30 Mar 2011

RCPE Press Release

30 March 2011

In an unprecedented step, the Royal College of Physicians of Edinburgh (RCPE) has issued a warning that Scotland is in danger of creating a generation of inadequately trained doctors and, in turn, potentially compromising patient safety unless urgent action is taken by the incoming Scottish Government.

The warning has been made against a background of an increasing body of evidence which has highlighted major problems within medical training throughout Scotland and the UK, but which has been met with limited response by those involved, including government [1]. Successive Independent Inquiry reports [2] and numerous surveys conducted by the Royal Colleges throughout Scotland and the UK (including new survey data released today) have highlighted that –

  • the traditional balance between training, for doctors training to be consultants, and the provision of direct patient care has been eroded, with many Trainee Doctors being required to plug gaps in hospital rotas at the expense of their training. In a recent Scottish survey of Trainee Doctors, only 42% of respondents believed they would be adequately trained to become consultants by the end of their training [3];
  • there are insufficient numbers of doctors (Trainees and Consultants) in some hospitals to safely staff rotas, particularly out of hours, leading to a number of patient safety incidents or ‘near misses’;
  • many consultants have insufficient time within their job plans to adequately supervise the training of Trainee doctors. A General Medical Council survey conducted in 2010 found that many consultants were having to supervise Trainees outwith their contracted working hours [4];
  • the full impact of the implementation of the European Working Time Regulations (EWTR) on the NHS, which enforce a maximum working week of 48-hours, may yet to be realised, with repeated survey data highlighting a major disparity between the number of hospital rotas which are deemed EWTR-compliant (not exceeding 48 hours per week) on paper and which are compliant in reality [3]. Recent data has also shown that almost 80% of Trainee Doctors who responded to a survey believe the EWTR has had an adverse impact upon their training [3]. In addition, anonymised survey data has provided anecdotal evidence that some Trainees may feel compelled to falsify their rotas in order to achieve rota compliance on paper and obtain greater experience [5].

The RCPE believes that the foregoing points, individually and collectively, have the potential to seriously undermine patient safety, the quality of patient care and the future sustainability of the NHS in Scotland. Furthermore, they risk undermining much of the progress which has been made in the NHS in Scotland in recent years by successive governments.

In order to address this situation, the RCPE has recommended a series of measures which it believes must be adopted by the incoming Scottish Government as an urgent priority. These recommendations include –

  • guaranteeing protected training time for Trainee Doctors and for Consultants involved in supervising training by readjusting the balance between service and training (this will require governmental action in order to ensure that NHS Boards, as doctors’ employers, recognise these training needs);
  • accounting for training time when planning future Trainee and Consultant workforce numbers;
  • increasing patient access to patient care delivered by consultants

Dr Neil Dewhurst, President of the Royal College of Physicians of Edinburgh (RCPE), said,

“Scotland has an enviable reputation as a healthcare provider and in improving public health, but much of the progress made by consecutive governments to date risks being undone.  Successive Independent Inquiry Reports and surveys have highlighted major problems within the NHS in relation to the training of doctors and their ability to provide high quality patient care. We have now reached a tipping point, where this evidence can no longer be ignored or considered in isolation. Instead, it is imperative that policymakers look at the totality of this evidence and recognise the fundamental problems which exist.

“It is essential that we safeguard the future ability of the NHS in Scotland to deliver safe, high-quality, patient care.  To do this, we need to ensure an adequately planned, trained and resourced medical workforce.  Failure to do so could lead to a generation of inadequately trained doctors and in turn, compromise patient safety. This would not be in the interests of patients, doctors or policymakers and we urge politicians from all parties to recognise the gravity of this situation and to commit to the recommended actions.

“Increasing pressures on the NHS also threaten to reduce patient access to consultants and the RCPE believes strongly that such access should be protected for the benefit of patients. Whilst it is clear that the Scottish and UK Governments may need to work together to achieve a relaxation of the European Working Time Regulations this is, realistically, a longer-term objective and more urgent action is required from the Scottish Government in the interim. Clearly, an expansion of the Trainee and Consultant workforce, in order to relieve the training problems and to increase access to consultants, will have resource implications. We recognise that this may be an unpalatable message for policymakers at a time of financial difficulty, but it is essential that these matters are addressed.  By protecting time for training, the NHS could actually save some resources, as this would better inform decisions made by inexperienced Trainee doctors when determining what level of, sometimes expensive, investigations to undertake”.

Dr Kerri Baker, Chair, RCPE Trainees & Members’ Committee, said,

"Trainee Doctors report feeling disillusioned and let down by their training experience gained within the NHS. Many Trainee Doctors believe they are gaining insufficient training to enable them to function safely and efficiently as the consultants of the future and are also increasingly used only to plug gaps in hospital rotas, often being forced to sacrifice quality training for service provision where, in reality, a balance must be achieved if we are to protect future patient safety. It is vital that they receive protected, quality training time which will enable them to become fully trained to provide the standard of specialist care rightly expected by patients once these doctors have completed their training and become consultants."

Dr John Colvin, Chair of the Academy of Medical Royal Colleges & Faculties in Scotland [6], said,

“There is clear evidence that the implementation of the EWTR has had a significant impact on clinical practice in Scotland. Whilst compliance rates vary across specialties, there would still appear to be significant problems within medicine and surgery. Even in those specialties where EWTR compliance is less problematic, there are still real concerns about the adverse impact of the EWTR upon training. We share the belief that the balance between service provision and training has been eroded and that protected time for training and integrated clinical experience is essential to produce fully trained doctors. More effective workforce planning requires to be undertaken to ensure a stable high quality medical service for the future.”

