The aftermath of the Tooke Report

In the wake of the DH response to the Tooke Report, what now for medical training and debate? Lynne Greenwood picks up the trail with Dr Michael Bannon’s research report on the impact of WTD on postgraduate medical training.

Everyone agrees: medical education and training must be of the highest quality - professional, well-funded, delivered by qualified trainers and expertly evaluated. That is everyone from the health secretary and postgraduate medical deans to junior doctors and medical students.

In the formal DH response to the Tooke Report last month (March 2008) Secretary of State Alan Johnson said: “I want to mark the importance we attach to ensuring that the training of our doctors, and indeed all health professionals, is in keeping with Sir John’s aspirations to excellence.”

His words reiterated the title of Professor Sir John Tooke’s Independent Inquiry into Modernising Medical Careers , ‘Aspiring to Excellence’, established in April last year (2007) following the crisis caused by MTAS.

In his response, the minister also said: “The value of how we train our doctors is a touchstone of our aspirations for the NHS and services for patients as a whole.”

But how that high quality training should be delivered, has yet to be agreed.

The Tooke Report's final recommendation, for the creation of a new body, NHS Medical Education England, was described in the minister's response as "the single most significant addition to the (Tooke) interim report and, as such, requires very careful consideration".

Tooke suggested that junior doctor training should become the responsibility of a new medical education body with a ringfenced budget.

Alan Johnson said that idea needed to be considered alongside the work of the Workforce Planning, Education and Training (WPET), part of the Next Stage Review (NSR) of the NHS, which is due to report by the end of June.

Another major influence on future training will be the requirements of the WTD, which requires the average working week to fall to a maximum of 48 hours in 2009.

The Tooke Report recommended that "urgent attention be given to ways in which a more flexible approach to WTD could be legitimately embraced" and to whether additional compensatory mechanisms can offset any further reduction in clinical experience.

The DH's response made it clear that the Government negotiated an extension of up to 12 years to help the NHS prepare for full implementation of WTD for doctors in training.

It said the Government would continue to seek amendments to the WTD to enable more flexibility over the timing of compensatory rest breaks for missed rest and ensuring that time on-call in the workplace, but not spent on active duty, was not counted as working time.

“However the specific suggestion that training time be discounted from working hours is unrealistic as it does not have the agreement of all Member States which would be required to amend the Directive,” says the DH.

The Secretary of State acknowledged that there are a number of projects under way to ensure that trainee doctors get the most out of available training time, including research at Sheffield University which includes examining the benefits of 'wet lab' simulation exercises for trainee surgeons.

Dr Michael Bannon, dean of the Oxford Deanery and postgraduate dean for the Conference of Postgraduate Medical Deans (COPMeD), recently completed a research report on the impact of WTD on postgraduate medical training.

The six month scoping phase of the project, which included focus groups and interviews with trainees, trainers and WTD leads as well as literature reviews, identified “significant concern about the impact of WTD compliance on postgraduate medical training” which was particularly acute in respect of the acquisition of technical skills.” It states that compliance “heightens the tension between service delivery and training”.

Research also highlighted organisational barriers to training such as targets, increased workload and time constraints. The project found that models of training need to adapt to the changing patterns of work and reported the importance of organisational culture in promoting a supportive training environment.

Good motivation on the part of both trainer and trainee was identified as essential to successful training outcomes, with the provision of adequate training and good support for trainers as a relevant factor.

The ability of trainees to access elements of training flexibly, including e-learning tools, was important, particularly during shift work. The need for technical and team-based training, such as wet labs and simulations, to supplement on the job training opportunities, was also identified as essential within the context of shorter working hours.

“The challenge is to provide a working environment that facilitates both 'on the job' training and the training transfer of learning from 'off the job' training activities to ‘on the job performance’,” says the report.

The primary research phase of the project, focused on the organisational element, to include the organisational climate and training evaluation, and the individual element looking look at optimising ‘on the job’ training opportunities.

Dr Bannon says: “Changing the organisational culture will be a challenge and that is where deans can help."

“There is already a new culture among foundation trusts with whom it is important to have a dialogue. I have been out to foundation trusts to meet their medical and clinical directors and supervisors and their HR directors, who are very willing to discuss this. They tell me that any suggestion that they do not want to train doctors is nonsense - it is embedded in their founding principles.”

On training, Dr Bannon says: “For me as a dean, it is quite straightforward: we have a bunch of new trainees, a new curriculum, a framework for assessing them - let’s get on with it.” He says the three key elements are: a commitment by the organisation that training is important and has to happen, a recognition by those who deliver training that the environment is changing and will continue to do so and that trainees will “have to make every possible effort to squeeze every bit of training out of their clinical exposure.

“We have to make sure we make a really good job of professionalising the training we deliver with good quality programmes, adequate funding, trained trainers and proper evaluation.”

Dr Bannon’s report suggests that potential areas of future research include successful handover procedures, which are crucial to the effectiveness of new working patterns, an area where work is already being conducted by Skills for Health - Workforce Projects Team and Hospital at Night (HaN).

Dr David Sowden, dean director for the East Midlands Healthcare Workforce Deanery and the DH director for Modernising Medical Careers, says that there must be a “fundamental reworking of the current education and training model.

“We need to move to a position where there is an understanding that the primary purpose for which a trainee is in the system is to be trained, whereas at the moment, it is as a service provider. That is the basis on which medical education and training has been based since the onset of the NHS.”

He believes that training can be adequately delivered within the working pattern to be determined by WTD if trainees are exposed to experience which relates directly to their particular specialty. There must also be means of monitoring individuals’ progression and ways to ‘bring them back on track’ if and where necessary.

Dr Sowden believes it requires much more professional training of the trainers.

Dr Sarah Thomas, postgraduate dean South Yorkshire and Humberside, says that all trainers within the Deanery are currently required to be trained.

“It is protective for the trainers and we now have a good network of people,” she says.

“It is mandatory that trainers complete an educational supervisors’ course as a minimum.,” she explains. “If they take on non-medical education - for example for programme director - they have to be trained.”

She says: “It is also one of the quality markers when we review trusts who are required to tell us how many of their trainers have attended which courses. If there is a gap, we arrange for them to take the courses.

“And we are prepared to take action if they do not fulfil our requirements - we have already done so with one mental health trust.”

She suggests that for certain specialties - for example anaesthetics - that it should be mandatory for trainees to access four weeks of knowledge learning to give them a theoretical base “before they start to learn on the patient.” Added to that would be rostered face-to-face time with a trainer.

But she also believes that trusts must recognise their responsibilities around training. “They have to recognise that it takes time by giving them clear opportunities - allow training clinics to go more slowly.”