Aspiring to Excellence: The Tooke Report

As the Department of Health considers the final recommendations in ‘Aspiring to Excellence', Professor Tooke's Independent Inquiry into Modernising Medical Careers, Lynne Greenwood takes a look at the report and the implications for WTD.

Junior doctor training should become the responsibility of a new medical education body with a ring-fenced budget, according to the final report of Professor Sir John Tooke's Independent Inquiry into Modernising Medical Careers.

In his final recommendations last month (Jan 08), Professor Tooke suggests the creation of a body called NHS Medical Education for England (NHS:MEE).

In Aspiring to Excellence, the title of his report, Professor Tooke says that the new body "will relate to the revised medical workforce advisory machinery and act as the professional interface between policy development and implementation on matters relating to the Post Graduate Medical Entrance Test (PGMET)".

He says it will also promote "national cohesion" as well as working with equivalent bodies in the four Devolved Administrations to facilitate UK wide collaboration.

The Department of Health (DH) is now considering the proposals and is expected to respond next month.

Established by the Secretary of State for Health in April 2007 following the crisis caused by the on-line Medical Training Application Service (MTAS) last spring, the Tooke Inquiry gained a UK wide perspective by relating to the key authorities in all four countries. It also arranged a series of workshops at which junior doctors were invited to express their views and suggest solutions to a range of critical issues.

The interim findings were published on 8th October 2007. In his foreword, Professor Tooke, the dean of the Peninsula College of Medicine in Exeter, stated that "postgraduate medical education and training in the UK is at a crossroads".

The original 45 recommendations were then subject to a six-week consultation period - including e-consultation, written submissions by key organisations and meetings in England and the Devolved Administrations.

Of the 39,850 e-consultation responses, 87 percent agreed or strongly agreed, nine percent were neutral and only four percent disagreed or strongly disagreed with the recommendations. A further 118 emails of support were sent to the Inquiry's website.

The Conference of Postgraduate Medical Deans (COPMeD), who discussed the interim report of the Tooke Inquiry at a residential conference, welcomed the analysis and findings.

They expressed their support for the principles of Modernising Medical Careers (MMC) and "for the reforms that are urgently needed to continue the modernisation of the structure, content, delivery and assessment of postgraduate medical education and training in the UK".

In his chapter on the background and context for reform of postgraduate training in the Interim report, Professor Tooke referred to the effect of the implementation of the Working Time Directive (WTD) across the NHS on such training.

"In a profession which requires a large experiential component to training, anything that reduces the opportunity of exposure to clinical activity runs the risk of having a negative impact on the quality of training," he wrote. He cited exposure to unplanned emergency activity as being "particularly at risk".

The report went on to say that the required move to a service pattern based more on shift working to ensure that both trainee doctors - and many consultants - did not exceed the allowed hours, resulted in the disruption of the traditional ‘clinical firm structure' which has underpinned postgraduate medical training over the decades.

Professor Tooke reported that the only way to meet the requirements of the WTD in many hospitals had been to introduce multidisciplinary teams covering clinical problems arising out of normal working hours, such as the Hospital at Night (HaN) teams.

He concluded: "Whilst there are many benefits that come from such an approach, there is a risk that the reduction of exposure to clinical problems arising out of hours further reduces the experience and ultimately the competence and capacity to assume responsibility of postgraduate doctors in training as well as the continuity of both care and training."

In his final report, Professor Tooke added a new recommendation on WTD after deliberating further on its impact. He states that: "the effect of the current interpretation in UK legislation impedes the acquisition of experience, of confidence and the ability to shoulder responsibility. This promotes further the ‘trainee mentality' over and above a recognition of the trainee's service contribution."

He suggests ‘urgent attention' be given to seeking a more flexible approach to WTD, giving an example of the separation of service and educational contracts.

"The DH should explore the potential for contractual solutions," he recommends. "The profession, service, medical schools and deaneries should come together to define compensatory approaches."

Dr Michael Bannon, postgraduate dean for COPMeD, has recently completed a research report on the Impact of the Working Time Directive (WTD) on Postgraduate Medical Training, which unfortunately was not available to Professor Tooke before the deadline for his Inquiry results.

In his final report of the scoping phase to the DH, Dr Bannon agrees that "the delivery of both effective services and quality training needs to be taken into account when introducing new working patterns such as shift work and multiprofessional teams.

"Both managers and clinicians have a responsibility to facilitate the provision of quality training… and good motivation on the part of both the trainer and the trainee was identified as essential to successful training outcomes".

Dr Bannon says that in 2009 when the WTD requires the average working week to fall to a maximum of 48 hours, a cultural change in the way in which training is delivered and received will be necessary, in order to protect it.

"If hospitals are busy in the evening - some specialties have twilight shifts - that may be the time to do some training," he says, "That may need to be topped up outside the clinical scenario, for example with simulation, with a way found to transfer that learning into career practice."

Wendy Reid, postgraduate dean for the London deanery and Skills for Health - Workforce Projects Team clinical lead for HaN, who believes that training must be embedded in service, acknowledges that the Tooke report offers no barriers to looking ‘innovatively' at WTD.

"Whilst it remains imperative that service and training go together, the recognition that top-up training may be necessary is very positive."

She says that every opportunity must be taken within service to provide training: for example in obstetrics and gynaecology, training may be appropriate during night-time hours when 50 percent of babies are delivered.

Contrary to the interim Tooke report, which suggested the HaN service may create a potential risk, there is emerging evidence that it is reducing risk and benefiting clinical safety.

Although HaN is not a solution for all specialties, its multiprofessional team of competent practitioners approach minimises the number of doctors in training required at night, retaining the ability to call on key staff if needed. It therefore allows for protection of daytime training with the required support, supervision and education.

Dr David Sowden, dean director for the East Midlands Healthcare Workforce Deanery, believes that the separation of service and educational contracts, as suggested by Tooke, is not feasible.

"If a trainee is employed as trainee, education and training has to be part of the working week," he says. "you cannot arbitrarily separate the two if you are employing someone in training capacity."

Rather than trying to reshape the WTD, he believes a "move away from experiential and osmotic model where people gradually acquire their skills through process of apprenticeship" is needed… "We must look again at effective training," he says, "If you optimise the way they utilise their experience, you do not need as much experience, because it becomes high quality rather than high quantity."

He and his colleagues accept that the drop from 56 to 48 hours will pose a challenge and ideally there would be flexibility around the extra eight hours.

Dr Sowden suggests a need to look at the whole service environment to allow people proper work/life balance.

Professor Tooke's recommendations come in eight categories:

• Clarification of policy objectives
• The role of the doctor
• Policy development and governance
• Workforce planning
• Medical professional engagement
• The commissioning and management of postgraduate medical education and training
• Streamlining regulations
• The structure of postgraduate medical training.

Although COPMeD supports many of the recommendations, one of which draws particular criticism from the postgraduate medical deans is the suggestion that within Foundation training - the first two years post graduation - the link between Foundation Years 1 and 2 (FY1 And FY2) be broken. The report says this would allow FY2 to become the first of a three-year Core training programme which would be broad based and involve six six-month attachments.

It follows the Panels' findings that "the experience of FY2 placements has been very variable and for many trainees did not provide experience that matched their career aspiration". But Dr Bannon says his experience is different.

"We have invested a tremendous amount of time in building up the Foundation programme," he says. "I have just completed quality assurance inspection visits to trusts about the programme and have had very good reports and feedback.

"Everyone I have spoken to, including trainees, has agreed that year two of the programme produces well-rounded, mature doctors with a broad based experience.

"To dismantle the programme now would be wrong in my view, and very sad."