CAIPE response to The Shape of Training document
CAIPE is dedicated to the promotion and development of interprofessional education
(IPE) with and through its individual and corporate members, in collaboration with
like minded organisations.
CAIPE acts on the belief, corroborated by a growing body of evidence, that well
planned IPE can cultivate closer collaboration not only between professions but also
between organisations and with service users and their carers; collaboration which,
in turn, can improve care and quality of life for individuals, families and communities.
It seeks therefore to optimise its impact by working with others, in the best tradition
of the collaboration that it espouses, acknowledging and appreciating their
commitment in common cause.
Questions:
1. Over the next 30 years, how do you think the way patients are cared for will
change?
Patients expectations are rising and there is a clear message for more care to
happen at home, and to reduce the need for hospital admissions. Treatment at home
will require a redistribution of the workforce to a community team based set up,
perhaps resembling the Community mental health team model, with a
multiprofessional workforce with clear roles and responsibilities and closer working
than currently exists. Patients require more say over their care, where it happens,
and who will deliver it.
The focus will be on care in the community involving professionals from both primary
and secondary care backgrounds. Boundaries between the two will need to become
blurred and roles flexible. Effective collaborative working will be required both within
the medical profession (inter-disciplinary) and without the medical profession,
working with other professions (inter-professional).
2. What will this mean for the kinds of doctors that will be needed in primary
care? In secondary care? In other kinds of care?
There needs to be a shift in focus from hospital based care to secondary care.
Specialists will still be needed working closely with GPs and with other professionals
in teams, delivering more care in patients’ homes. With the aging population there
needs to be more specialist care of the elderly available outside of the hospital
setting. Doctors in primary care will need to be able to function within large
multidisciplinary teams, to deliver appropriate care.
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As medicine becomes more highly specialised there will be an increasing need for
the generalist. Patients will benefit from the different philosophy and attitudes of
doctors working in primary and secondary care. Both are equally required and need
to be integrated with an understanding of the changing roles, challenges and
limitations of one another. Differences should be recognised and celebrated in an
atmosphere of mutual respect and equality.
3. What do you think will be the specific role of general practitioners (GPs) in
all of this?
GPs will need to coordinate care and take on a collaborative leadership role where
appropriate, working alongside other health and social care professionals.
Collaborative leadership is focused on leadership skills and attributes needed to
deliver results across organisational boundaries. It is much more than being a clinical
leader.
As medicine becomes more specialised so there is a changing emphasis with the
generalist taking on more secondary care activities. This is particularly exemplified
by the general practitioner gradually taking more of the role of the traditional hospital
general physician, or general practitioners developing special interests. This in turn
influences a change of roles in other professions.
For this to occur there need to be a shift in emphasis in undergraduate training with
clinical teaching occurring equally in both primary and secondary care. This in turn
requires a change in attitude to clinical teaching by some general practitioners.
Teaching should not be considered an “add on extra” but an integral part of being a
professional.
In addition each profession needs to be aware of the changing role of their
colleagues. Interprofessional education is an effective tool to achieve this goal.
Collaborative leadership is focused on leadership skills and attributes needed
to deliver results across organisational boundaries. It is much more than being
a clinical leader.
4. If the balance between general practitioners, generalists and specialists will
be different in the future, how should doctors’ training (including GP training)
change to meet these needs?
GP training is usually 3 years, and as a result many trainees who go straight from
Foundation year 2 to GPVTS training, are ill equipped upon gaining their CCT to
manage individuals with complex care needs, without recourse to secondary care. If
more care is to be delivered outside of hospital care, GP training needs to be longer,
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and needs to focus on the health priorities of the UK, which includes care of the
elderly and mental health care. Specialists should also be community based working
within teams linked to several practices. Much of doctors training, including the
training of GPs happens in hospital. More training needs to be provided in the
community, within large multidisciplinary teams, and needs to include
interprofessional and interdisciplinary learning. All specialists and GPs are trained in
silos with very little interaction between different branches of medicine. There is also
very little formal postgraduate training in team working and interprofessional
collaborative practice.
If there is to be more flexibility in roles between primary and secondary care, it is
important that all doctors require some experience and training in both environments.
Positive attitudes and mutual respect should be should be encouraged.
5. How can the need for clinical academics and researchers best be
accommodated within such changes?
The skills of teaching and research are different. Within clinical academia an equal
status should be applicable to both with equal opportunities for professional
development.
6. How would a more flexible approach to postgraduate training look in
relation to:
a. Doctors in training as employees?
b. The service and workforce planning?
Clearly if there is to be a large change in services, including more community based,
team based working, then this needs to be reflected in undergraduate and
postgraduate curriculum early to start to produce the doctors the service/UK needs.
There should be flexible training opportunities to allow some doctors to change
specialties, particularly if roles change, of if society’s needs change.
c. The outcome of training – the kinds and functions of doctors?
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All professionals working in health and social care, including doctors, will require the
skills of caring, compassion and effective communication. In addition if the needs of
patients are constantly changing, then they need to be integral to the education
process with the focus on improving patient care. These issues are ideally
addressed by the use of interprofessional education and should not be considered
inferior options in an academic hierarchy.
d. The current postgraduate medical education and training structure itself
(including clinical academic structures)?
There needs to be less training in silos, so that individuals perhaps training for their
GP CCT, can sub specialise and spend extra periods of training in various
specialities, to develop more skills, for treating and caring for more complex patients
in the community.
7. How should the way doctors train and work change in order to meet their
patients’ needs over the next 30 years?
This has already been addressed in previous sections. In summary, more team
based, community based working using interprofessioanal education with patient
involvement.
8. Are there ways that we can clarify for patients the different roles and
responsibilities of doctors at different points in their training and career and
does this matter?
It does matter, patients should know whom they are seeing and their
role/responsibilities. Doctors should always carefully introduce themselves to
patients by name and role. This is emphasised in undergraduate training but in
practice still does not always occur.
9. How should the rise of multi professional teams to provide care affect the
way doctors are trained?
Doctors need to be trained along, with and from team members, and specific
learning events need to be structured for the team to ensure good interprofessional
collaboration and good quality care with a focus on patient problems and improving
care. There needs to be more interprofessional learning within all aspects of medical
education including postgraduate medical education.
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10. Are the doctors coming out of training now able to step into consultant
level jobs as we currently understand them?
11. Is the current length and end point of training right?
12. If training is made more general, how should the meaning of the CCT
change and what are the implications for doctors’ subsequent CPD?
Where relevant, CPD should include the use of interprofessional education to learn
from team based learning experiences.
13. How do we make sure doctors in training get the right breadth and quality
of learning experiences and time to reflect on these experiences?
14. What needs to be done to improve the transitions as doctors move
between the different stages of their training and then into independent
practice?
There could be moves to truly implement 360 degree appraisals for trainees, with
feedback from not only staff but service users. Most trainers find the 360 appraisal
the most accurate workbased-placed assessment of trainees attitudes, and at
present service user feedback is not required. Trainees are also able to nominate
there assessors from colleagues, rather than all colleagues automatically asked to
give feedback.
Doctors should learn the skills of becoming independent learning professionals with
the ability to learn in and from practice, in particular using skills of reflection and
giving and receiving feedback. Professional support such as mentoring is helpful
when undergoing transition times. The support may come from other disciplines and
professions.
15. Have we currently got the right balance between trainees delivering service
and having opportunities to learn through experience?
16. Are there other ways trainees can work and train within the service?
Should the service be dependent on delivery by trainees at all?
Services are dependent on trainees, and this has clear implications for both patient
safety and for training.
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This must be applied with caution as if doctors are registered they should have
some responsibility but this must be carefully delineated and they must never
undertake tasks outside their competence.
17. What is good in the current system and should not be lost in any changes?
The structure of supervision, a separate clinical and educational supervisor, with
additional staff in the deaneries responsible for the training programmes, to balance
the service needs of the Local Education Providers. There is also dedicated time and
money for postgraduate medical training.
18. Are there other changes needed to the organisation of medical education
and training to make sure it remains fit for purpose in 30 years time that we
have not touched on so far in this written call for evidence?
In order for the organisation of medical education to focus on the problems of
patients and the needs of society, the process should be flexible, constantly
monitored and assessed intermittently allowing relevant modifications as required.
Interprofessional education is now built into undergraduate medical education in the
UK endorsed by the GMC , the BMA and a number of Royal Colleges. Medical
students are sharing studies in the classroom, clinical or virtual settings with nursing,
pharmaceutical, allied health, social work and other student groups to promote
mutual understanding regarding their respective expertise, roles and responsibilities
toward closer collaboration in practice. There is a growing recognition of the need to
complement these developments by putting a renewed emphasis on postregistration IPE in specialist fields.
To improve patient care, reduce medical error and foster collaborative working,
medical education cannot be developed entirely as a separate silo from that of other
the health and social care professions. The future lies with different disciplines and
different professions, where relevant, working together.
Richard Gray
Dan Kinnair
February 2013
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