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MODERNISING GENERAL PRACTICE VOCATIONAL TRAINING

An update on the RCGP Review of the Curriculum for General Practice Training Programmes

By Professor Steve Field
Chair of RCGP Education Network
July 2004
Contact the author via the editor by e-mail at christopher.johnstone@ntlworld.com

For a Microsoft Word version of this article, please click here.

The Curriculum Review Process

In June 2003, the RCGP Council supported the RCGP Education Network to take on the daunting task of reviewing the curriculum for general practice training. A Steering Group was set up which includes representatives from the devolved Royal College of General Practitioners Councils, COGPED, GPC, CAOGP, JCPTGP, GP tutors, course organisers, patients, trainees, the Quality Network, the RCGP Hospital Recognition Committees, the Examination Board.

The detailed work is led by the Professor Steve Field, Chair of the Education Network, supported by Alison Baker as RCGP Director of Professional Development and Quality. Two further sub-groups have also been established. The Education & Training Group has taken responsibility for aspects of the curriculum concerned with the content and process of training programmes while an Assessment Group has focused on aspects of assessment both formative and summative. This latter group was established by expanding the existing Liaison group that comprised members of the RCGP's Examination Board and the National Summative Assessment Board. It has been jointly chaired by the Professor Val Wass, Chair of the Examination Board and the Dr Agnes McKnight Chair of the National Summative Assessment Board.

The Aims and Objectives of the Curriculum Review The three main aims

• Describe and analyse current practice in the vocational training of general practitioners in the UK.
  
• Review alternative approaches to training, taking account of the changing context of practice.
  
• Make recommendations on curriculum options for the vocational training of general practitioners.
  

The six operational objectives

• Review the existing literature on the role of general practitioners and their training in the UK and elsewhere.
  
• Draw together evidence on current and emergent practice in the training of general practitioners in selected other countries of the European Union.
  
• Consult with a wide range of stakeholders across the UK on their views about the nature of current training and how it might develop.
  
• Examine perspectives on current training from trainees, trainers and GP principals with up to six years experience.
  
• Analyse the impact of the changing context of NHS provision, establishment of the PMETB and labour market changes as they effect the medical profession.
  
• In the light of the review, report on possible options for the curriculum for general practice training programmes.

The literature review - the framework for analysis
A literature review has been led by Professor Hywell Thomas, Director of the Centre for Research in Dental and Medical Education at the University of Birmingham. At the core of the review of the literature is the standard and quality of General Practitioner trainee's learning. Figure 1 below is designed to provide that focus. It gives primacy to the standard and quality of learning by trainee GPs and shows how these are dependent upon (i) the content of the curriculum and its pedagogy, (ii) continuity of learning between different phases of education and training, (iii) processes of formative and summative assessment and (iv) the support provided to trainees through mentoring and pastoral care.

The nature and quality of the four factors in the top part of the Figure are themselves dependent upon the components in the bottom part of the Figure, which are the means by which ideas become realities. Primary and secondary care educators are the principal budgetary resource whose number, quality and commitment are central to achievement during training. Administrative systems are also critical, for example in ensuring that records are maintained and enabling deaneries and trainers to maintain reliable records on the progress of trainees. The physical resources used by trainees include learning resources and the premises used in both the hospital and the general practice phases of training. Less attention is normally given to external perspectives but experience and practice elsewhere (in other professions and in other countries) can contribute to change and development in training for general practice.

Leadership, management and planning are shown on the left and right side of the Figure. These are the means by which the link is made between resources and learning. Their location in the Figure is intended to emphasise their distinctive place in the education and training of GPs. It might be expected that it is through leadership, management and planning that health systems define their aims and purposes, determine how to achieve them and monitor system performance.

It is this framework that is used as the basis for presenting the analysis of the literature on the vocational training of general practitioners.

The summary that follows begins with 'Goals and Facilities', showing summary points on the standard and quality of learning and on facilities and resources.

