The foundation years

Authors: Caroline White 

Publication date:  05 Jan 2011


Caroline White looks at John Collins’ report on junior doctor training and asks what it will mean for future practice

When John Collins published his review of foundation training in November, Foundation for excellence: an evaluation of the foundation programme, he concluded that the two year programme had “many strengths.” But Professor Collins made 33 recommendations to bolster its design and content and to tackle safety and quality concerns, some of which were prompted by the often repeated complaint of the trainees he interviewed that they sometimes felt out of their depth and did not have adequate supervision.

Michael Goldacre, who has been tracking the career choices of medical graduates from the United Kingdom since 1993 for the UK Medical Careers Research Group at the University of Oxford, says that this complaint is not peculiar to the foundation programme. Survey evidence from the research group, dating back several years, shows that one in five recent graduates felt they worked beyond their level of experience, he explains.

“This is not new, but what may be new is that it is harder to reach more senior doctors quickly,” he says. “In a bygone era very experienced middle grade doctors were in a hospital day and night. But with shorter working hours, it’s not as easy to have different levels of doctor working at the same time, particularly out of hours.”

The European Working Time Directive, which limits doctors’ working hours to 48 hours a week, is undoubtedly an issue, says Peter Kopelman, principal of St George’s, University of London. But it’s assumed that the directive will be changed, he says. “Even if it does, it will be after 2015 [when the next review of the foundation programme is due], and we have to address this now,” he adds.

“It is perfectly possible to train doctors well [in fewer hours]; it’s about the way we deliver that and the way we configure teams,” he insists. “And if you talk to the next generation of doctors coming through, they all think a 48 hour working week is perfectly reasonable.”

But he acknowledges that financial pressures could squeeze supervision further. “Trust boards need to take a very close interest in the medical workforce. If you stretch rotas and don’t have enough senior staff on, the likelihood of patients being harmed is greatly increased,” he warns. And he adds: “We do need to be more sophisticated about medical workforce planning.”

Regulating supervision

The report makes it clear that a good deal of confusion prevails about the role of junior doctors in the NHS and what is expected of them both as employees and as trainees, which may contribute to inadequate supervision and, in some cases, a lack of respect.

Mike Watson, medical director of NHS Scotland, thinks that clinical supervision is less clearly defined and understood than educational supervision, with the result that trainees delivering clinical services end up being treated like any other doctor, putting them “at unacceptable risk.”

But there’s “a whole constellation” of factors in the supervisory mix, he suggests. “Part of it is historical: you would often have had a very experienced SHO [senior house officer] in an F2 [foundation year 2] post before,” with the assumption that the F2 has the same level of competencies, he says. “But it’s also about the time available for training and education. One of the benefits of revalidation is that there will be more formal recognition of [these activities] and they will be in the job plan.”

Immediate past chair of the Royal College of General Practitioners, Steve Field, feels that the supervisory role needs to be valued more, particularly in the acute sector. “We spend a lot of time training and selecting supervisors in primary care, but in hospitals, the assumption is that consultants automatically teach juniors,” he suggests. “We need to be much more selective and recognise that some doctors don’t want juniors and that others don’t have the necessary knowledge and skills.”

The report recognises the need for more formal accreditation of all those involved in the training and assessment of trainees as a matter of urgency, particularly as the foundation programme requires additional skills, including workplace assessments. And it recommends that the Academy of Medical Educators and the General Medical Council should ensure this is in place by 2012.

Assessing assessments

The report also calls for the number of assessments undertaken in the foundation programme to be reviewed, describing the current tally as excessive, onerous, and poorly valued.

Professor Watson thinks that greater clarity is needed on what the assessments aim to achieve. “We need to separate out those that are interventions designed to provide training and education from those that are end points and make only the end point assessments mandatory,” he suggests, adding that a name change to distinguish between the two entities might be helpful.

The GMC has already identified the need to review this issue in its education strategy. “We want to avoid repetitive assessment, and one of the ways we can do that is by improving the transfer of information from undergraduate to foundation years,” explains Niall Dickson, its chief executive. “We are keen to work with others to do that, but we do need to ensure that we can measure whether doctors are acquiring the knowledge and skills they require.”

