Maintaining the Quality of Training

Education and training should be treated by the NHS as being part of the cost of care, rather than an externality.

The introduction of the Modernising Medical Careers (MMC) programme for doctors is not just about career pathways it is also about trying to improve training standards and the quality of the training junior doctors receive.

However the introduction of the European Directive on Working Time has presented challenges in how to maintain quality of training whilst trainees have fewer hours at work. The MMC Programme Board has set up a ‘Task and Finish group' to look at these issues.

Dr Ian Wilson, who chaired the task and finish group emphasises that the 48 hour week is not the only reason that trainees have fewer training opportunities than before. He said: "Systems designed to make the NHS more efficient mean that taking the time to train is not as easy as perhaps it once was. Time is precious, and there have been few, if any, incentives to prioritise training."

The group have been keen to refocus training as a shared responsibility between regulators, providers and commissioners of care, the medical profession and trainees. "All have a duty to ensure that patients will, in the future, have access to the highest quality skills and the best care".

The group will recommend to the Programme Board that trainees must be proactive in seeking out and using every learning opportunity, and that they should have greater influence over, and indeed responsibility for, their own training. To help this, the group has developed the concept of a "training opportunity matrix" - a system that maps the best training against requirements of a curriculum and the needs of individual trainees. Regularly updated locally by deaneries, trainers and employers, this process could help to allocate trainees to appropriate posts as well as helping trainees to be active in ensuring that their own training requirements are delivered both within and outside clinical attachments.

The group has placed a lot of emphasis on better organisation of training, whether concentrating availability and resource towards times of the day or week when it can be most effective, or in effectively identifying patients whose clinical care could be reasonably allocated to "training sessions". Dr Wilson says: "The impact of training on numerical productivity must be acknowledged. Building funding systems where investment in training flows more clearly to support the costs and opportunities of training is more effective for trainers and trainees, and more efficient for training organisations who also have service targets to meet. Funding systems must not act as disincentives to send patients to, or indeed be, a training organisation.

However the group also suggests that trainees benefit from elements of service provision as a core part of training, with a balance between education, training and experience in developing both competence, and the confidence to deliver those skills. Striking such a balance would require guidance from Royal Colleges and careful monitoring by regulators, increased ownership for trainees, and, crucially, time and resource for trainers who have significantly increased requirements placed upon them. Trainers need to make sure that they have planned regular time for dialogue with trainees as well as enough time to carry out their role as a teacher and trainer. The group will emphasise the need to ensure active management of poorly performing trainees, as well as reconsidering the length of training where opportunities to train have not been sufficient.

Monitoring of standards is core to the group's thinking and it will recommend a role for national regulators overseeing NHS organisations, as well as clearly defined roles and responsibilities for local oversight and implementation at SHA, deanery and trust (or equivalent) levels. "Education and training should be treated by the NHS as being part of the cost of care, rather than an externality. Whilst it is important to encourage good practice and innovation, systems do need measures to identify and remedy problem areas". Commissioners and PCTs also have a role in ensuring that new and existing services have educational impact assessments built in to plans.

Ultimately, trainees themselves must be encouraged to see the long term goal of training. They need good careers guidance to help them plan their careers-not just their speciality. NHS employers can also go a long way to helping trainees feel part of the NHS as a whole as well as part of the organisations in which they work by including them in departmental and hospital management meetings and decision making.

Dr Wilson's group believes that moving the education and training of the next generation of doctors to being core objective for all organisations has benefits at individual, organisational and, obviously, population levels; by focussing on quality and new ways of providing both training and care, many of the complex problems surrounding reduced working hours may be less insurmountable.