Summary

Postgraduate training in the UK has undergone significant changes over the last 2 to 3 years, prompted largely by the "Modernising Medical Careers" initiative. On the whole the changes strengthen general practice training, and build more educational activity into the early postgraduate years.

This paper summarises the key developments in postgraduate medical training with a focus on Family Medicine. It includes a description of recent changes to visa regulations which have restricted the availability of UK-based training for non-EU doctors.

Finally, the paper examines some of the developments in Family Medicine in Hong Kong in light of the changes undertaken in the UK. Family Medicine leaders in Hong Kong should examine the UK reforms critically, and look for lessons which have relevance in Hong Kong. It is vital that formal training for Family Medicine in Hong Kong continues to grow and develop, and new ways of overcoming structural, financial and other barriers to this development need to be constantly sought.

摘要

過去2-3年，主要受“醫學生涯現代化”活動的推動，英國的畢業後培訓發生了重要的改變，整體上加強了全科醫療培訓，並在畢業後培訓的早期加入了更多的教育活動。

本文以家庭醫生為重點，總結了畢業後醫學培訓領域的重要進展。文章敘述了簽證規則的最新變化，限制歐盟以外的醫生獲得在英國培訓的機會。

最後，本文以英國為借鑒，檢視了香港家庭醫學的一些進展。本港家庭醫學領域的領導者應評判性學習英國的改革，並找出對香港有用的經驗。香港家庭醫學的正規培訓一定要不斷壯大和發展，並且不斷尋求能突破制約發展的結構、資金及其它障礙的新途徑。

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Introduction

Postgraduate medical training in the UK has changed significantly over the past 2 to 3 years. Most of the changes have been guided by the "Modernising Medical Careers" (MMC) framework - a review process which recognised shortcomings in the structure of medical careers in the UK, and provided an analysis of a number of new possible specialty training models.¹ This work was taken forward with subsequent reviews which outlined structure, content and context of new training models - and included an emphasis on both acutely and chronically ill patients, not just in hospitals but also in mental health and general practice settings.²

"House officer" posts and the new Foundation Programme

One of the immediate challenges was to address the perception that the training of UK doctors takes too long. Unstructured learning in early "house officer" years and excessively long specialty training were both identified as problems. For example, UK senior house officers have typically been kept waiting for several years in hospital posts for specialist registrar posts and the training they have received has often been minimal - while delivering a very demanding service.

In response to many of these concerns, Sir Liam Donaldson led a review entitled "Unfinished business".³ A major outcome of this review was the creation of a two year "Foundation Programme" immediately following graduation - this is now well established in the UK. Broadly, the Foundation Programme aims to produce "safe" doctors who are experienced in a broad range of specialties with a broad range of competencies (which are defined in the various curriculae of the Academy of Medical Colleges).

The Foundation Programme has a much stronger emphasis on education; there is more expectation on trainers, and there are objective competency-based assessments. The curriculum articulates an educational philosophy along with a range of learning opportunities available to trainees.

There is also a stronger emphasis on providing career guidance to recently graduated doctors and to expose them to a wide range of career options. The aim is to produce medical practitioners who are "patient focused and accountable to the public for delivering safe medical care". The curriculum has also been developed with a view to try and match changing workforce demands. There is a focus on both clinical skills (with particular emphasis on chronic disease management and the care of acutely ill patients), as well as more generic skills such as communications and team working.

A range of feedback and assessment tools have also been developed, including the mini clinical evaluation exercise, multi source feedback, direct observation of procedural skills and case based discussion. Satisfactory results in the assessment during the first year (F1) post will lead to full registration with the GMC (although this will, by and large, be insufficient for progression through training). The assessment at the end of F2 will be a major indicator of whether or not the trainee may proceed to further specialist training in the NHS.

Hence, this is a major shift from previous years which often featured junior and senior "house officer" posts with long hours and little structure and education. The programme was implemented nationally in 2005. It is hoped that most doctors completing F2 will proceed directly into the new specialty training pathways on 1 August 2007. The old-fashioned SHO posts are being phased out over this current 3 year transition period.

Of course Modernising Medical Careers has also attracted controversy in the UK. Many have seen it as a way of shortening, and reducing, the cost of medical postgraduate training. There is also concern over getting the balance right between supply and demand for Foundation Programme and specialist training posts, and that doctors might become "locked in" to training pathways too early in their career (whereas before there was more potential to "sample" a range of specialties through taking on a range of SHO posts). Only time will tell, but there is little doubt that postgraduate medical training in the UK needed revising, and much of the MMC framework is openly based on sound educational and training principles.

The Foundation Programme and Family Medicine

One of the specific goals of the Foundation Programme has been to provide doctors with a better understanding of both primary and secondary care. For those of us in Family Medicine, there was a specific concern that Foundation doctors would receive adequate exposure to primary care settings. F2 doctors from August 2006 are able to apply for placements - 55% of all doctors on the Foundation Programme should be able to undertake part of their training in general practice (this should be increased to 80% from August 2007). This is a major development and one which recognises the integral role of general practice in postgraduate training in the UK. Further information on the Foundation Programme can be found at www.mmc.nhs.uk/pages/foundation.

