Association of Course Organisers response to the Tooke Report

MMC Inquiry: An Independent Review of Modernising Medical Careers (MMC) – led by Professor Sir John Tooke

The ACO welcomes the chance to comment on the Independent Review of Modernising Medical Careers.

The ACO represents the interest of over half of the UK’s Course Organisers (or Programme Directors) who organise and deliver education for aspiring GPs throughout their training.

The ACO will limit its comments to those relating to general practice training.

1.     We generally support the suggestion GP training should increased to 5 years after full registration. This acknowledges what David Haslam, our recent RCGP president has said “General practice is the easiest job to do badly, and the most difficult to do well” We are sorry that it is not a full recommendation. This suggestion would need to be held in tension with 4. below. There is a tension between the proposal to increase the length of training to 5 years and the move to competency based assessments for progression.  We believe that this tension needs to be more explicitly explored whilst ensuring more training in Primary care for General Practice. . We suggest that the models of Higher Professional Education that were available early in the 3^rd millennium needs to be re-explored as a model for provision of longer GP training.

4.4.7 Special Case: General Practice

General Practice is a specialty in its own right with more general practitioners than consultants in all hospital specialties combined. Further, 95% of patient contacts in the NHS take place in Primary Care. In the context of an ageing population GPs see patients in the 85 – 89 age group on average 12.9 times a year. Given these statistics and the health policy of shifting more care closer to home the lack of emphasis of MMC on general practitioner training is inconsistent. Furthermore given this shift it becomes more important for all doctors to experience training in (as opposed to for) General Practice as favourably experienced by 55% of doctors in their Foundation Years.

Evidence from a number of sources to the Inquiry strongly supports the extension of GP training to at least 5 years to bring GP training in line with Specialist Training in other medical disciplines.

Although such an extension carries a cost implication it is argued that this is partly offset by potentially fewer referrals to secondary care and more older people being looked after effectively in the community. In addition the extra years in GP training would be on a salaried basis which would be less expensive than GP principal posts. There would also be the possibility of siting senior trainees in areas where recruitment and retention is poor. It is time to acknowledge that to be a skilled generalist possibly takes longer than being a narrowly confined specialist. Academic development too, must catch up with hospital specialties, to provide the evidence base to drive up quality of patient care.

2.     We agree with comments in 5.4 (p 88)

Specialty training structures and opportunities inadequately reflect the service shift towards the community and the need to deal with growing chronic disease co-morbidity in that setting. Contrary to some service perspectives such work is complex and cannot easily be subject to simple protocol led management.

and would use this to support longer training in General Practice.

3.     We agree with the comments in

4.6.8 Lessons from General Practice

In many respects the implementation of General Practice Specialty Training Programmes has gone better than other specialisms with 100% fill rates in most Deaneries. Reasons for this are speculative but are likely to include: 

•  Course organisers/programme directors are selected for their managerial and educational skills and are properly funded.

•  Being a trainer brings both status and some financial reward; trainers are selected (and re-selected) after specific preparation.

•  There is a clear summative process for assessment of all trainees with national quality control of the actual assessment process, not of the documentation.

•   The Assessment Centre approach for selection into the specialty was developed over a seven year period involving consensus, and was designed specifically for the Primary Care environment.

and believe that these four areas need to be treasured and developed. We are concerned however that the turnover of course organisers is increasing and the length of tenure of many individuals is shortening reducing the effectiveness of bullet point 1.

4.     We support the educational principle that competence is not only time-dependent and would look for robust assessment guiding suggested duration of training.

5.     We support the value of all doctors experiencing General Practice. The funding for this needs to be explicit. Money was vied from general practice training to pay for this in some deaneries.

6.     We regret the recent loss of training money into shoring up Acute Trusts.

7.     Issues such as workforce planning, the role of HSMP doctors and the larger issues as to the role of doctors in relation to other health care workers are both germane and enormous.

ACO November 2007