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Unfinished Business: Proposals for Reform of the Senior House Officer Grade
Summary
Most young doctors seek a senior house officer (SHO) appointment when they complete their first postgraduate year as a pre-registration house officer.
There have been significant reforms of pre-registration and higher specialist training and improvements to vocational training for general practice. In contrast, long-standing problems with the job structure, working conditions and training opportunities of SHOs remain.
The Government is committed to reform the SHO grade. This Report sets out proposals for progressing that reform.
The case for change
The problems of the SHO grade are widely accepted but, unlike the emphasis on education and training for other groups of professional staff, SHOs have not benefited from a substantial or coherent investment in their professional development.
In England about:
half of all doctors in training are SHOs;
one third of SHOs are non-UK graduates;
half of the UK graduates in the grade are women and that proportion is increasing.
Although these ratios may vary across the United Kingdom, the pattern is broadly similar.
Reform must take account of:
poor job structure: half of all SHO appointments are short-term and do not form part of any training rotation or programme;
poorly planned training: there is no defined end-point to SHO training. Time spent in the grade varies and is often independent of training requirements;
weak selection and appointment procedures: these are not standardised and are frequently not informed by core competencies;
increasing workload;
inadequate supervision, assessment, appraisal and career advice;
insufficient opportunities for flexible training;
unsatisfactory arrangements for meeting the training needs of
non-UK graduates;
the relationship between Royal College examinations and their relevance to training programmes varies greatly.
A new framework for training of SHOs
The relatively recent implementation of the specialist registrar system provides important lessons for change to the SHO grade. For example in a reform of medical training it is important to:
set out a clear set of principles to guide reform;
publish programme curricula;
ensure a coherent approach to setting standards and managing the delivery of training;
provide robust and reliable information systems to support the management of training;
ensure a consistent and valid approach to assessment;
place a strong emphasis on the quality assurance of training;
introduce a sound process for the selection of trainees;
manage training - service tensions.
Training should:
be programme-based;
be broadly-based to begin with for all trainees;
provide individually-tailored programmes to meet specific needs;
be time-capped;
support movement of doctors into and out of training and between training programmes.
Structure. Following graduation, all doctors will enter:
first a two year
foundation programme which includes the current pre-registration year. An objective of the foundation programme would be to develop and enhance core or generic clinical skills essential for all doctors (e.g. team-working, communication, ability to produce high standards of clinical governance and patient safety, expertise in accessing, appraising and using evidence as well as time management skills).
second one of eight (or so) broad-based, time-capped
basic specialist training programmes including training for general practice. During the foundation years, the doctor would have had the chance to sample a range of practice and would then compete to enter one of the basic specialist training programmes.
A limited number of
individual programmes will be provided designed to meet specific training needs of individual doctors.
Programmes. These would ensure that as many doctors as practicable wishing to enter higher specialist or general practice training can do so. The programmes will enable doctors in SHO training to gain the right knowledge, skills, attitudes and experience in the minimum time and will:
deliver training to a high standard;
be flexible in design and operation;
respond to changing service needs;
address the needs of non-UK graduates;
provide opportunities for flexible training;
be time-capped;
provide opportunities to leave and re-enter training;
present a robust structured framework to support compliance with the requirements of the European Working Time Directive;
provide a foundation to support moves towards more integrated training along the continuum.
A single training grade
The advantages of moving to a single training grade encompassing: foundation; basic specialist; general practice; higher specialist; and individual training programmes should be urgently explored. In such an arrangement doctors in training would move seamlessly through the grade subject to satisfactory performance and assessment. This could not be implemented immediately and some element of application and competition may still need to be retained to meet the needs of the service and availability of training places. This should be explored specialty by specialty.
Assessment and examination
The proposals for reform to SHO training place greater emphasis on competency-based assessment throughout training as evidence of successful completion of training. Progress through training will continue to be informed by success in medical Royal College examinations and increasingly through the Record of In Training Assessment (RITA) process as it is introduced for SHOs.
An analysis has found a striking variation in examination practice across medical Royal Colleges and Faculties:
pass rates for Royal College Part I examinations ranged between 33.3% and 81.4%;
pass rates for Royal College Part II examinations ranged between 27.5% and 79.0%;
pass rates for UK graduates ranged between 44.4% and 78.8%;
pass rates for non-UK graduates ranged from 28.0% to 66.7%;
the minimum costs for candidates completing the examination ranged from the cheapest college examinations at 530 to the most expensive at 1,460.
Royal College examinations will remain a vital component of medical training, but there has been no comprehensive and fundamental review of the College examination system in the round and the 'fitness' of the examinations for purpose. Nor are the examinations subject to any external quality assurance, which is unusual compared to other fields of education and training. It is proposed that a system of external accreditation of medical Royal College examinations should be introduced. It is understood that the Academy of Medical Royal Colleges has already started a fundamental review of the examination system.
Managing training and recruitment
It is proposed that:
postgraduate medical deans should be responsible for the overall management of programme-based training, using programme directors accountable to them;
postgraduate deans would also be responsible for ensuring that trainers were adequately supported and trained, and for ensuring the quality of training placements;
it is also proposed that postgraduate deans should be responsible for the appointment arrangements to all programmes (foundation, basic and higher specialist and individual).
Non-UK trained doctors
Wider Proposals
Conclusions
The 19 proposals set out in this report are for consultation. They aim to reform the Senior House Officer grade, a grade occupied by half the doctors in training in this country.
The opportunity of this fundamental review of the SHO grade has raised wider points about the structure of the medical workforce and as a result proposals are made to change the nature and timing of the Certificate of Completion of Specialist Training (CCST) and to reform the non-consultant career grade.
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