Specialty training programmes

Just as the early postgraduate years have been reformed, training programmes have new and revitalised curricula. Most specialties (including General Practice) will select most of their trainees directly from Foundation Programme graduates. The structure of training is illustrated in Figure 1.

Training programmes will be competency based and of variable duration. Once a doctor is awarded a Certificate of Satisfactory Completion by the Postgraduate Medical Education Training Board (PMETB) at the end of a training programme they will be eligible for entry into a specialist or GP register held by the GMC. As illustrated in Figure 1 a doctor who has not completed such a training programme can still apply to the register through the PMETB (a route which is defined by special articles 11 and 14 of the "General and Specialist Medical Practice Education Training and Qualifications Audit", 2003). The intention is that such a route would only be undertaken under exceptional circumstances and, in general, the concept of putting together one's own training programme in an unregulated way is being discouraged. Once the doctor is on the register then they can apply for an appropriate senior medical appointment.

Of course it is possible that some doctors will not pass the necessary exams and fail to complete training in the designated time. While arrangements will vary between training programmes, in general there will be an emphasis on providing reasonable opportunities for extensions and re-assessments, with appropriate guidance and assistance in entering alternative training pathways for those who continue to fail to meet set standards. The hope is that with more career-focused experiences in earlier (e.g. foundation year) stages there will be less doctors left in the difficult situation of not meeting requirements of training programmes, and spending substantial periods of time "in limbo".

"Career posts" remain in the structure, with a primary aim to "undertake the job required" although they will also contain opportunities to undertake continuous professional development. They are not specifically designed with the end point of entry to the specialist or GP register in mind, although at some point post-holders may be able to apply for such entry under article 14. There is a strong desire for these career posts not to be considered alternative "mainstream" routes to the specialist register.

Specialist training in General Practice

General Practice educational training has a long history in the UK - it dates back to the beginning of the National Health Service in 1948. There has long been a recognition that Family Medicine has its own unique set of competencies which require their own curricula and assessment. It has a unique organisational structure; the Joint Committee on Postgraduate Training for General Practice (now replaced by the PMETB) was founded in 1976 and was responsible for setting and monitoring standards for training GPs and for issuing certificates on completion of GP training. Around this there has been a network of GP trainers, all of whom have been trained to teach, course organisers, associate advisors and regional advisors (as part of the postgraduate deans' organisation at a regional level, organised jointly by the universities). This has led to a well recognised training programme for family doctors. There are overwhelming economic and professional incentives to participate in formal Family Medicine training in the UK - a certificate of satisfactory completion of training long been the requirement for unsupervised practice (this contrasts with the situation in Hong Kong in which many years of Family Medicine training do not necessarily lead to any economic reward).

Under the new arrangements the General Practice training programme will remain at 3 years (compared to 8 years for some medical and paediatric specialties), post Foundation. A new GP curriculum has been the subject of a UK wide consultation led by the Royal College of General Practitioners;

• it contains the knowledge competencies and professional approaches that will be recommended by deaneries for GP training when the current curriculum is replaced in August this 2007
• instead of exam-based endpoint assessment, the new curriculum requires trainees to meet key competencies throughout the entire postgraduate training programme
• it will reflect current best practice in training and will provide GPs with a range of clinical skills and experience they need to practice effectively in the contemporary NHS
• the process has now begun to bring summative assessment (traditionally the end-point of GP training) and the MRCGP examination (which has been an 'optional extra' albeit taken up by most candidates) together in a unified assessment framework for licensing. While concern has been expressed that this process might reduce the quality or rigour of the MRCGP exam, there is generally optimism that bringing the two processes together will be more efficient, and encourage higher standards

It is likely that assessment in the workplace will play a central role in the new curriculum. The programme builds on a long history of Family Medicine training in the UK; the aim has been to draw on the best features of the programme while modernising its structure and content to meet the changing needs of the NHS.

Implications for applicants from abroad

As readers of the Journal will be aware, the NHS has traditionally relied on a large number of doctors from overseas in training grades.⁴ Many such doctors have stayed in the UK and have provided services in training doctors in the Health Service. In 2003 a record 15549 doctors joined the medical register (of whom 9336 were not citizens of the European Union).

There is still relatively little detail in the Foundation Programme documentation on key issues such as recognition of equivalent overseas experience. However, there has been recent controversy after the UK government decided in April 2006 to abolish lenient visa rules for doctors trained outside the EU. The new regulations mean that doctors from outside the EU can only be awarded posts if it is demonstrated there are no British graduates who could perform the same job.

It is desirable, with current work force fluctuations, that overseas doctors should obtain as much information as possible before coming to the UK as there are currently large numbers of applicants for junior posts and a significant number of doctors unable to find positions. As many readers of the Journal will be aware, a number of postgraduate deaneries now have induction courses for international doctors (for example, see www.wmdeanery.org/misc/intdoctors.asp).

