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Unfinished Business: Proposals for Reform of the Senior House Officer Grade

The Case for Change

This section describes current arrangements for SHO training, identifies the different aims of doctors training in the SHO grade and describes the current problems and issues particular to this group of trainee doctors.

2.1 Doctors entering the SHO grade hold Full or (for most non-UK graduates) Limited Registration with the General Medical Council. The grade represents the phase of training now commonly called basic specialist training, and is supervised by two 'competent authorities' ³ appointed by the Government.

2.2 The number of doctors in SHO posts is large: in England, they represent almost half of all doctors in training.

Numbers of NHS medical staff in training

PRHO = Pre-Registration House Officer, GP = General Practitioner, SpR = Specialist Registrar

2.3 At any one time there will be SHOs:

• in vocational training for general practice;

• in basic specialist training;

• gaining broader training or experience (often before making a career choice);

• 'marking time' waiting for an opportunity to progress their career;

• choosing to remain in the SHO grade, sometimes for many years.

However, the current service pressure on SHOs is great. In service terms their numbers are potentially inflated further by an increasing cohort of 'trust doctors' who undertake work equivalent to that of an SHO, although they are in reality a non-consultant career grade.

2.4 It is generally accepted that SHO training requires radical overhaul. Reforms already undertaken in other areas of the medical training continuum have identified deficiencies in SHO training, in particular:

• the General Medical Council's report The New Doctor⁴ which led to improvements in pre-registration house officer training;

• the 'Calman' reforms of higher specialist training ⁵ now fully implemented;

• several reports supporting better management of general practitioner vocational training;

• the 'Savill Report' ⁶, addressing training for academic medicine, identified bright SHOs being effectively forced into undertaking pre-Specialist Registrar doctoral research in order to enhance their competitiveness to gain entry to specialist registrar programmes.

2.5 In recent years a number of reports have been published by different organisations on SHO training (a bibliography is at Annex D). They have explored ways to improve training, but almost all have sought changes to existing training structures and focused mainly on educational issues. There has been little analysis of the case for more radical reform, for strategic or structural change, or of the need to take into account the wider implications of reform on service delivery now and in the future.

The senior house officer grade - principal challenges:

• job structure;

• planning training;

• selection and appointment procedures;

• supervision, assessment and appraisal;

• tension between service and training needs;

• arrangements for flexible training;

• career advice;

• meeting the needs of non-UK graduates;

• workforce planning;

• the role of Royal College examinations;

• adapting higher specialist training to changing service demands.

Job structure

2.6 About half of all SHO posts are free-standing and do not form part of any training rotation or programme. As a consequence:

• many SHOs receive limited career guidance and are left to decide on and to follow their own career pathways in the hope that their choice of posts will support their final career choice;

• even where posts have been grouped to form a rotation this does not usually meet the requirements of a managed programme of training;

• the quality of training can be indifferent;

• the constant need to secure short-term posts means frequent job applications and participation in appointments committees. This creates uncertainty for trainees and is an added burden for the service.

Planning training

2.7 There is no defined end point to SHO training. The length of time spent in the grade varies greatly. Progress beyond the grade is largely dependent on a doctor's ability to secure a specialist or general practice registrar position. This in turn depends on:

• the number of places available in programmes of higher specialist or general practice vocational training;

• the requirement in most specialties to pass medical Royal College examinations before entry to higher specialist training.

2.8 Many trainees spend considerably longer as SHOs than is required to satisfy training requirements and, although continuing to gain some experience, are effectively repeating training. Additional time spent in basic specialist training does not normally count towards higher specialist training.

Selection and appointment procedures

2.9 Selection and appointment procedures are often inefficient and expensive:

• appointment procedures have not been standardised as they have for appointments to specialist registrar programmes and there is a risk they may not always comply with good employment or equal opportunities practice;

• selection is not always based upon meeting and assessing the competencies SHOs require to provide good quality care and to progress through training. There has been insufficient progress made in defining these competencies.