OTHER RECOMMENDATIONS

The RCPE has also made a number of wider-ranging recommendations aimed at improving Patient Safety, the Quality of Patient Care and Public Health in a new report entitled Health Priorities for Scotland. These priorities were identified on the basis of a survey of RCPE members (primarily doctors working in hospital settings), in which doctors were asked to identify their priorities for the incoming Scottish Government on the basis of their practical clinical experiences and concerns. Other recommendations include –

  • the development of standardised clinical documentation throughout Scotland (to reduce prescribing and other medical errors);
  • improving hospital care for acutely (seriously) ill patients (including greater availability of consultants to manage seriously ill patient admissions and improved out of hours availability and access to diagnostic services);
  • improving the continuity of care for patients (by working towards a modest relaxation of the EWTR);
  • combating and reducing obesity (through promoting smaller food package sizes and increasing access to bariatric surgery for the severely obese);
  • reducing alcohol consumption (by reconsidering the introduction of minimum pricing)

Contact: Graeme McAlister on 0131-247-3693 or 07733-263453

ENDS

Notes to Editors

[1]   The system of medical training in Scotland and the UK is quite complex and involves multiple organisations. In broad terms, the system can be summarised as follows –

  • Trainee Doctors’ contracts are with their employing NHS Board, and their training (undertaken during their employment) is overseen by local postgraduate Deaneries (based around University Medical Schools)
  • The Royal Colleges of Physicians of the UK (in Edinburgh, Glasgow are London) are responsible for developing and overseeing the medical curricula within the training programmes for Medical Trainees throughout Scotland and the UK, covering 30 medical specialties (i.e. cardiology, gastroenterology etc)
  • The General Medical Council regulates training
  • Whilst training remains a reserved issue, under the control of the UK Government, the four Departments of Health (Scotland, England, Northern Ireland and Wales) are responsible for overseeing the administration and implementation of the overarching training programmes and policies in their respective countries

[2]   Two major Independent Reviews were published in 2010 –

  • The Temple Review of the Impact of the European Working Time Directive (EWTD) on Training (published in June 2010), which recognised that as a result of working less hours, Trainee doctors are being less well trained.

This report concluded that “With a reduction in the number of hours available for trainees, the NHS can no longer afford to sacrifice the training of the medical workforce of tomorrow to cover service today. This is evidenced by the frequent necessity to fill gaps in rota and shift systems but leaving trainees and their learning poorly supervised.” 

Whilst the Temple Review was commissioned by Medical Education England, the RCPE presented written and oral evidence to this Inquiry, believes there is much commonality regarding the impact of the EWTR throughout the UK and that many of its recommendations and findings are directly relevant to doctors working within the NHS in Scotland and England.

  • the Collins Review of Foundation Training  (published in Nov 2010) which found that many Foundation Trainees (trainee doctors in their first two years of medical training) are often required to practice beyond their competence and without adequate supervision. 

This Review concluded that  “Trainees provide an important contribution to the healthcare of patients and are not super numerary [extra] to service requirements... the key is maintaining a balance between the demands of the clinical service and the requirements for their learning”

[3]   The RCPE has conducted multiple surveys on the impact of the EWTR pre- and post implementation (1 August 2009) both directly and on behalf of the Scottish Academy of Medical Royal Colleges (the results of which have not previously been published).

In October 2009, a snapshot survey by the Scottish Academy of Medical Royal Colleges highlighted that 72% of Trainee respondents believed that the implementation of the EWTR had had an adverse impact upon their training (approx 650 Trainees responded to this survey). In a repeat snapshot survey, conducted in October – November 2010, this figure had risen to 78% of respondents.

The 2010 survey also found that only 42% of Trainee respondents in Scotland believed they would be adequately trained by the end of their specialty training.

With regard to EWTR rota compliance (i.e. not exceeding a 48-hour week), in the 2009 survey 81% of Trainee respondents indicated that their rotas were deemed compliant on paper, but only 16% of rotas were compliant in reality. In the repeat survey in 2010, 82% of Trainee respondents’ rotas were deemed compliant on paper and 28% were compliant in reality. While the number of compliant rotas had increased, the survey found that 15 months after the implementation of the EWTR more than 70% of Trainees who responded to the survey stated that their rotas were not compliant in reality.

Similar findings have been reported in a number of other surveys conducted by other medical organisations including the Royal College of Surgeons of England.

[4]    The GMC National Training Survey found that  “Educational Supervisors are contracted to spend on average less than an hour and a half on educational activity but actually spend three hours”

[5]   An anonymised sample response from a Trainee doctor to the survey conducted in 2009 stated “Unfortunately, I repeatedly break rules on working time or falsify monitoring statements in order to provide adequate ward cover and training opportunities for myself”

[6]   The Academy of Medical Royal Colleges and Faculties in Scotland is a representative forum for members of the Scottish Royal Colleges (Royal College of Physicians of Edinburgh, Royal College of Surgeons of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow) and Scottish Offices or Officers of the UK Royal Colleges and Faculties (of Anaesthetists, Emergency Medicine, General Practice, Obstetricians & Gynaecologists, Psychiatrists, Paediatrics & Child Health, Radiologists, Opthalmologists, Public Health, Dental Surgery and Occupational Medicine).