Clinical academic careers

With the introduction of these changes, it was recognised that appropriate clinical academic career pathways needed to be identified as part of modernised medical careers. In our discipline, development of an academic base is critical⁵ - we need to ensure that a robust and sustainable career ladder, producing new senior university-based academics in Family Medicine is developed. The career structure for academic Family Medicine has typically been different than that of hospital specialties; for example, our professional training tends to precede academic training and does not occur in parallel with it. There has typically been a lesser expectation in Family Medicine that we might pursue academic routes.

A committee examining the issue, led by Professor Mark Walport, produced several recommendations for clinical academic careers including those in General Practice;⁶ they recognised significant problems of recruitment at all levels. For General Practice an additional academic year to the existing 3 year general practitioner vocational training phase is proposed. The purpose of the year is to put trainees in a position to apply for the "next step of the ladder" which is generally to apply for a PhD fellowship. The aim in this process is to achieve integrated academic and clinical training and to establish for the first time an identifiable career path for academic Family Medicine. Other key features of the new academic structure (which so far apply only to England) include academic clinical fellowships and clinical lectureships.

Comparisons with Hong Kong

Some Journal readers will have been involved in the development of Family Medicine in Hong Kong; they are likely looking at the changes in the UK with some interest. There is now a depth of experience in Family Medicine Training in Hong Kong;

• the establishment of a Working Party in 1986 examining postgraduate medical education and training issues produced some key recommendations for training (they were similar to those produced by the Hong Kong College of General Practitioners in 1985)
• with the establishment of the Hong Kong Academy of Medicine in 1993 postgraduate medical education and training developed a great deal more structure and organisation
• the establishment of Family Medicine training positions in public hospitals was a key development

There are, of course, fundamental structural differences between Family Medicine in Hong Kong and the UK. It has taken many years for the systems of clinical governance, quality assurance, continuing medical education and other forms of professional development and regulation to develop in UK General Practice, and family doctors, while independent contractors, are very much part of the broader National Health Service.

In contrast, medical graduates in Hong Kong are still able to practice Family Medicine without formal postgraduate qualifications, and it remains a relatively unregulated environment. Hong Kong practitioners are, by and large, in private practice, and there are relatively few incentives to participate in quality-improvement and training activities. Further, Hong Kong practitioners receive no financial reward for activities such as teaching medical students, or meeting quality and performance targets in their practice. These systems will hopefully evolve over time (indeed, they are still developing in the UK), but it will take a concerted effort from Hong Kong family doctors and their representatives (including the College, and academic departments at Hong Kong University and Chinese University of Hong Kong), to encourage government investment in these systems.

Further, it will remain important to seek ideas from other countries. It is interesting to note in Hong Kong that a doctor needs to complete 6 years of formal vocational training in Family Medicine on top of other requirements in order to be eligible for election to Fellowship of the Hong Kong Academy of Medicine (Family Medicine). The final 2 years have the aim of ensuring that trainees in Family Medicine will "continue to strive for the highest possible standards of patient care throughout their professional lives". It is vital that the length and difficulty of this training process does not serve as a major barrier to training, and it is essential that all incentives possible are given to trainees to undertake formal programmes.

The development of the MMC framework in the UK should be observed closely - in particular its focus on improved educational experiences in the early years of training and, overall, its more regulated approach to postgraduate training. Is this something which could be accommodated in the Hong Kong health system? Do the educational principles translate well to Hong Kong? These are the kinds of questions that professional leaders and policy makers will need to address as Family Medicine evolves in Hong Kong.

Conclusion

On the whole, the recent developments in postgraduate training in the UK over the last 2 to 3 years auger well for General Practice. More than ever, General Practice is imbedded in postgraduate training and there is a recognition of its central importance.

Further, General Practice is going through a process of change in the UK. Since April 2004 we have had a new GP contract which rewards meeting targets for various quality related activities.⁷ There is the development of "GPs with special interests"⁸ and other reforms. It is hoped that the new postgraduate career structures will lead to a workforce which is adequate to these new tasks and challenges, underpinned by an appropriate academic base. Family Medicine leaders in Hong Kong should examine the changes in postgraduate training in the UK, and perhaps try to identify some key features which might have local relevance (such as the more structured years of the Foundation Programme with their opportunities for GP content). Hong Kong has a history of rational development of its Family Medicine - it is hoped that, like the UK, there will continue to be an emphasis on encouraging new graduates to undertake training and to provide the infrastructure necessary to ensure this training is of a high standard, underpinned by appropriate academic and training structures.

Key messages

1. Family medicine leaders in Hong Kong should examine the changes to postgraduate training in the UK and other countries, and identify approaches which might promote development of Hong Kong's Family Medicine.
2. Whether the educational principles in the UK translate well to Hong Kong and others are the kinds of questions that professional leaders and policy makers in Hong Kong will need to address as Hong Kong's Family Medicine evolves.

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References