Equity in study leaveBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7184.2 (Published 06 March 1999) Cite this as: BMJ 1999;318:S2-7184
All doctors in training are equal but some are more equal than others. Yorkshire postgraduate dean Rosemary Macdonald reports from a working party that addressed the issue
- Rosemary Macdonald, postgraduate dean (Yorkshire)
Is it fair that orthopaedic trainees should have their study leave funded at the expense of trainees in palliative care? Should plastic surgical specialist registrars attend courses in preference to paediatric specialist registrars? Before 1996 in the Yorkshire deanery the average annual cost of study leave for orthopaedic trainees was £835 per trainee and for palliative care trainees £235 per trainee. One orthopaedic trainee received £2,000 of funded leave in one year and is now a consultant with an entirely different subspecialty interest. That same year, a trainee in learning disability had £25 of funded study leave. Trainees in plastic surgery had been given a list of “essential” and “desirable” courses to attend. There was minimal guidance for paediatric trainees. Medical senior house officers seemed to attend innumerable MRCP courses such as PASTEST (costing £400-1,000), never received educational advice between attendances, and still failed the exam. Trainees attending the same course often submitted grossly different expenses. This was discovered only in the mid-1990s, when computerised records became the norm. The records reveal many anomalies.
How could a hospital trust's clinical tutor adjudicate the educational requirements of trainees in different specialties? It was easy for college regional advisors and chairs of specialty training committees to recommend mandatory study leave for specialist registrars, knowing that the organisation and funding was someone else's problem. Why did trainees wish to attend so many courses in London, Edinburgh, and Davos? Surely not just because of academic excellence - perhaps also cultural and sporting activities.
Strategic principles for study leave
Study leave should:
Enhance clinical education and training
Be planned as far in advance as possible as an integral part of the educational process
Provide education and training not easily acquired in the clinical setting
All trainees should be encouraged to develop coherent plans for study leave early in their senior house officer post, rotation, and general practitioner registrar or specialist registrar training programme.
Putting the house in order
With study leave in apparent chaos, both financial and educational, the Conference of Postgraduate Medical Deans of the United Kingdom (COPMeD) set up a working party to review it. The working party has recently published guidelines for study leave.(1) If implemented these guidelines should bring the organisation and management of study leave much closer to trainees and should facilitate the educational management of study leave, thus increasing its relevance to trainees' needs. In order to understand these guidelines and appreciate how they have evolved, some historical perspective is necessary.
Before 1990, study leave for senior house officers was organised and funded by the hospital in which these doctors were working. Study leave for registrars and senior registrars' was funded by regional health authorities, with advice sought and given by various consultant colleagues and academic departments.
After 1990, funding for study leave was transferred to postgraduate deans' budgets, which were set on the basis of what had been spent previously. Postgraduate deans devolved the budget for study leave to hospitals (by then, trusts) and to the clinical tutors, who then managed the budget and gave guidance to trainees on behalf of the postgraduate deans. Some trusts and specialties received a greater share of the budget, which was historically derived. In some deaneries the cost of providing locums to cover study leave was included in the dean's budget. The allocation of locum costs to trusts varied and, in the Yorkshire deanery, did not seem to follow a rational pattern.
Change focuses attention
Publication of the chief medical officer's report on specialist medical training in 19922 served to focus the attention of deanery specialty training committees, colleges, faculties, and their specialist advisory committees on the relevance of study leave to trainees' needs, year by year, throughout structured training. Various initiatives to focus attention on senior house officers' training also led to a greater demand for funded study leave for this grade.
Vocational trainees in hospital posts often found themselves the “poor relations” of their specialist colleagues, in relation to both actual leave and to funding. Furthermore, vocational trainees often require leave to complement clinical training in another part of the scheme and may therefore receive leave and funding from a different trust to which they have rotated.
Increasingly, clinical tutors found themselves left to juggle with the issues of leave, funding, and educational relevance. The National Association of Clinical Tutors pressed deans to provide guidance - another reason for the working party.
