British Association of Dermatologists (BAD)
Education Sub-Committee response to
GMC Shape of Training
- Over the next 30 years, how do you think the way patients are cared for will change?
This is a difficult prediction since governments are continuing to change the delivery of healthcare. The BAD would wish that Consultant Dermatologists continue to be the experts and principal providers of dermatological care in the UK. It is likely that there will continue to be an increased demand from increasingly ageing and well informed patients and that delivery of such care will be requested to be closer to their home. If patients are provided with a personal health budget it could be argued that instead of seeing general practitioners with little knowledge of dermatology, patients could be seen by a new class of office dermatologists who have just completed higher specialist training in Dermatology. A smaller percentage of more complex patients would then be seen by highly specialised consultant dermatologists located in centres of excellence who would have access to inpatient beds and other specialties. There may also be a greater demand for e-consultation and telemedicine but this should not deflect from the principle that such communications should not be a substitute for face-to-face consultations.
- What will this mean for the kinds of doctors that will be needed in primary care? In secondary care? In other kinds of care?
The above model would allow patients to determine whether they had a skin disease and would prevent the current wastage of patients being treated unsuccessfully by GPs who are less skilled and trained in the management of skin diseases. In addition the current disincentive to refer patients to secondary care would disappear. The model of having dermatologically trained and qualified trained office dermatologists seeing the bulk of dermatological care would result in the termination of GPSIs (and with the increasing difficulty in maintaining accreditation this would be appropriate), and therefore most patients would be seen in a setting which would be low cost and have a high new to follow-up ratio. The office dermatologists would employ specialist nurses located in the community who could advise and undertake wound care, ulcer dressings etc. Primary care doctors would still have the ability to refer patients to dermatologists and would continue prescribing the bulk of medicines. Secondary care would continue to be delivered by more specialised consultant dermatologists.
There are already large numbers of unfilled consultant dermatology posts in the UK. In order for the above model to be fulfilled there must be an expansion of dermatology training posts in the UK.
- What do you think will be the specific role of general practitioners (GPs) in all of this?
If the current provision of service remains with primary care commissioning dermatology services, GPs would remain as the gatekeeper for patient referral and there will inevitably cost pressures to reduce referrals to secondary care. If on the other hand office based dermatologists were established, GPs would still act as the gatekeeper but if patients had a personal health budget, referrals would be directly to office based dermatologists and this would lighten the burden on GPs. However the BAD would wish to encourage incorporation of dermatology and assessment of competency in this subject to be a component of general practitioner training.
- If the balance between general practitioners, generalists and specialists will be different in the future, how should doctors’ training (including GP training) change to meet these needs?
The BAD firmly believes that doctors who are delivering dermatological care (consultant dermatologists in secondary care and office dermatologists) should still have physicianly training, obtain MRCP and then pursue higher specialist training in dermatology. If GPs were to include formal dermatological training within their curriculum then their training would have to be prolonged.
- How can the need for clinical academics and researchers best be accommodated within such changes?
The BAD is most concerned that the emphasis by the management of most hospitals is focused on service provision. There must be incentives forconsultant dermatologiststo undertake research and that in job planning, time is set aside for research and teaching of under- and post-graduates. The research could be accessed through the UK Clinical Trials Network or by the UK Translational Research Network in Dermatology. The highly specialised consultants in centres of excellence should have in their contract appropriate time and support for research and outcomes will need to be measured. Trainees also should be encouraged to develop an interest in research through out of programme research and academic research fellowships
- How would a more flexible approach to postgraduate training look in relation to:
- Doctors in training as employees?
The BAD is concerned that any increased flexibility does not result in any reduction in the quality of training and that strict quality assurance and management processes remain in place. The changing structure of training and education through HEE and LETBs is not yet in place and so there is no guarantee that the currently well working structures through the JRCPTB, specialty SACs and in parallel through the Deaneries and STCs will be maintained. There is a concern that Any Qualified Provider may not understand and could not provide the required educational and research training. The BAD is also concerned that specialists outwith what we understand as the current NHS, may not understand and provide the training requirements to meet the educational standards laid down by the GMC.
- The service and workforce planning?
Again the BAD has serious reservations about LETBs being able to micromanage service and workforce planning separate from a national strategy.
- The outcome of training – the kinds and functions of doctors?
The BAD is of the absolute opinion that all dermatologists providing dermatological care should be trained to high standards with curriculum and assessments being supervised by the Dermatology SAC of the JRCPTB. Perhaps it might become appropriate for those undertaking higher training after gaining CCT to become the consultants in specialised centres and these doctors would have different portfolio of competencies compared to those who do not wish to take further training and become the “office” dermatologists as described in Para 1.
- The current postgraduate medical education and training structure itself(including clinical academic structures)?
The only change the BAD would recommend is a lengthening of training to 5 years if on call commitments were removed. We would recommend continuing the current quality management and assurance structures.
- How should the way doctors train and work change in order to meet their patients' needs over the next 30 years?
See above. Patient expectations are likely to continue rising and therefore consultations may be longer, greater communication skills will be required there may be demands for easier access to doctors with increasing IT support.There is a predicted year on year rise in the incidence of skin cancers and sufficient manpower needs to be in place to treat this demand.
