Response to the Independent Inquiry into Modernising Medical Careers

Published: 23/11/2007

1. The UK Foundation Programme Office (UKFPO) shares the aspiration for excellence of the Independent Inquiry into Modernising Medical Careers and welcomes the opportunity to respond to the Interim Report.
2. Set up by the four UK Health Departments, the UKFPO is responsible for administering the Foundation Programme, promoting best practice, developing a robust recruitment system and acting as a central point of information for all stakeholders. The Medical Schools’ Council, the British Medical Association, NACT UK and NHS Employers are among the organisations represented on our committees and working groups, which look at all aspects of the Foundation Programme. These include academic foundation programmes, career management, recruitment, curriculum and assessment, portfolio and communications. Consequently, the UKFPO is in a unique position to comment on foundation training.
3. We have confined our response to those sections of the Independent Inquiry’s Interim Report relating to the Foundation Programme (including recommendations 1-4, 5, and 31-33.) To contextualise our response, we have considered how the Foundation Programme was developed, how it is currently working and areas for future development.

The Foundation Programme - the development

1. Sir Liam Donaldson, Chief Medical Officer, proposed the introduction of the Foundation Programme in his consultation paper, Unfinished Business (2002). The case for reform of the early stages of postgraduate training recognised deficiencies in the job structure, training and recruitment processes for SHOs and the challenges of delivering clinical services following the implementation of the European Working Time Directive.
2. The high burden of morbidity and mortality due to medical errors and delays in recognising the acutely ill patient highlighted the need for further focussed training following graduation to consolidate and develop skills in the workplace (Vincent 2001, Dean 2002, McQuillan 1998).
3. Following extensive consultation, the four UK Health Ministers recognised that reform should not be confined to the SHO grade and proposed a new structure beginning with the Foundation Programme (Modernising Medical Careers 2003).
4. Prior to the national launch in 2005, the Foundation Programme was extensively evaluated with over 2000 doctors taking part in F2 pilots across the country.
5. The two year Foundation Programme, which forms a bridge between medical school and specialty training provides opportunities for medical graduates to:
   • develop and gain confidence in their clinical skills, particularly when they are treating acutely ill patients, so that they can regularly and reliably diagnose and care for seriously ill patients;
   • display professional attitudes and behaviour in their clinical practice;
   • demonstrate their competence in these areas through a thorough and reliable system of assessment; and
   • have the opportunity to explore a range of career opportunities in different settings and in different areas of medicine (Operational Framework 2005, revised 2007).

The Foudation Programme - the present

9. Stakeholder engagement. The success of the Foundation Programme is testament to the close working relationships between postgraduate deaneries, medical schools and NHS trusts. The Operational Framework formally recognises the importance of these relationships for quality controlling education and training.
10. Expectations and role of a doctor. For the first time we have a UK-wide curriculum describing the roles and competences expected of a doctor completing F1 and F2. Developed by the Academy of Medical Royal Colleges, the curriculum uses a spiral model to enable foundation doctors to consolidate and develop their knowledge and skill. Building on the outcomes for FY1 set by the GMC and the agreed national priorities outlined in Modernising Medical Careers: The next steps (2004), the Foundation Programme Curriculum (2nd Edition, 2007) places greater emphasis on the management of chronic diseases.
11. Competence assessment. Recognising the importance of assessment of performance and not just knowledge, foundation doctors are assessed in the workplace using a range of tools. These tools provide a framework for the assessment of doctors’ competence and performance from three perspectives: multi-source feedback, doctor-patient interactions and case-based discussions. All assessors are trained. Assessment takes around one hour per month, which we believe is a small price to pay for constructive feedback and the early identification of problems.
12. Safer patient care. All foundation doctors have an educational supervisor. The educational supervisor is typically assigned for a year and is well-placed to monitor progress and identify difficulties at an early stage.
13. Broad-based education. Although there is local variation in placement length, the majority are four-months. This allows for the development of generic competences in a range of setting and allows assessment in a range of settings as required by the GMC. The four month placement length has made new GP placements, academic training opportunities and placements in shortage specialties affordable.
14. General practice. More than half of foundation doctors have access to a placement in General Practice. These successful placements enable doctors to better understand the interface between primary and secondary care and have encouraged doctors to consider General Practice at an earlier stage of their training (Grant 2005).
15. Academic foundation programmes. There are academic training opportunities for 331 foundation doctors (around 5%) as part of F2. These programmes, which were recommended by the Report of the Academic Careers Sub-Committee of MMC and UKCRC (2004), allow foundation doctors to explore a career in academia as well as develop specific research and teaching skills. Five foundation schools are also about to pilot innovative programmes in experimental medicine units with pharmaceutical industry sponsorship.
16. Career management. As part of the initial £73 million investment in the Foundation Programme, all foundation schools in England receive dedicated funding for a career management service. This is an invaluable service and supports foundation doctors as they reflect on their aspirations and abilities so they can match these to the needs of the NHS. The UKFPO has facilitated four UK-wide meetings of career advisors and works closely with NHS Employers and the National Education Advisors Forum.
17. Recruitment. Recruitment to the Foundation Programmes is fair, open and allows for free movement across the UK. As many medical schools produce more graduates than vacancies in their local deanery, this national process allows all graduates to compete for places anywhere in the country, simultaneously, by ranking the foundation schools in order of preference. In 2006, 23% of medical students applied for a foundation school outside their local deanery. Nearly 95% of applicants were assigned to their first-ranked school. Inter-foundation school transfers provide an additional opportunity for foundation doctors to move if their needs change ensuring that programmes are trainee-centred wherever possible.

