The Shape of Training Professor Jacky Hayden

Securing the future of excellent patient care Prof David Greenaway 29th October 2013 All UK http://www.shapeoftraining.co.uk/reviewsofar/1788.asp

Key Messages General care in broad specialities - generalists Still need Specialist Sustainable career – opportunity to change Opportunities driven by local patients need Academic training pathways Full registration to point of graduation Managed time out of programme

Certificate Registration Of Speciality Training Professional practice Postgraduate Postgraduate Undergraduate Medical School Foundation Year Training 2 years Broad-based Specialty Training 4-6 years Generic and transferable competencies OOP year No clinical supervision Rest of career MDT CPD Credentialing Registration Certificate Of Speciality Training

Controversies Moving registration Training Shorter for hospital specialties, therefore less doctors in training Longer for GP Impact on the numbers of trained consultants Potential for a sub consultant grade (will CST be less than CCT or just different)

Provisional issue definition What will the impact of Shape of Training be on the supply of people with a CCT or a CST (Certificate of Speciality Training); on the linked requirements for post-CST credentialing; and on the costs of training. A potential second stage could also address: “What will the impact of the Shape of Training be on the overall medical workforce capacity and the generalist/specialist split within this workforce?”

Model boundaries The system being modelled would need to include entry to F1, i.e. two years earlier than current medical workforce models; However, it would not need to include current workforce if the suggested issue definition were accepted: Current models: F1/F2 ? Training Consultant workforce Shape of Training model: F1/F2 Training ? Consultant workforce

Key considerations “Full registration will occur at the point of graduation from medical school” – this introduces a new point of ‘competition’ for further medical training, as well as a potential cohort of registered doctors who are “fit to work as fully registered doctors….. in an approved training environment” “Broad based speciality training will last between four and six years” – this, together with a range of other statements emphasising continual progress through training, effectively fixes the time in training and rules out all but minor extensions, meaning that: GP training will be extended to a fourth year; All other training programmes that are currently more than 6 years will be reduced Further specialty or sub-specialty training will take place through the credentialing process.

Statements that need to be accommodated within the model Full registration at completion of medical school places UK trainees in a competitive position for F1 places (including competition with overseas entrants); That all training programmes >6 years will reduce to this limit; That GP training will be extended by 1 year; That out of programme activities are regulated and structured more tightly and remain within the 4-6yr training programme; That ‘recycling’ will be significantly reduced and that access back into training will be made easier, thus reducing the overall time to achieve a CST.

Statements that need to be accommodated within the model CST outputs will be by broad specialty; Due to the reduction in overall training length to CST the years of service post-CST, and hence the overall consultant wte capacity, will increase; Demand for sub-specialty competences can be managed through credentialing but are assumed to be in over-supply at the moment (at an aggregate level); That there is a clear but separate nationally commissioned academic pathway after F2; That the balance between non-GP generalist and specialist medical workforce will shift over time.

Expected impact over time The challenge of transition…. The overlap of completion of training due to reduced time to CST will create a ‘bulge’ of newly qualified doctors 4-6 years after the introduction of SofT………… What is a ‘worst case’ scenario in terms of overlap and temporary ‘over-production’? What behaviours or unintended consequences might arise due to this bulge? What transitional measures can be identified and modelled to manage this anticipated ‘bulge’? CCT production Existing trainees: Years Today CST production SofT trainees: Years Today SofT starts

Other areas of impact Today Years Today Years Today Years Today Years Numbers completing either CCT or CST: Cost of training: Today Years Today Years Total qualified medical workforce: Generalist v’s specialist skill mix Specialists Specialty generalists Today Years Today Years

Second stage If the model is extended to explore the impact on the shape of the workforce we might expect…. GPs Specialists Proportions – not to a precise scale Specialty generalists Career grade Trainees Timeframe of c.20 years

Second stage ‘story lines’ GP expansion will work through the system over the next 3-5 years and will continue to grow gradually over time; Specialists will reduce once SofT is introduced but will then ‘recover’ with the introduction of credentialing; Specialty generalists will see the most dramatic increase in the medium term, moderated by credentialing in the longer term; Career Grade posts will reduce due to tighter control over the training programme, less leakage and more potential to train as specialty generalists; The number of trainees in the system will reduce because of the shorter length of training.

Provisional model specification To run in years for 20 years from 2013, with the introduction of the SofT in 2015 (options for 2016 or later can be included); The model will commence at entry to F1, but may need to factor in numbers in medical school at some point; Modelling at a national level without gender or other detail; Arraying the speciality training section of the pathway by broad speciality to reflect SofT recommendations and to allow for differential impact on the length of training.

Outputs A description of the implications of the SofT in the terms of the defined issue for modelling, i.e. the impact over time on the supply, skill mix and costs of medical trainees completing their training; In the light of this the identification of issues that need to be addressed in the transitional phase to SofT.

The impact for the North West Opportunity to consider the needs of the different geographies Opportunity to work on realistic workforce models based on the outputs of training. Opportunity to contribute to the ‘credentialed’ workforce Opportunity to influence the content of four year GP training (leadership v additional clinical skills) Better managed out of programme.

The impact for the North West Fewer doctors in training staffing middle grade rotas. Potential threat to the outputs from the three medical schools. Consultants who enter the grade less experienced but (if we get it right) have improved skills in holistic care. Fewer out of programme trainees working as clinical fellows

How do we prepare? Engagement in the national workshops. Development of the faculty of trainers Involvement of the existing workforce to plan for new consultants with different skills. Productive fourth year of general practice training. Continue with transforming the workforce.