“Modernising Medical Careers” to “Shape of Training”—how soon we forget

Modernising Medical Careers (MMC) changed all aspects of medical training in the United Kingdom from its introduction in 2005. It shortened the duration of training, introduced “run-through training” (removing the need to reapply for higher specialty training places, but which some specialties subsequently reversed), and reduced flexibility.1 2 3 MMC got doctors protesting on the streets and led to questions being asked in parliament and to John Tooke’s independent report into its failings.4 The longest run-through programmes are just completing their first cycle.

It would be useful to analyse the current state of training—and thus identify the sources of several problems. These include the shortfall in core medical trainees needed to fill specialist training in acute medicine and geriatrics; difficulties in appointing locums, with consequent disruption of training and service delivery; and falling numbers of specialist trainees dually accredited in general medicine, because limited training time is only just enough to train adequately as a specialist.5

Instead we have the Shape of Training review of all medical and surgical specialties.6 Despite explicitly excluding workforce or economic analysis, Shape of Training gives very specific recommendations on the duration and content of specialist training that will have far reaching consequences for the training of specialists—and thus the practice of these specialties in the future.

The review’s central thesis is that we need more doctors capable of providing general care in broad specialties, a need driven by the ageing population and the growing number of people with comorbidities.6 Shape of Training’s proposal is to increase the amount of generalism and reduce the amount of specialism in an overall shorter training period, with the specialist deficit being made up for with “credentialing” (certification or a “credential” for skill in a particular service or procedure) after training is completed.

This thesis and approach are worth questioning. Patients undoubtedly need access to competent generalists (such as when presenting in an emergency to hospital), but they also need access to specialists with expertise in their problems—in the acute setting and in the long term. Not only do patients have more comorbidities, but treatments for each disease have become more complex. Patients expect to see specialists with expertise in their particular problem, something enshrined in guidelines issued by the National Institute for Health and Care Excellence. This guidance reflects the evidence: specialist care has better outcomes—for example, better survival in stroke units,7 and reduced mortality among patients with heart failure who are treated by cardiologists.8 The increasing complexity of treatment might argue for longer rather than shorter specialist training. The presumption in the proposed model is that a wholly new concept, credentialing, could fill this gap. It would pose a significant risk for patients if it did not—and if, as we suspect, specialty training is in fact more than just a series of modules bolted together.

Older doctors may find the proposed system familiar: it describes the training they had as senior house officers and registrars, but without the subsequent training as senior registrars.

The review of evidence for Shape of Training recognises that a range of interpretations of “generalism” exist and that evidence comparing generalist and specialist approaches is lacking.9 Shape of Training recommends that “any changes . . . that promote an increasingly generalist slant to the profession should be accompanied by primary research and evaluation.”9 In other words, there is not enough evidence for the wholesale introduction of generalism proposed by Shape of Training. More generalism will mean less specialism. Surely the balance between the number of competent generalists and specialists depends on careful analysis of the numbers of each needed by our patients, but the review’s brief specifically excludes such an analysis of workforce planning and services. Shape of Training proposes greater flexibility between programmes (which we welcome) to rectify the balance if it goes wrong, but a swing to generalism across the board, with dilution of all specialist training, seems likely to deprive many patients of access to the specialists they need.

In addition, the process is flawed. MMC was introduced with a fairly inflexible framework and little debate. Many of the unintended consequences of MMC were predicted and hence avoidable. It seems extraordinary that a forward looking report on training is being adopted without subjecting these interesting and innovative proposals to scrutiny, discussion, and debate.

Change comes at a cost, but Shape of Training has no costings, whether of financial costs, opportunity costs, or costs to the service and to trainees—or to medical education in general from another wholesale reorganisation. If the ideas, such as credentialing, are sound, they should be costed and piloted rather than implemented untested and at unknown cost. It seems unlikely that one model will fit all specialties. The greatest cost of all may be the effect on patient care.

Shape of Training should be a “green paper” for discussion and debate, not a “bill” for implementation. This would allow the effective involvement of the medical profession in policy making on training, something that was identified as being weak in MMC.4 As Tooke wrote recently, we need “care in transition.”10 Good ideas could then be developed and unintended consequences avoided, with minimum disruption and cost. And no protests on the streets.

Have we forgotten the lessons of MMC?