Study leave allowance
Since the terms and conditions of service relating to study leave were negotiated, there have been considerable changes in postgraduate medical and dental education, both in general practice and in hospital. The requirements for, and terms of, study leave should be reviewed within the context of the terms and conditions of service for doctors in training.
“Bleep-free” teaching time within the hospital trust in which the trainee is based and NHS initiatives such as audit and CEPOD should not count towards their study leave allowance. Neither should leave to sit examinations, although only two attempts are permitted: further attempts should come from annual leave. Deanery half day or day release courses that take trainees away from the trust in which they are placed should normally count against the study leave allocation. However, such courses should be approved by the specialty training committee and the postgraduate dean. General practitioner senior house officers who attend half or full days organised for the vocational training scheme by course organisers may have this time counted against their study leave allowance. Most deaneries give these trainees 15 days annually on top of their days or half days (personal survey).
Following on from this and in the interests of equity between specialties and training rotations, weekly or full day sessions for research or private study recommended by colleges or faculties may also count as part of trainees' study leave allowance. What is fundamentally more important is that trainees and their educational supervisors should agree plans for this time, and evidence of objectives having been achieved must be provided. Too often, trainees drift during their research time and achieve little. Those who do not rush to do research may benefit from development or refinement of a clinical skill, which would also enhance their curriculum vitae.
Educational approval for study leave for senior house officers should remain the responsibility of clinical tutors in trusts. They work closely with college tutors and are close to the senior house officers. Most trusts' postgraduate centres have devised guidelines for senior house officers which are revised and modified as training changes. Senior house officers need to discuss study leave with their educational supervisors soon after their appointment. Plans may be modified after appraisal, as needs become apparent.
Educational approval for vocational training schemes for general practitioner trainees should be the responsibility of the course organisers, who need to work in close collaboration with college and faculty tutors in trusts as well as with clinical tutors.
Educational approval for study leave for specialist registrars should be given “corporately” by deanery specialty training committees, which may appoint a specialty study leave advisor. This person will oversee the specialist registrar's study leave for the duration of the training programme. Increasingly, specialist registrars' requirements for study leave will be planned as a result of the appraisal and assessment processes, although each specialty has addressed basic requirements, often endorsed by its Specialist Advisory Committee.
Locum cover for leave
This is a service issue and, as such, the funding should be “remapped” back to health authorities. It does not make sense for clinical tutors to have funding for locums within their study leave budget.
Sharing the budget fairly
Funding for study leave is finite. Postgraduate deans are required to manage this budget efficiently. Equity of funding for all trainees irrespective of specialty or trust seems fair, and this has been achieved in many deaneries. Postgraduate deans are therefore encouraged to identify a notional per capita sum for all senior house officers and specialist registrars. This is the sum within which clinical tutors and specialty study leave advisors must work.
Should some specialties feel the need for greater funding for study leave, this should not be achieved at the expense of other specialties. It is for colleges, their specialist advisory committees, and deans to address this issue in collaboration and initiate discussions with the NHS Executive and Department of Health.
All trainees should submit a follow up report of their study leave to continually inform those responsible for advising trainees. The COPMeD guidelines suggest introducing a deanery record of senior house officers' study leave, which those trainees not on rotations with appropriate log books or training records should use. This card should be taken from trust to trust to assist tutors giving advice. Increasingly, specialist registrars record study leave in their training records.
If the COPMeD guidelines are implemented they will help the development of educational and financial equity. They will also permit analyses of requirements and perceived deficiencies to inform continual modification of the guidelines. The main aim is to encourage a coherent approach and make study leave a planned process in every deanery so that trainees are treated consistently.
The other members of the COPMeD working party were: Jacky Hayden, postgraduate dean (North West), Shelley Heard, postgraduate dean (North Thames), Alex Muir, postgraduate dean (South East Scotland), Gordon Jackson and Kwee Matheson (National Association for Clinical Tutors).