Supervision, assessment and appraisal

2.10 There have been recent improvements in the supervision of SHOs but there are still no robust mechanisms for regularly appraising performance nor for formal assessment. These are difficult to introduce without the support of a structured training programme. Poor performance is not reliably recognised or addressed. An SHO's suitability to progress to the specialist registrar grade is measured largely on success at passing Royal College examinations and on ability to secure further posts.

Tension between service and training needs

2.11 In an apprentice-based training system, tension between the competing demands of training and service is to be expected. This is nothing new and should be a positive dynamic especially where working and learning are not always easily separated. However, within the SHO grade this tension is often addressed in an inadequate and ad hoc way:

• there is no general understanding of the appropriate service contribution that SHOs should make;

• the potential benefits of SHO ability to 'cross-cover' between related disciplines, or their participation in multi-professional teams, have not been fully explored.

As a result there are marked variations in the amount of service SHOs provide in different posts and inconsistency in the quality of the training they receive.

2.12 SHOs make a major contribution to the provision of health services. Implementation of the European Working Time Directive for doctors in training will impact on the way they work and will force a fresh look at how the demands of providing service and training are met.

Flexible training

2.13 As more women graduate from UK medical schools, so more become SHOs, creating an important need for family friendly policies and for flexible training. Men too are seeking more flexible working arrangements. In 1986 women doctors made up 25% of the hospital medical workforce in England. By 2001 that proportion had risen to 34%.

Numbers of women doctors in training and proportion in different grades

PRHO = Pre-Registration House Officer, GP = General Practitioner, SpR = Specialist Registrar

The case for improved flexible or part-time training in the SHO grade:

• 58% of medical school intake are women;

• 34% of the hospital medical workforce are women;

• 49% of UK graduates holding SHO posts are women.

Career advice

2.14 SHOs have to make important career decisions. Yet many receive poor career advice and guidance. Improvements are necessary but need to be flexible, recognising that not everybody can or indeed wishes to make definitive career decisions early in their postgraduate training. For example, a cohort study ⁷ of medical graduates found that:

• 24% of doctors entering the SHO grade changed their career preference at least once within the three year period following entry to the SHO grade; and

• five years after graduation:

• 7% were still undecided as to their preferred career;

• 17% had changed their main specialty in the previous twelve months.

2.15 Doctors should not be pressed or expected to make premature career decisions. This is neither in their interests nor that of patients. Exposure to a variety of settings and experiences early in their postgraduate career can help them to make an informed career choice.

Meeting the needs of non-UK graduates

2.16 Graduates from overseas and elsewhere in the European Economic Area form a significant part of the training workforce.

Numbers of non-UK graduates in training and proportion in different grades

(na = not available)
PRHO = Pre-Registration House Officer, GP = General Practitioner, SpR = Specialist Registrar

2.17 Their reasons for seeking to train in the UK differ:

• many come to fulfil a specific training goal and then return to their home country;

• others come to undertake full postgraduate training in the UK leading to a Certificate of Completion of Specialist Training and then return to their home country;

• others plan to complete their training here and settle in the UK;

• some may be undecided about their ultimate career aspirations;

• some are refugees with particular needs.

Most arrive after varying levels of training, qualifications and experience and consequently have different training needs. Many encounter real difficulties in securing an initial appointment (particularly in their chosen specialty). They often hold short-term SHO contracts or face unemployment between posts when their contracts end. Their aspirations for career advance are frequently unmet.

Workforce planning

2.18 SHO numbers are not planned nationally and have not so far taken account of educational goals or of the longer-term needs of the medical workforce. Numbers have largely been influenced by the output of new medical graduates and service pressures, and are currently primarily controlled by exercising broad financial constraints (an education levy or equivalent system). Training programmes and the numbers within them to support service needs have not been routinely identified. Even now when a more flexible approach to workforce planning is being adopted these criticisms remain valid.

