Wider experience of primary care would create a more rounded learning experience for student doctors, suggest Chris Barrett and Andy Knapton

Rudyard Kipling may be famous for his poetry and prose but he was also an unlikely pioneer of renewable energy. On finding he had no use for the water-powered mill in his garden, Kipling converted it to an electricity generating plant, an enlightened move in 1903.

The National Trust is now renovating the old waterwheel at Kipling's beautiful home, Bateman's, near Burwash in Sussex, and has converted it back to a working mill. Grain is milled twice a week and children can turn a miniature mill wheel to produce flour.

Like Kipling and his mill, the NHS has to make decisions daily to ensure it makes best use of the resources at our disposal. The recent Tooke report - reviewing the training of junior doctors in the wake of the problems with Modernising Medical Careers - is a case in point. On the surface its aspirations are commendable but the implications for service delivery and resource management are less clear.

Health professionals and the public will welcome the report's emphasis on excellence in training and the medical student's learning experience. But dig deeper and the Tooke proposals call for some serious decisions about risk assessment and NHS workforce planning for the future.

Budgets determine the number and type of staff the NHS employs and creating the right skill-mix presents an interesting challenge. Using the analogy of a mill, with regard to medical training, delivery of good healthcare needs to process and refine the 'flour' (medical students) to produce high quality 'bread' (highly qualified and experienced doctors and consultants).

While Tooke report's 45 recommendations and eight principles clearly aim to do this, we are concerned by the proposed methods of milling the flour, in particular some of the inquiry's recommendations for postgraduate training, such as:

  • a break in the link between the two foundation years, F1 (the pre-registration year) and F2 (the post-registration year) and incorporation of F2 into the three-year core specialty training (CST) (recommendation 31, 33, 34);

  • at the end of F1, entry into specialty training (recommendation 34), or non-speciality experience in four core areas (recommendation 35);

  • permission to interrupt training for up to one year (recommendation 39);

  • F2 GP placements to continue in CST (recommendation 3).

The report's proposals appear to return to the same training system that we had before Modernising Medical Careers. It appears to make the assumption that the old way was the best.

But the world has changed. Previously there were approximately 3,250 students graduating annually from medical school and the service was able to draw on foreign doctors to supplement supply. Now, as a result of medical school expansion, more than 6,000 will graduate and enter the system each year.

The NHS needs trained doctors at the right time, and of the right quality. Tooke's plans and the repercussions of the recent Court of Appeal ruling on the rights of overseas medical to take up training places in the NHS could increase the length of training and the number in training.

Deep pool

The pool of trainees includes those doing the 'run-through' certificate of specialist training and higher specialist training and it could continue to get larger as more students opt to change direction in their training, re-enter CST or return from one-year breaks.

As the pool gets larger, and there is increasing student choice and change of career direction, watch out for headlines as flexibility in education and finite capacity is translated as 'unemployable doctors'.

There are other possible implications. By extending the training period for GPs, a whole GP cohort may be lost at the very time that the Darzi review and Our Health, Our Care, Our Say are supporting a shift to primary care provision.

Is there a potential risk of destabilising the GP workforce for a year? Would not a more holistic training for medical students, which exposes them to the work of GPs, be a more rounded learning experience even if this is not their intended area of work in the future? Furthermore, reducing exposure to a broader range of specialties, which the two-year foundation programme had provided, may make it hard to recruit into some specialties, such as pathology.

To summarise, it seems likely that the proposals in the Tooke report will lead to:

  • increased numbers of pre-registration doctors;

  • an increasingly large training pool;

  • a reduction in primary care experience.

A possible solution would be to reinstate F1 as a two-year programme, increase CST to four years and award certificate of completion of training on completion of CST.

The aim of this would be to ensure CST provides competent, trained doctors equipped to work safely in most specialties. These doctors would have had adequate exposure to primary care in F1 and the widest possible experience before committing to a specialty.

Only a small number of doctors would enter higher specialist training and this move would be determined by an assessed service need in defined areas of care. The size of the training pool would be manageable.

Our suggestions are:

  • reinstate a two-year F1 for medical training;

  • run a four-year CST resulting in the award of the CCT.

The Tooke inquiry interim report requires wide discussion to inform the final proposals. We have attempted to offer one of many possible interpretations of the report and hope these proposals will stimulate discussion.