 | | Many thanks for the six hundred and forty five full responses that we received to our consultation on the Next Stage NHS Review led by Lord Darzi. Broadly our results demonstrate what many of us would suspect - that doctors remain suspicious of the continued reform of the NHS because they fear that the positive talk will not be backed by positive action.
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A vast majority of respondents were sceptical of the ‘patient choice’ agenda, the increased use of the private sector and the idea of an NHS constitution, and the devastating effects of the privatization and reform on training was of great concern. The idea of NHS MEE (Medical Education for England) was greeted with a lukewarm reception, many respondents feared that NHS MEE had the potential to be another toothless body. Run through training (RTT) as a blanket phenomenon was also unpopular. Concerns were expressed as regards current training systems with the EWTD being of particular concern.
Introduction
The Tooke inquiry (Tooke 2008) highlighted a number of important issues around the training and education of doctors. The NHS Next Stage Review, led by Professor the Lord Darzi, was published in June of this year (Darzi 2008). This review superseded the earlier response from the Secretary of State for Health (Johnson 2008) and developed several of Sir John Tooke’s recommendations; it also covered many other issues as well as the future of medical training.
In this context we carried out a survey of doctors’ opinion on the NHS Next Stage Review (Darzi 2008) with a particular emphasis on the potential implications for medical training.
Methods
We carried out a structured survey which was available online at the RemedyUK website. Notification was sent to RemedyUK members, and it was advertised on the website. The consultation survey was available online from the 27th of July to the 13th of September.
Results and Discussion
There were 645 full responses to the survey in total; in addition there were 105 partially completed responses that were not included the results.
The demographics of our respondents are shown in Table 1. The majority of respondents were hospital doctors in training (67%); the remainder was made up of GPs (9%), hospital consultants (8%), GPs in training (8%) and non-training hospital grades (4%).
The questions were grouped into the following main categories: Medical and NHS politics, career pathways for doctors, modular credentialing, NHS MEE/Continuing Professional Development (CPD) and a final general section. Respondents were asked to rate a series of 21 statements on a five-point score.
Medical and NHS Politics | | Strongly agree % | Mostly agree % | Unsure % | Mostly disagree % | Strongly disagree % | | Most patients understand the choices that are available within the NHS | 2 | 10 | 11 | 49 | 27 | | There is adequate spare capacity within the system to permit genuine preference and freedom of choice | 2 | 6 | 7 | 33 | 52 | | The direct funding of private sector providers with NHS money is something to be generally welcomed and encouraged | 1 | 4 | 10 | 24 | 60 | | Patient satisfaction is an accurate reflection of the quality of care received | 1 | 20 | 17 | 39 | 23 | | An NHS Constitution will make a real difference to the quality of patient care | 2 | 6 | 31 | 30 | 29 | | Diverting the more straightforward and ‘routine’ cases to non-training centres will impair training | 74 | 18 | 2 | 3 | 3 |
Many of our respondents are sceptical of the political aspects of the NHS review. Patient choice will only work if the patients fully understand the choices available to them and there is adequate spare capacity in the system. However many doctors feel that patients do not fully understand the choices available, and that there is insufficient spare capacity to permit genuine choice.
The direct funding of the private sector was unpopular. This may reflect matters of general political attitudes rather than any particular medical viewpoint.
Support for an NHS Constitution was lukewarm with 59% opposed to the idea and a further 31% unsure. Doctors have become cynical and battle-weary of wordy promises that deliver nothing, and of nurse-driven ‘Philosophies of Care’.
Diversion of ‘routine’ cases to non-training centres was very unpopular, with many comments commenting on the detrimental this will have on training. Doctors need to gain hands-on experience with the more straightforward cases to gain confidence and expertise.
Career pathways for doctors. | | Strongly agree % | Mostly agree % | Unsure % | Mostly disagree % | Strongly disagree % | | The current two-year Foundation programme model is largely correct | 1 | 25 | 23 | 27 | 22 | | All successful UK graduates should be guaranteed a place in FY1 | 73 | 18 | 4 | 2 | 2 | | The length of GP training should be extended | 24 | 29 | 27 | 12 | 5 | | There should be an expansion in the number of General Practice training schemes | 9 | 26 | 44 | 11 | 5 |
Opinions were much divided over the two-year Foundation Programme. The Next Stage Review announced that one of MEE’s first jobs would be to formally evaluate the Foundation Programme, but if our sample is typical then this evaluation will not be easy. Arguments in support of the two-year programme revolved around the breadth of training it offered and the risks of making premature decisions. Those favouring a one-year programme felt it represented a waste of time for doctors that had already decided on their future career.
A large majority of respondents felt that all successful UK graduates should be guaranteed a place in FY1. This is something that the DH openly disagreed with in its response to Sir John Tooke (Alan Johnson 2008) who proposed that “all such posts must be sought in open competition.” The Next Stage Review revealed a shift in government direction with a subtle change of wording to read: “We will seek to ensure that all successful UK medical graduates have access to Foundation Programme Year 1 placements to complete their GMC registration.” (our emphasis).
It was also felt that GP training should be extended, but expanding the number of trainees in General Practice was not something that a majority of respondents agreed with.
Run through Training. | Which of the following sums up your views on Run Though Training (RTT)? | % of responses | | Should be adopted by all specialties | 5 | | Some specialties should offer run-though training, others should not | 41 | | RTT should not be adopted by any specialties | 49 | | No answer | 5 | One of the key changes produced by MMC was the introduction of the Run through grade, a unified pathway from the end of Foundation through to CCT level. Opinion was largely split. Some felt that “Run through is an unmitigated disaster. It is not appropriate for any speciality training and leaves those who don't get a post with no prospects in this country.” Many respondents felt that RTT discouraged the pursuit of excellence, encouraged bland uniformity, was anti-competitive, and that is forced juniors to choose career prematurely. The lack of flexibility of RTT was also a great concern for many respondents, and losing the broad base of experience was not seen as a positive:
On the other hand Run-through training was seen as fine for those who know what specialty they want to do and do not change their minds. It was accepted that there needs to be flexibility for those wanting to try out different specialties and change their minds. The fact that those selected for RTT posts at an early stage may not subsequently make satisfactory progress in the specialty was also remarked upon:
“I am a surgical registrar and I do not feel that surgical training can satisfactorily be run through from ST1 as not all applicants will subsequently master surgical skills.” Modular Accreditation. | | Strongly agree % | Mostly agree % | Unsure % | Mostly disagree % | Strongly disagree % | | Formal accreditation of capabilities (knowledge, behaviour, attitude) at defined points within the career pathway, which could facilitate movement in and out of training programmes, would improve professional development | 7 | 36 | 24 | 20 | 11 |
Modular credentialing is still a poorly defined concept, but there was cautious support for the principle. Respondents did not like the emphasis on box-ticking, and were anxious to see the system properly validated.
MEE (Medical Education for England) | | Strongly agree % | Mostly agree % | Unsure % | Mostly disagree % | Strongly disagree % | | The establishment of MEE (Medical Education for England) is potentially a good idea | 14 | 38 | 29 | 10 | 7 | | The chair of MEE should be elected by the medical profession | 59 | 28 | 9 | 1 | 1 | | RemedyUK should be invited to join MEE | 63 | 22 | 10 | 1 | 1 | | Universities should work more closely with providers of healthcare, in order to encourage research and education/training | 50 | 40 | 5 | 1 | 1 | | A tariff payment system, whereby funding for training follows the trainee, would be an improvement on the present arrangements | 31 | 36 | 26 | 2 | 1 | | A named member of the Board of each NHS provider should be responsible for overseeing education and development | 40 | 37 | 15 | 2 | 1 |
The establishment of a body overseeing medical education was welcomed by just over half of respondents but 38% were unsure. These results hint that many people see the devil being in the detail for NHS MEE. A strong majority wanted the chair of MEE to be elected by the medical profession The danger of it becoming a failed or impotent organization was raised frequently – a typical comment being “Do any other cynics think MEE will become another unelected, DH-appointed committee, responsible for enforcing government diktats under the veil of "professional acquiescence" by a handful of gong-seekers?. This smells very badly of another pseudo-quango”
For this to be avoided MEE must genuinely involve the medical profession, with real power and authority. Respondents were keen for universities to become more involved in medical training,
A tariff payment system in which funding followed the trainee was seen as a promising idea despite the lack of details to have emerged as regards its practical implementation. The implication of this proposal is that Trusts or departments providing poor training will lose funding and may lose their trainees.
Other questions | | Strongly agree % | Mostly agree % | Unsure % | Mostly disagree % | Strongly disagree % | | The Working Time Directive (WTD) and New Deal are significant impediments to adequate training | 50 | 31 | 6 | 9 | 3 | | The undergraduate medical curriculum’s reduction in basic science content has not impaired the overall quality of medical training | 4 | 10 | 13 | 25 | 47 | | Over the last few years the standard of postgraduate exams (eg MRCP) has fallen | 10 | 15 | 44 | 16 | 9 | | Before any further reform of medical training is undertaken those responsible for the failings in MMC and MTAS must be held to account | 77 | 14 | 4 | 3 | 1 | The reduction in working hours was seen by many respondents as significantly impeding medical education. This is consistent with a recent article by Cairns et al (2008) which drew attention to the deterioration in training as a result of the European Working Time Directive.
The large negative impact of the EWTD on training is only going to increase as hours continue to reduce and it is essential that we try to find a solution to this problem as a profession. The Barbados plan remains an option (RemedyUK 2008).
Here was considerable support for holding those responsible for the failings of MTAS and MMC to account before further reform was undertaken. The emphasis of the NHS review (Darzi 2008) is very much upon teamwork: “Healthcare is delivered by a team.” Teamwork is indeed crucial in healthcare, however it is also important that leadership is clearly defined. A recurring theme throughout the MMC and MTAS has been the lack of accountability and defined structures shown (Tooke 2008). Clinicians are accountable for our day to day clinical actions. Yet our medical leaders and NHS managers do not appear to be subject to the same level of scrutiny, despite the fact that their decisions can have significant effects upon patient care. Conclusions
The NHS review is full of many promising phrases such as ‘locally-led, patient-centred and clinically driven’, but much of the detail remains lacking. In particular the remit and authority of MEE needs to be addressed. There are several key problems in medical training today – especially the reducing number of training hours and the reducing content of medical school curricula. The medical profession needs to take its own destiny in hand.
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