The Foundation Programme - future developments

18. There is no room for complacency and the UKFPO recognises that a lot more work is needed to improve the experiences of foundation doctors and ensure that patients and the NHS are best served.
19. It is essential that there is an independent and centrally-funded evaluation of the Foundation Programme.
20. The four CMOs have written to the Academy of Medical Royal Colleges to ask for their recommendations on which tools should be used for work-place based assessment in the Foundation Programme. More work is needed to ensure that assessments are conducted to the same standards across the UK.

Conclusions

21. The UKFPO recognises that the implementation of Modernising Medical Careers and in particular the introduction of new processes for the selection and recruitment of doctors into specialty training has been difficult and has resulted in significant distress. However, we must not lose sight of the reasons for reforming postgraduate training and the PRHO/SHO grades in particular. As the Interim Report recognises, the Foundation Programmes possesses strengths.
22. We assert that the Foundation Programme is working and is faithful to the principles underpinning Unfinished Business. There is no guarantee that dismantling foundation would solve the recruitment problems identified by the report. Dismantling the Foundation Programme would require doctors to make a decision about their future career a year earlier. The case for change has not been made and we are concerned that further change will have a detrimental effect on the morale and careers of medical students and graduates.
23. evertheless, there are many areas of agreement:
    • Recommendation 1 - We agree with the principles and recommendations articulated in Unfinished Business (including the establishment of a two-year Foundation Programme).
    • Recommendation 2 - Policy development should be evidence-based and we note that the Foundation programme is the product of extensive piloting.
    • Recommendation 3 -The UKFPO is built on an extensive network of stakeholder engagement. We agree that any further development in foundation training should be the product of extensive consultation with the medical profession and the NHS.
    • Recommendation 4 - We agree that any further changes to the structure of postgraduate medical education should be consistent with policy objectives and conform to agreed guiding principles.
    • Recommendation 5 - We welcome further discussion and clarification about the role of the doctor in the healthcare team. Such clarification will build on existing work which has underpinned the Foundation Programme Curriculum and enable us to ensure that foundation doctors are able to deliver safer and more effective patient care.
24. owever, while there is still much work to do to ensure foundation training best serves the needs of patients, the NHS and doctors in training, we do not believe that this will be achieved through the dismantling of the Foundation Programme. We strongly urge Professor Sir John Tooke and his colleagues to reconsider the recommendation to decouple F1 and F2 (Recommendation 31) and abolish F2 (Recommendation 33).

Professor Derek Gallen
National Director,
On behalf of the UK Foundation Programme Office

References

Academic Careers Sub-Committee of Modernising Medical Careers and the UK Clinical Research Collaboration. Medically and dentally-qualified academic staff: recommendations for training the researchers and educators of the future. 2005; UK Clinical Research Collaboration and Modernising Medical Careers, London

The Academy of Medical Royal Colleges, Department of Health, NHS Scotland, DHSSPS, NHS Wales. The Foundation Programme Curriculum. 2nd Edition. 2007
http://www.foundationprogramme.nhs.uk/pages/home/key-documents

Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. The Lancet 2002;359:1373-8

Department of Health, NHS Scotland, DHSSPS, NHS Wales. Operational Framework for Foundation Training. 1st Revision, 1st Edition. 2007
http://www.foundationprogramme.nhs.uk/pages/home/key-documents

Department of Health, Scottish Executive, DHSSPS Northern Ireland, Welsh Assembly Government. Modernising Medical Careers: the response of the four UK Health Ministers to the consultation on Unfinished Business: Proposals for reform of the Senior House Officer grade. 2003. Department of Health, London.

Department of Health, Scottish Executive, DHSSPS Northern Ireland, Welsh Assembly Government. Modernising Medical Careers: the next steps – the future shape of foundation, specialist and general practice training programmes. 2004. Department of Health, London.

Donaldson L. Unfinished business, proposals for reform of the Senior House Officer Grade. 2002. Department of Health, London.

Grant J, Chambers K, Maxted M, Owen H. Identification of Career Intentions as a function of foundation programme experience. 2005. http://www.mmc.nhs.uk/download/Career-intentions-and-the-foundation-programme.doc

McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316:1853-8

Vincent C, Noble G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-9

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