By TRISHA McGARRY, Senior Hospital Specialist – Psychiatry

The training structure for doctors is currently undergoing major reform. Understanding these changes is not only important to the Pharma Industry for effective targeting, but also to enable us to have credible conversations about what this means to them when choosing their career path.

PRE-REGISTRATION HOUSE OFFICERS, Senior House Officers and Specialist Registrars will soon be titles of the past. ‘Foundation 1 and 2’ and ‘Specialist Training 1-7’ doctors are emerging, and by August 2007, when the metamorphosis is complete, you will be calling on F and ST doctors who will be part of the new fully-integrated training and career structure. Modernising Medical Careers (MMC) updates current medical training to ensure it meets the increasingly demanding expectations of patients and the NHS. The new structure will align doctors’ career aspirations with the reality of healthcare in a world of unprecedented medical progress.

The current structure

During the transition period the new training will be introduced and the old styles phased out. Competitive entry to specialities will be available at a number of levels. Doctors who currently have different ranges of experience and competencies will enter the programme at the most appropriate level (between Jan–Aug 07). First year Senior House Officers will be replaced by F2s, whilst ST3s are likely to be the start of the new SPR level, where entry requirement is currently based on passing exams.

In England during 2001, almost 46% of our NHS medical staff in training comprised SHO grades (Scotland 49% in 2000, Wales 53% in 2002 and Northern Ireland 50% in 2001). The current job structure for SHOs means a constant need to secure short-term posts, creating uncertainty for the trainees and an added burden for the service. There is currently no defined end point to SHO training, and the length of time a doctor will spend in a grade varies greatly. Progression to specialist or GP register position is dependent on the doctor’s ability to secure one of these posts. Some SHOs will spend considerably longer as SHOs than required whilst awaiting a suitable post to satisfy their training requirements. Securing future posts is measured largely on success at passing the Royal College examinations, causing bottlenecks at SPR level. This has produced waiting lists for popular specialities whilst less sought after vacancies are left unfilled.

Reform proposals

In August 2002, Sir Liam Donaldson, Chief Medical Officer for England, wrote the Department of Health document ‘Unfinished Business’. This publication outlined proposals to reform the Pre-Registration House Officer (PRHO) and Senior House Officer (SHO) grade training. The last decade of major reforms was with the higher specialist training of Senior Registrar Grades. The document highlighted that for pre-registration house officers and general practice registrars the current Senior House Officer Grade had been left behind. The phrase ‘workhorse of the NHS’, as has been used for that grade, implies a disproportionate amount of service work and training plus a lack of coherence in the organisation of training. The document proposed that the SHO grade be reformed, so all SHOs pass through timelimited and managed basic specialist training. A working group was set up to gather evidence and views on reform. Modernising Medical Careers (MMC) was the response by the four UK Health Ministers endorsing proposals that were outlined in the document. The reform encourages exposure to different specialities, informed career advice and structured training, plus assessment. It states that training should:

• be programme-based
• be broadly based to begin with
• provide individually tailored programmes to meet specific needs
• be time-capped
• support the movement of doctors into, and out of, training and also those between training programmes
• whilst the PRHO year will remain largely unchanged, it will form part of a two-year foundation programme focusing on developing generic competencies and providing general medical/surgical experience, including specialties not previously encountered (these will be Foundation 1 and 2 (F1 and F2)
• have flexibility for part-time working with a growing number of female applicants.

This will allow more doctors to complete their training and, therefore, more NHS patient care will be delivered by fully trained doctors. Every speciality will have a run-through training program, which will last three years for general practice or five to seven years depending on speciality.

Whilst the training will now be more structured, there are concerns among some of the trainees that this reform will lack flexibility. Although the new programme will afford a beginning and an end, and the security of a job, it may be more problematic if a trainee decides he/she wants to take a year out or change their career speciality path.

Implementation

Late 2006 and early 2007 will be the transition phase in preparation for August 2007 when the new curriculum commences. The two FT grades give the candidate the opportunity to find out as much as possible about the specialities they are interested in in readiness for application to the ST programme. F1 builds upon the knowledge, skills and competencies acquired in medical school, whilst the F2 placement will build on the first year of training and focus on assessment and management of the acutely ill patient. This part of the training will also encompass the generic professional skills applicable to all areas of medicine, i.e. teamwork, time management, communication and IT skills.

It is estimated that nationally there will be approximately 17,000 training opportunities in 2007, together with approx. 400 training posts. Structured specialist or GP training will begin directly after foundation training with a competitive entry process followed by a period of continuous training leading to the Certificate of Completion of Specialist Training (CCST), subject to satisfactory in-training assessment and progress. New and shorter higher specialist training programmes should lead to the award of an earlier CCST for those satisfactorily completing training in the ‘generalist’ elements for the speciality (e.g. general surgery or medicine).

The training will move towards a more competency-based programme and away from the need for more academic qualities. Doctors interviewed had concerns that this could make training to become a doctor easier and possibly reduce the standards for the future. On the other hand, those who found examinations a poor reflection of their ability welcomed this as a fairer assessment of their skills.

Changing roles

One third of our SHOs are non-UK graduates. The reform suggests that the training needs of these graduates are currently unsatisfactory. At present SHO, SPR and equivalent grades are considered as being ‘in training’ and therefore not ‘employed’ in the UK for immigration purposes. On 7th March 2006 the Department of Health announced a new policy for immigrant doctors and dentists applying for post-graduate training. Candidates will now need to meet the requirements of an employment category of the Immigration Rules, such as the work permit provisions. These changes to the system are deemed necessary since there are now more training places available and more UK graduates seeking relevant training posts.

Most overseas doctors arrive after varying levels of training, qualifications and experience. Many encounter difficulties in securing initial appointments, particularly in their chosen speciality. This means they have often been forced to hold short-term SHO contracts or face unemployment between posts when their contracts end, leaving their aspirations for career advancement unfulfilled.

Consideration has also been given to the nonconsultant career grade. The reform recommends restructure to remove some of the stigma associated with this grade. Its prestige will be enhanced and the opportunities to enter (or reenter) higher specialist training from it will be much greater than at present. There has been concern for some time that doctors in these posts undertake valuable roles for the NHS but are not always valued. There are currently few opportunities to leave the grade and return to full-time training. A doctor deciding to remain in a non-consultant career grade should be able to do so with pride, knowing that their experience and expertise in their chosen area of medicine is valued and cherished by the NHS.