Medical Education England and the Medical Schools Council have set up a working group to look at the whole transition period, says Professor Kopelman. “In the past it was simpler because graduates worked within the locality of their medical school, but now that there’s national selection, they move to new deaneries.” He adds: “Data protection has created hurdles in the past. But irrespective of that, patient safety must come first.”

The report also calls on the GMC to revisit student registration in a bid to smooth the transition from student to doctor and enhance patient safety. The regulator had already been considering this, explains Mr Dickson. “But we have to be clear about why we are introducing it,” he says.

“Will it support students to think through the professional issues of becoming a doctor in a rapidly changing world and would this enhance the transition from student to fully registered doctor?” he asks. “We also have to ask whether this is proportionate for students, and whether we couldn’t have a closer relationship with them without going down the registration route.”

Length of the programme

One of the hotly debated areas was the length of the programme itself. The report concludes that this should remain two years for now but that it should be reviewed in 2015 when the impact of the GMC’s Tomorrow’s Doctors (2009), which will change undergraduate education, will have become clearer. “In the meantime F2 must demonstrate that it is a step-up in experience from F1 [foundation year 1] and be able to prove its overall value beyond doubt,” it states.

Professor Goldacre says that the UK Medical Research Group surveys indicate that many doctors know what they want to do in the first year after qualifying, 60% of whom end up in their preferred specialty. But that still leaves 40%, and he backs a two year programme.

“Many doctors want to be surgeons, but surgery is oversubscribed, and many who say they want to be surgeons don’t go on to do it,” he says. “So early training must be broad and general and provide sufficiently transferrable skills to enable doctors to move to another specialty.”

But he adds: “The issue for F2 is to acknowledge that many doctors do know what they want to do, and to tailor rotations accordingly in the second year, while at the same time providing a wide variety of options.”

The report found that some rotations lasted as little as two months, which trainees felt was too short, and it recommends that each should be a minimum of four months and a maximum of six.

“The advantage of six is that this provides better continuity within a unit and allows the trainee to feel more part of a team and acquire specialist skills, but the disadvantage is that it limits the range of exposure [to different specialties],” which may make it harder to decide on a career path, says Professor Watson.

But the balance of placements needs to be reviewed, says the report. These are still heavily weighted towards adult surgery and medicine—despite the GMC lifting this requirement in 2007—at the expense of paediatrics, psychiatry, and community and primary care. And it points out that around half of current trainees will need to become general practitioners, yet there are no foundation year 1 placements in general practice and these made up only 15% of the total in 2008.

Making specialty decisions

“This is not about recruiting more doctors to become GPs, but to ensure they have a better understanding of health and healthcare,” he contends. “There’s no shortage of money; it’s where it’s spent, and it needs to be moved into primary care as a priority, because that’s where care will increasingly be.”

Professor Goldacre points out that his survey results show a “dramatic” decline in the numbers of doctors wanting to take up general practice from around half of respondents in the 1980s to 25% by the late 1990s. “The issue is not so much exposure as inspiration,” he suggests, which reflects another theme raised by the report—the need for realistic careers advice.

Professor Kopelman believes this should start early as some specialties, such as surgery, are likely to become increasingly competitive. “From their very first year, medical students need to understand where the opportunities are,” he explains. “We need to give students a nudge at a much earlier stage rather than giving them a shove later on.”

“As part of our major review of Good Medical Practice we will be looking at whether there needs to be specialist or separate guidance for doctors at different points of their career, and that will include trainees,” confirms Niall Dickson.

Professor Watson is convinced that for all the areas for improvement highlighted by the report, the foundation programme has achieved a great deal and will continue to develop well. “We have a defined curriculum and a pretty unified process across the UK, and an integrated infrastructure that we didn’t have before,” he says. “It’s easy to underestimate just how much of a transformation there has been. We have come a long way in a relatively short time.”

Competing interests: None declared.

Caroline White freelance journalist London

 cwhite@bmj.com

Cite this as BMJ Careers ; doi: