Scrapped generalist training programme was working well, review concludes

BMJ 2016; 355 doi: (Published 11 October 2016) Cite this as: BMJ 2016;355:i5486
  1. Matthew Limb, freelance journalist
  1. BMJ Careers

The broad based training programme introduced in 2012 by the UK Academy of Medical Royal Colleges had shown promise in improving medical education before it was closed to recruitment last year, a review of the programme has concluded.

An independent evaluation found that the programme was meeting key targets, and one of the review’s researchers told BMJ Careers that the decision to halt recruitment was a “surprise.”1 2 Health Education England (HEE) announced that it would stop recruitment last November, saying that places were being scrapped to help fill more general practice posts instead.

Alison Bullock, a professor at Cardiff University’s school of postgraduate medical and dental education, led an HEE funded evaluation of the broad based training programme for the Academy of Medical Royal Colleges. She said that the training could prepare doctors for a changing NHS and suggested that HEE might come to rethink its decision or modify the scheme. “I think there is a need for it,” she told BMJ Careers. “I hope this isn’t the end of the story.”

Bullock said that, compared with trainees following traditional routes, “a very positive story” had been emerging. “I’d be very surprised if they took things from it—our evaluation—to make the decision to stop the programme,” she told BMJ Careers.

The review, which analysed evidence from trainees, said that the programme showed promise in developing “better doctors” with a “wider perspective” who could potentially improve healthcare. It found that patients with complex health needs might have a better experience and outcomes because of a more “holistic” model, where trainee generalists spanned boundaries between specialties. However, some “unintended consequences” were also revealed in the analysis, such as trainees feeling isolated—like “black sheep” in the clinical environment—and uncertain of their professional identity.

Esther Muddiman, a co-author with Bullock, said, “We were really pleased with some of the findings about the potential for this form of training to contribute towards more efficient healthcare, with patient benefits and improved interdisciplinary working. There’s some real promise there but also some key challenges in terms of fitting into existing structures and gaining the trust of other healthcare practitioners.”

Broad based training was developed to provide specialty trainees with experience in delivering patient focused healthcare across the whole of the health and social care sectors. It was designed specifically to equip doctors to understand and practise more integrated care and give them the skills needed to manage patients with complex needs.

The programme provided six month placements in general practice, core medical training, paediatrics, and psychiatry. Trainees began after completing two years of postgraduate foundation training, at which point they would traditionally be specialising in just one medical discipline. In addition, each placement trainee spent 10% of their time in another of the four specialties to encourage interspecialty links.

The study, published in BMJ Open, explored what 61 trainees from the 2013 and 2014 intakes thought about generalist training. It found that the programme “was achieving many of its stated aims.” Trainees said that they were pleased to be gaining a “wider perspective” and could better understand patients’ journeys through the health system. They thought that this was enabling them to become “better doctors” and to add value to a specialty team, for example by being more aware of “holistic” care and how to make appropriate referrals.

But it was not clear, the review said, how this would translate into everyday practice and to what extent trainees could embed this learning in the wider NHS. Researchers highlighted concerns with the programme and also “costs” to trainees. These included how trainees felt they were regarded by colleagues on traditional training—as if they were receiving special treatment.

The provision of so called 10% time, while good for developing the wider perspective, was also “problematic” in other ways. It was a possible source of conflict, said the study, with both senior and junior staff “questioning the legitimacy” of trainees’ additional opportunities and time. The researchers said, “If trainees feel like black sheep in the clinical environment this may inhibit their potential for effective learning.”

Conversely, being marked out as different might enable trainees to benefit from novel training experiences that they were confident would make them better doctors. “We suggest that feeling different is construed as both a benefit and a cost of the programme by trainees,” the researchers wrote.

Muddiman told BMJ Careers, “There’s real potential but significant challenges in terms of the established norms and hierarchies of the medical system. We would need to back the results up with further studies because it is just the views of the trainees themselves.”

Bullock said that, as with any training programme, there was always likely to “be scope for further development and improvement.” She said, “Whether broad based training might come back in some form in the future I don’t know. Wales is doing a pilot this year, and Scotland has a lot of interest in running a programme. I think the whole idea of training for a more generalist approach is still very much on the agenda.”


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