2.19 In contrast, the number of specialist registrar placements is planned to ensure an adequate supply of consultants to the NHS geared to the needs of individual specialties. NHS Trusts, however, continue to seek more SHO posts (or use NHS Trust grade doctors working at SHO level) because of their current excellent value for service and, until the European Working Time Directive begins to take effect, their versatility to cover out of hours work and emergency care.

2.20 Trainee preferences are a further factor contributing to an imbalance between SHO and specialist registrar training opportunities in different specialties. The situation varies between parts of the country. The example given below illustrates the marked imbalances that have arisen over time.

2.21 The excess of SHOs attempting to enter higher specialist training in some specialties means not all doctors can pursue their chosen specialty and have to make alternative training or career choices. With little good career advice, many seek repetitive posts hoping eventually to advance their particular career choice. In other specialties, insufficient trainees wishing to enter higher specialist training or to enter general practice causes a shortfall in applicants for consultant or general practice posts needed to meet service requirements.

The role of Royal College examinations

2.22 Entry into higher specialist programmes is governed by minimum entry requirements set by the Specialist Training Authority of the Medical Royal Colleges on the advice of the Royal Colleges. In many cases, these require that a candidate for higher specialist training has been successful in the relevant Royal College examination. Therefore, for many trainees the primary goal of the SHO grade is simply to pass the necessary examination.

2.23 Evidence provided to the Working Group on all Royal College examinations demonstrated wide variations in success rates across different examinations and in the minimum costs for completing the examinations. The differences were striking. In summary:

[Note: data from 2000]

There appeared no ready explanation for these findings other than the traditions, practice and attitudes of Royal Colleges differed greatly. In many Colleges significant numbers of overseas doctors, who have not trained in the United Kingdom, take the examinations.

2.24 The important function of examinations within the training continuum is recognised. However, the relationship between these examinations and their role within specialist training varies greatly between the Royal Colleges. Success in their examinations may mean that the candidate:

• has the knowledge, skills and attitudes to be eligible to apply in open competition to enter higher specialist training;

• is eligible to enter the final stages of higher specialist training;

• has demonstrated evidence to support the award of a Certificate of Completion of Specialist Training;

• is an overseas doctor wishing to use an examination pass as an important demonstration that they have reached an identified level of skill and knowledge, but does not wish to proceed through the UK training system.

2.25 Neither the timing nor the content of these examinations is clearly linked to doctors' progress through training. Indeed, examination failure may lead to 'dead time' in which doctors, ready to move on to the next phase of training, cannot do so and mark time until they pass the required examination.

Adapting higher specialist training to changing service demands

2.26 Following basic specialist training, many doctors move on to higher specialist training. There are almost 60 higher specialist training programmes varying between two and six years in length dependent upon the specialty. Successful completion of a programme results in the award of a Certificate of Completion of Specialist Training and the opportunity to become a consultant.

2.27 There is now a growing view that patient care would be enhanced if delivered by doctors whose training is not as deeply specialised as some of the current Certificate of Completion of Specialist Training programmes demand. If properly grounded in the medical career structure there could be clear benefits to both the service and individual doctors in developing new, shorter Certificate programmes designed to produce fully-trained specialists with a wide range of skills more closely attuned to the current needs of the NHS. Some doctors would acquire further specialist and sub-specialist skills in their careers in response to service needs.

2.28 To benefit fully from such shorter, more broadly-based higher specialist training programmes, a trainee must be properly prepared, with the appropriate grounding at the basic specialist stage. The current SHO training system is in the main unstructured and would be entirely unsuitable in preparing doctors for new higher specialist training programmes. Reform of the SHO grade is, therefore, an essential ingredient in establishing the right platform experience and broad specialty training for entry into higher specialist training.

2.29 The case is made elsewhere in this report for a more integrated approach to training and for more thought on the benefits of a single training grade - a clearer link between structured basic specialist training and reformed higher specialist training will add to the impetus to integrate training more fully.

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