Scarlett McNally: Fixing postgraduate training requires rebalancing funding and workload

Reducing workload

The Tooke review in 2008 described doctors as the “diagnosticians and handlers of uncertainty.”4 Well trained doctors reduce waste, unnecessary hospital admissions, and unwarranted tests, reviews, and interventions.56 But unless we can get doctors through 5-10 years of postgraduate training, we lose decades of their potential as general practitioners (GPs), consultants, and specialist, associate specialist, and specialty (SAS) doctors.

The NHS has reconfigured multiple services, but most presentations do not need a 24/7 approach, and many hospital admissions are preventable. Experienced staff should make decisions about who may need an investigation or intervention—ideally delegating these decisions to rapid assessment clinics and general practice. Increasing the number of GPs would be the best and most cost effective way to improve health and would reduce the workload of resident and other doctors in secondary care.7 But we currently have many unemployed trained GPs, and many GP services are at risk of closing.8 Budgets for acute services are seven times that of primary care, so rebalancing funding could help.9

We need to be honest that resident doctors are often delivering service and work that might be unnecessary. Most of their time is not spent saving lives, instead it is used on administrative work and dealing with inefficient computer systems.710111213 This inefficiency is contributing to them working overtime, with 60% regularly exceeding their rostered hours.1415 Some of this administrative work could be delegated to doctors’ assistants13 or scribes. There are support workers for seven other healthcare professions, but none for doctors.16

Improving training

In the 15 years since I was director of medical education for my trust, there’s been a 25% increase in doctors qualifying from UK medical schools17 and a 78% increase in international medical graduates working in the UK,18 yet there hasn’t been a commensurate increase in training posts. More training posts are needed, with more funding to allow each placement to deliver focused education.

Once they are in training posts, resident doctors could be trained better and more efficiently.19 Reducing the burden of administrative and unnecessary work would free up their time for more clinic interactions with patients and supervisors, team meetings, responsibility, interventional sessions, and self-development time.20

With increasing subspecialisation, doctors could do short secondments, or attend regular shared specialist clinics, for topics that are important to know about. This could reduce the time spent on lengthy rotations in training posts learning the detail of complex interventions they will never deliver.

The Shape of Training review in 2014 wanted to make all doctors generalists.12 I argue that we will never teach generalism while the system is arranged with doctors being siloed in single specialty departments. Courses and team working can build on the holistic foundations from medical school. At the Centre for Perioperative Care, we are designing modules to educate doctors at all stages to fill in the gaps across care pathways.21 Such education could help diversify careers and establish generalist skills for resident doctors.

We should ensure that all doctors are valued, with high quality ongoing medical education. This includes SAS and locally employed doctors who currently have large unmet educational needs and unequal training opportunities. Having access to portfolio training is good, but it needs funding and support.

We need to value resident doctors with focused funding to get them through postgraduate training efficiently and ensure that they are confident in their skills. We also need more GPs and support workers to help reduce their workload.