and grossly inadequate.  High quality evidence was not provided, the review appeared to simply rely on non peer reviewed opinion which generally resembled dogmatic hot air (this piece is excellent on a tangent to this theme in that it exposes the problem basing policy on evidence free dogma).  The review stated “No papers looked specifically at whether current postgraduate medical education prepares doctors for working with patients and the public in such a way as current trends dictate.”  but never defined what was meant by 'current trends'; the huge flaws in this kind of approach are obvious.  In order to adequately address the future needs of patients one needs to adequately analyse the evidence in this area, this was never done.

Straw man 6: Training needs to be more flexible, thus Shape is justified

Flexibility can easily be improved within current training structures.  There is some degree of sense in 'transferable' competencies, however the use and applicability of this has probably been massively over hyped by those intent on distracting from the potentially harmful aspects of ShOT.

Straw man 7: Patients need more 'integrated' care, hence Shape is justified

The review's evidence section stated “an acknowledgement of integration as the direction of travel for UK health and social care is vital to the decisions made in the Review” however the evidence gathered totally failed to justify making this dogmatic acknowledgement, it was also notable that 'integration' was never properly defined at any point in the evidence section.  Ironically the greatest 'disintegrator' of care has been Lansley's HSCA, using the major structural reform of training as a lever to increase the 'integration' of care appears misguided at best.

Straw man 8: We need more 'generalists' and less 'specialists', hence Shape is justified

This is a largely a false dichotomy.  As explained in straw man 4 the UK training system is already fairly generalist in many ways and particularly in many specialities such as geriatrics and orthopaedics.  Many consultants are trained as generalist specialists at current CCST level as things stand, certainly there is no way one can train competent autonomous 'generalist' consultant in a shorter time than it currently takes to train a specialist.  Shape's solution of re branding generically trained middle grades as 'generalist' consultants is not honest and it will not provide an equivalent quality of care to that provided today by today's properly trained generalist consultants.  Notably the review ignored the majority of consultation respondents in this regard "...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”.  In areas like acute medicine it would be perfectly feasible to encourage more trainees to dual-accredit, a simple way of increasing the number of proper generalists without engaging in yet more destructive major structural change.  This brilliant analysis exposes the huge problems if one applies Shape's ideas to Gastro training.

Straw man 9: Shape means patients will see the most 'appropriate' doctor

Patients want a high quality service and they often want to be treated by a properly trained consultant.  Who decides what this 'appropriate' means and how?  I doubt many patients would be keen on the government decided that it was 'appropriate' for them to be seen by a lower quality 'consultant' who cannot practise autonomously and who is still in training via the 'credentialing' route. 

Straw man 10: Genuine clinical competency is reliably measured by competency based assessment methods, thus training time is unimportant

There is an abundance of evidence in the educational literature which demonstrates that an over reliance on competency based training methods is harmful to standards and that many competency based assessment methods are far from valid.  The official line from the likes of HEE and the GMC is that competency based assessments reflect training 'outcomes', sadly the vast majority of these assessment tools are poorly validated and do not reflect any meaningful outcomes for anyone.  There is also a paucity of evidence to justify ticking off targets on an extensive curricula bit by bit as a way of developing genuine clinical expertise.  'Medicine by numbers' is a good way of making the regulator appear effective to the uneducated bystander, but a very poor way of training high quality clinicians and maintaining motivation in trainees.

Straw man 11: The crises in acute rotas justify creating a cohort of sub-consultants to provide this service

There are crises in acute and emergency medicine, and Shape's plan appears to be addressing this by making everyone a middle grade in acute care, issuing a CST and then stopping most career development at that point. Only in the UK can the solution to an unattractive career be to force everyone to do it, rather than trying to work out why it is unattractive and resolve those issues.  Ultimately if one doesn't address the root causes by making these acute jobs attractive to work in, then strategies such as Shape are doomed to fail and in the process worsen the existing recruitment/retention problems.

Straw man 12: Formal accreditation such as 'credentialing' provides inevitable benefits and does no harm

A recurrent theme in health policy is the negative 'unintended consequences' which rapidly become apparent after yet another hare brained policy is railroaded through.  Perhaps 'credentialing' has some roles in some niche areas but to ignore its potential negative effects is foolish.  Informal accreditation is cheaper, less bureaucratic and will do less harm in terms of time spent on the accreditation process.  The routine use of 'credentialing' for post CST consultants is potentially dangerous as employers will have excessive power of who becomes properly trained and who does not, there are problems for workforce planning in this area too.  Note the problems in the erratic employer controlled training of HCAs remarked upon by the Francis report.  Not only that but the costs of training will be passed onto the 'trainee' consultants.  Also there is a real paucity of evidence to demonstrate any benefits of formal accreditation over informal means in terms of patients outcomes.

These are just a select number of straw man I have seen thrown around by the minority of individuals who support Shape in its current form.   The bottom line remains that ShOT has not been justified by credible evidence or coherent rationale, it is largely confused in logical terms and potentially very harmful.  It is interesting that virtually all those who support Shape have some rather interesting links to those forcing the review's recommendations through against the will of the majority of front line trainees and trainers, can't imagine why this would be?  If you feel that Shape is bad for training and bad for patients then please sign the petition to protest against these major changes:

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