With European law and the emphasis on work-life balance already shaking things up, what does the future hold for medical education? Three experts predict the shape of things to come

With European law and the emphasis on work-life balance already shaking things up, what does the future hold for medical education? Three experts predict the shape of things to come

Paul Streets
Chief executive, Postgraduate Medical Education and Training Board

When I speak to groups of doctors about what medicine will look like in 10 years I begin by asking them to forget what comes out of Whitehall. The drivers that are changing medicine are UK-wide, long-term and common to many Western economies.

The first driver is the patient. There is evidence to suggest that patients want a different kind of relationship with their healthcare professionals. They want to improve clinical outcomes in areas such as chronic disease, where the patient plays a crucial role in their own care. The UK already has over 17 million people with chronic disease, and as the population ages that number will grow.

Evidence from the Picker Institute suggests that, in comparison with other countries, the UK performs poorly in patient involvement. It also suggests that in elective care, patients want to know more about why a procedure is necessary, who will undertake it and what the outcomes might be. Patient expectations rise with each generation.

The second driver is the trainee. The consultant and GP contract, coupled with the arrival of the European working time directive, might give new doctors the opportunity to aspire to a work-life balance weighted more towards the latter than was possible in the past. This raises issues about how we train - given the reduction in clinical exposure - and how we provide continuity of care.

Changes to the workforce provide additional impetus. An increasing number of women are entering the medical workforce - most medical undergraduates are now women. Over a quarter of consultants and 40 per cent of GPs are women - a 40 and 60 per cent increase respectively over 15 years. While the evidence suggests both men and women are increasingly likely to want to work part time, three times more female doctors currently do.

The third driver is medical technology and innovation. Cardiothoracic surgery is an often-cited example, with the coronary artery bypass graft increasingly replaced by angioplasty, or prevented altogether with statins. This was perceived as a shortage specialty in the NHS Plan - a salutary lesson in how difficult it is to predict the future.

Finally come the changes driven by the service itself: acute trust and service reconfiguration; the shift to more care delivered in the community; and questions of skill mix. Many might argue that these would happen with or without the various white papers and policy pronouncements.

For the first time, in the Postgraduate Medical Education and Training Board there is a UK-wide body with statutory responsibility for the content and outcomes of all postgraduate medical training.

But doctors don't work in a vacuum. The training the future doctor receives, and the doctor this training produces, is central to the health service of the future. The PMETB needs to harness the views of trainee doctors, the health service that employs them and the patients on the receiving end.

We are beginning a major piece of work that will ask what these drivers mean for the 'future doctor' and how training should respond to them. Questions that need answering are: What should the balance be between generic and specialist training? How can training respond to the changing needs of patients, trainees and the service? Our aim is to use our regulatory powers to translate the outcome of this debate into reality.

Jo Hilborne
Chair, British Medical Association's junior doctors committee

Being a doctor in the UK is changing. Specialty training is already very different compared to 20 years ago, and the pace of change continues to quicken.

The most obvious and substantial change for junior doctors is the reduction in the number of hours spent at work - both in terms of average weekly hours and number of years spent training.

Doctors initially drove the reduction in weekly hours. As the complexity of the medical task has increased, and the presence of doctors in the hospital working at all times has become more necessary, the long on-call shifts of the past have become untenable and unsafe for doctors and patients.

Working 80-hour weeks on-call was viable when night calls were unusual. Now, when for many doctors the intensity of night work is similar to during the day, it is no longer possible. This combines with the increasing expectation of successive generations, including doctors, of a different work-life balance from that achieved previously.

European legislation has brought in changes to reduce working hours for workers. Whatever one's views on the practicality of the working time directive, the need for the state to protect the health and safety of workers is indisputable.

As weekly hours have reduced, there has been a much slower acknowledgement that the way we train doctors must change. We can no longer assume that if you spend long enough as a trainee you will have seen everything by the time you're appointed as a consultant. Similarly, clinical governance and risk management have been developed and promulgated. Medical mistakes are no longer tolerated or ignored.

Patient expectations have also changed - there is a growing attitude of not wanting to be 'practised' on, and of their right as consumers to be seen and treated by fully trained staff.

These changes - reduced hours, clinical governance and changed patient expectation - mean the way we train doctors in the UK must change. The main question is how to actually train within these constraints.

There are three main changes which must underpin any new system: a move away from the 'service delivery first, training second' approach; a recognition by employers and politicians that time and money spent on medical training is paramount; and a new understanding of the importance of working conditions for staff morale. Recruitment and retention of the brightest and best into medical practice is also necessary.

Doctors need to be involved in discussions. There are many examples of the disastrous consequences of pushing through major changes to the NHS without full involvement of the medical profession.

I would encourage all junior doctors to seize the opportunity to participate in the forthcoming PMETB debate, and join the essential work of shaping their own future.

Ian Cumming
Chief executive, North Lancashire primary care trust and deputy chair, PMETB

Change is one thing the NHS never has been short of and never will be. Some change is driven by ideology, some by technological advances and some by policy.

Whatever has gone before, the next few years will see unprecedented change in how and from where healthcare is delivered. No-one in the NHS will be exempt from the impact of these changes. How do we prepare and ensure our professionals can adapt and flourish?

Let me give some examples of the non-technological potential future areas of impact on doctors:

-The role of the independent sector in delivering clinical assessment and treatment services will affect the traditional primary-secondary care. interface and significantly change the case-mix presenting in hospital outpatient departments. The growth in numbers of GPs with a special interest will also further reduce referrals to secondary care.

-The next round of European working time directive targets cannot be delivered simply by recruiting more doctors. Further flexibility from individuals and further implementation of
schemes such as hospital at night, where generic skills are used by doctors who may be working/training in a different area, will be essential.

-Generalist versus specialist: as more and more services (especially surgical) are provided from specialist centres, hospitals in more remote areas will have to ensure they have generalists able to deal with the 4am surgical emergency.

-Chronic disease management: as more resource and expertise is targeted at managing chronic disease in the community, hospital referrals/admissions will become less frequent.

As a chief executive I am concerned about the ability of the trust workforce, and organisations we commission from, to keep pace. It's sobering to think that students leaving medical school this autumn will in all likelihood be practising medicine into the 2050s. How confident can we be that the UK is training doctors to have all the skills they need for the future?.

The truth is we can't be. Although no-one can predict what healthcare will look like 40 years from now, we can spot some trends..

Most people accept that in the future more and more healthcare will be delivered in the community and hospitals will get smaller. Yet much of our training is still delivered in secondary care settings. Is it feasible to sustain secondary care-based training programmes in many specialties when much of the care delivery in that specialty will be moving into the community?

By the same token, the independent sector currently plays only a very minor role in training, yet are set to deliver quite a significant percentage of elective care in certain surgical specialties. Is this not a training resource we should exploit more?

Too often I come across doctors without some of the core skills you would hope for in a senior professional. Yet core skills such as leadership, teaching, communication and public health are likely to become more important as patient expectations change and the structure of the medical team changes. This begs serious questions about the mix of clinical and non-clinical skills taught at all stages of education and training.

We must ensure we train doctors who are able to respond to future needs. We need to train doctors who are flexible in the application of their skills and receptive to change.

Perhaps the logical starting point is for the service to decide what its needs are and then ensure these are incorporated into training programmes, rather than service provision being dictated by rigid training programmes.

Paul Streets, Jo Hilborne and Ian Cumming will be taking part in a conference organised by the Postgraduate Medical Education and Training Board on 23 May, What Does the Future Hold? Preparing Doctors for Tomorrow. To contribute to the debate, e-mail futuredoctors@pmetb.org.uk