Sadly, it is clear from the NHS “Developing the Healthcare Workforce” white paper that the Department of Health does not understand how doctors are trained, despite spending billions of pounds on the postgraduate medical education and training. That having been said I’m sure there are some doctors around who are occasionally unclear as to exactly who commissions, who provides, and who evaluates the education and training they receive. Nonetheless the starting point for this paper is one of ignorance, which then proceeds to make a series of nonsense recommendations about the training of the UKs 140,000 doctors. The current system is arguably complex, and perhaps unnecessarily so, but what the white paper fails to realize is that the lynchpins for the entire system are the Deaneries, with which all doctors will be familiar. Using their unparalleled expertise they hold the nebulous components together to create a training system that is second to none and the envy of the world.
Contained in the papers vision, the five objectives are difficult to argue with; including providing the right skills set, with high quality training, without wasting money and ensuring equity of access. However in the stream of logic that follows it is difficult to see how the recommendations made will realize these objectives any better than the current system. As we have seen with the other NHS white papers the justification for these reforms seems purely ideological and, in terms of medical education, completely without evidence or mandate.
It is deeply unhelpful that the paper lumps everyone together under the title of “healthcare professionals”, making it extremely difficult to understand the effects these changes with have on postgraduate medical education. Each of the health care professions have a very different skill set and need to be trained in a different way over varying lengths of time. Training doctors is not the same as training nurses or other healthcare professionals. I am no expert on nursing education, however what I do know is that doctors and nurses are not trained in the same way – we do very different jobs. Yet the white paper gives no consideration to this. Lumping nursing education, medical education, physiotherapist education and allied health professional education together makes no sense and demonstrates a complete lack of insight.
The impact of the localism agenda prevalent throughout the paper has effects on the structure of education and training. Having recognized that single local entities could not possible provide the range of experience and education required to train doctors the paper then recommends the formation of “provider skills networks” designed to take on the function of Deaneries. This conflates and confabulates together the separate issues of workforce planning with education and training both of doctors and all other healthcare professionals into an unhelpful mess. This expertise simply does not exist on a local level. After medical school it takes 5 – 15 years to train a doctor to consultant level, and it seems absurd that a local skills network would be able to deliver this kind of training. There is also the spectre of competition implicit in the paper, suggesting that competition in the provision of postgraduate medical education. Often the education and training is so highly specialized and specific that it would be hugely wasteful for there to be multiple providers vying for the training budget of doctors.
I am only qualified to discuss medical education, and in this respect the principle logic of the paper is that local providers are best placed to determine training for doctors in order to meet local workforce needs. I would argue that this is at best deeply flawed and at worse complete nonsense. There is not sufficient expertise in local hospital trusts to commission, provide or design whole medical training systems for clinical specialists. This takes at the very minimum a regional view, and for many specialties, a national view. The paper states that the current system is “too top down”, but fails to explain what this means. Taking a national approach to training doctors seems sensible in order to make the most of the best expertise and information possible. Decisions about how many doctors, what kind of doctors and where those doctors are needed cannot be made locally. If they were national oversight providing good workforce planning would be ruined. A statement that is repeated a number of times in the paper says “nor can we continue to expect top-down workforce planning to respond to the bottom-up changes in patterns of service that will be required by GP consortia”. This again makes no sense. This seems to suggest that GP consortia will have a role in determining the future healthcare workforce needs. Not only is Andrew Lansley expecting GPs to commission services for patients, but also to determine the number of nephrologists their community will need in two decades time, and thus the number of nephrologists trained nationwide.
The other suggestion is that employers should have a greater role in workforce planning. The paper states “employers do not have the incentives and levers to innovate and secure the skill-mix that they want to deliver better outcomes and productivity”, which may be true, however the changes suggested will only incentivize employers to consider short term service delivery needs to meet the fashionable political objective of the moment, rather than the education and training of the future medical workforce. Employers within the NHS are not best suited to manage workforce planning. Their primary concern is with ongoing service delivery, with education and training seen as secondary. This is understandable; their job is to employ doctors to provide high quality healthcare for their patients. It is certainly not their job to plan how many doctors that hospital may need far in the future. These suggestions mean that short-termism will reign, running a serious risk of over or under supply of specialists, when considering changing workforce needs on a national level.
It is profoundly unrealistic that the many functions of the Deaneries could be taken up and managed by other organisations within such a short timescale. That this is even being considered is extremely damaging. Medical education must remain separate from the influences of politics and of the economics of day-to-day service delivery. The paper obsesses about the role of the Deaneries within the SHA, however it is certainly possible to consider the situation whereby the Deaneries could continue with their current function independently of the SHAs (if they are abolished by 2012). This seems not to have been considered as an option.
The reforms set out in the Developing the Healthcare Workforce paper are worrying and potentially extremely damaging to doctors education and training. I for one certainly do not want to be trained by a “skills provider network”. It aint broke. Stop trying to break it.