- Are there ways that we can clarify for patients the different roles and responsibilities of doctors at different points in their training and career and does this matter?
Yes it is important that patients are aware of the type of doctor they are consulting (Consultant, Junior {Year 1or 2} or Senior Trainee {Year 3 or 4}, GPsI) and there is absolute clarity about this. Perhaps staff should be required to wear badges declaring their role. It is imperative that trainees and GPsIs always have a consultant available to provide expertise and support.
- How should the rise of multi professional teams to provide care affect the way doctors are trained?
Doctors are already working as multi-professional teams and such competencies are already being delivered in the current Dermatology Training Curriculum. The trainees still need the breadth of exposure to all aspects of the curriculum as the multi-professional team will still look to the consultant to advise if there are problems. It is important therefore that trainees work as part of these teams but retain supervision from their consultant trainers.
There are a number of sub-specialty opportunities in Dermatology and many of these require multi-professional teams. These include Paediatric Dermatology, Dermatological Surgery, Cutaneous Allergy, Medical Dermatology, Genital Dermatology and Photodermatology. Higher training in these sub-specialities might require a dedicated fellowship for a period of time and these should be available, recognised and quality managed by the appropriate bodies such as the JRCPTB and the GMC.The BAD also believes that the delivery of paediatric dermatology should be undertaken by dermatologists.
- Are the doctors coming out of training now able to step into consultant level jobs as we currently understand them?
Yes and No. There are currently in excess of 70 vacant consultant dermatology posts in the UK. Therefore if trainees are geographically mobile they could step straight into a consultant post. However if doctors gaining CCT are geographically fixed, because of personal reasons, these doctors may then have to take up Locum consultant posts until they gain a substantive post. The problem has now arisen that many departments who have been unable to appoint a consultant post have become dysfunctional due to either dissipation of trained nursing staff, poaching of patients by private dermatology services or peripatetic dermatologists from other localities. The numbers of training posts should reflect the population needs around the country.
- Is the current length and end point of training right?
Currently, the trainees only just feel adequately trained after the minimum 4 years of training. This includes intensive clinical experience through the day and on call out of hours and weekend experience which is always under threat of withdrawal from trusts. The current length of training is probably too short and should be extended to 5 years and this should definitely be the case if out of hours emergency experience is decreased, as is happening in many centres.
- If training is made more general, how should the meaning of the CCT change and what are the implications for doctors’ subsequent CPD?
Doctors appointed to higher specialist training in dermatology arrive with little or no prior dermatology experience. The BAD does not believe that the mix of training should change. Training in general medicine needs to continue and specialist training should be extended particularly if on-call activity is reduced.
- How do we make sure doctors in training get the right breadth and quality of learning experiences and time to reflect on these experiences?
This requires a balance to be struck between service commitments, time for independent study and research. Again the Dermatology Curriculum suggests that an average weekly timetable should include between 7 half day sessions of direct clinical experience. This should include one surgery session for most of the training programme. The remaining 3 sessions should be used for administrative work, personal study and research. There is a requirement for additional on-call experience. It is important that all aspects of the curriculum are delivered and assessed on an annual basis to allow progression to the following year of training.The role of educational and clinical supervisors should be more highly regarded and adequate time in consultant job plans should be provided for this commitment.
- What needs to be done to improve the transitions as doctors move between the different stages of their training and then into independent practice?
There is an accepted feeling that 4 years of training is only just adequate to deliver an appropriately experienced general dermatologist without additional specialist expertise. The length of training would need to be extended to 5 years if on-call is withdrawn. The development and provision of post-CCT Fellowships would allow additional skills to be acquired in order to provide a higher specialised service. There may also be a role for mentoring of doctors who have completed training and are in their early years of “consultant” practice.
- Have we currently got the right balance between trainees delivering service and having opportunities to learn through experience?
There is currently insufficient flexibility in service provision to allow time for trainees to have reflection and discussion of patients seen, to undertake less service at the beginning of their training and then to undertake more service delivery over time astheir independence develops. The provision of on-call develops the autonomy and skills of trainees. Trainees should be given adequate protected time to sit in on consultant clinics and to observe different skills and practice.
- Are there other ways trainees can work and train within the service? Should the service be dependent on delivery by trainees at all?
Service delivery is an indivisible aspect of training to develop confidence and responsibility for patient management and must be dependent on trainees. However sufficient consultant time is required for supervision of the trainees.
- What is good in the current system and should not be lost in any changes?
- General medical training
- Detailed dermatology training curriculum which is quality managed and assured
- Experience of acute dermatology by maintenance of on-call
- Mapping of assessments to the curricular requirements
- Consultant led training and supervision
- Centralisation of workforce planning
- Are there other changes needed to the organisation of medical education and training to make sure it remains fit for purpose in 30 years time that we have not touched on so far in this written call for evidence?
Payment by educational results/outcomes would allow money to follow excellence in training and would incentivise good education and training.
About You
Finally, we would appreciate you providing the following information about yourself to help us analyse the consultation responses.
Your details
Name: Professor Malcolm Rustin
Job title (if responding as an organisation) Academic Vice-President
Organisation (if responding as an organisation) British Association of Dermatologists
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British Association of Dermatologists - December 2012