1. GOALS AND FACILITIES
The standard and quality of learning by GP trainees

• The professional literature shows some concern about quality
  
• Patient perspectives suggest otherwise, although the direction of change is not encouraging
  
• Dominant themes are lack of preparation for
  
• practice management
  
• multi-professional working
  
• teamwork skills
  
• communication and consultation

Facilities and resources

• Limited discussion of finance, financial mechanisms and financial flows
  
• Some emphasis on inadequacy of funding in certain areas, notably opportunities to move training to general practice

2. LEADERSHIP AND MANAGEMENT
Leadership, management and planning

• Historically a light governmental regulatory environment
  
• VTS regulations, 1979
  
• Summative assessment, 1997
  
• JCPTGP, advice and quality assurance
  
• Enhanced role of Directors in selection
  
• Emphasis on regulation by professional bodies and by individual doctors
  
• RCGP advice
  
• Membership
  
• Course organisers
  
• Trainers
  
• A literature of advocacy
  
• The challenge to professional autonomy
  
• Thatcherism and Public Choice Theory
  
• Bristol, Alder Hey and Shipman
  
• The significance and potential of the PMETB

3. THE COMPONENTS OF TRAINING
Curriculum and pedagogy
Curriculum as content

• Content highly decentralised
  
• Guidance on content from JCPTGP, GMC and RCGP
  
• Hospital experience also influenced by other Royal Colleges
  
• Balance of hospital and practice-based training
  
• Growing influence of clinical guidelines

The pedagogy of training

• Guidance on pedagogy emphasises adult learning
  
• Hospital practice emphasises principles of apprenticeship learning
  
• GP experience emphasises one-to-one learning and primacy of trainer
  
• Some limited opportunities for collaborative learning

Continuity of learning

• Guidance from GMC and JCPTGP on undergraduate and post-graduate training
  
• Poor links between all phases
  
• Integration is principally to be found only in the mind of the learner
  

Support through mentoring and pastoral care

• Literature gives some attention to tensions in multiple roles of trainers
  
• Little attention to role of education supervisors in hospital experience
  
• Some discussion of a role that provides continuity for the whole VTS period
  

The nature and effectiveness of assessment

• No national system of log books
  
• No national consensus on good practice
  
• Formative assessment through portfolios
  
• Summative assessment for CCT since 1998
  
• RCGP Membership increasingly important
  
• Debate on time and competence but is this really a debate about the adequacy of assessment

4. RESOURCES FOR TRAINING
Trainers and course organisers

• Critical roles yet relatively under-researched
  
• Tensions between multiple roles recognised but no resolution
  
• No challenge to the model of one-to-one relationship
  
• What should be the emphasis in their roles?

Administrative support systems

• Little research-based information but increasingly significant as training becomes more systematised.
  
• Quality of these systems significant for smooth administration and links between different components of the system

Physical resources

• Little attention in the literature.
  
• Does this suggest sufficient resources?

External perspectives and advice

• Discussion on training prone to self-reference
  
• Some attention to international models of training
  
• Little evidence of comparative studies with other professional groups

The approach that has been taken examines provision and does not, therefore, focus on the learners. Clearly, their diversity raises issues about different needs and the distinctive approaches required. Linked to this diversity and the inevitability of change during a GPs career, the need to develop GPs as lifelong learners will require added emphasis. Evidence from patient satisfaction surveys indicates high levels of satisfaction with GP care which raises the question of whether the pressure for change is based on a false premise or whether the evidence base on quality is inadequate.

These findings have been reported to the RCGP Council and have been presented at the RCGP Spring Meeting and other academic meetings across Europe, including the Ottawa Conference, in Barcelona. Papers have been accepted for the SAPC, ASME, AMEE and WONCA conferences in the autumn Feedback from the meetings so far has helped with the development of the Literature Review. The full document, which is still in development, will be placed on the Royal College of General Practitioners website, while a shortened version is being prepared for publication in an academic journal.

The Consultation Process
A key part of the Curriculum Review has been the engagement of stakeholders. Professor Hywell Thomas, Dr Mike Deighan (a Course Organiser) , Dr Adam Fraser (initially a GP Registrar and now a GP Principal) and Professor Steve Field have conducted interviews with selected individuals and facilitated focus group meeting. The team have met with the devolved College Councils, Faculties, the Association of Course Organisers, COGPED, UKCEA, groups of patients, trainees, trainers, GP Tutors, groups of nurses and professions allied to medicine and many others across the UK. These meetings have had a range of purposes. Firstly, they served to raise awareness of the changes planned across post-graduate medical education and training in light of the DoH's Modernising Medical Careers agenda. They allowed the team to collect views on key issues by sampling from a wide range of stakeholders. They stimulated discussion on options for change in the GP training curriculum and tested the suitability of the focus of the planned surveys. A field visit to Denmark was also held, while Dr Justin Allen, President of EURACT also contributed to the consultation by providing detailed information on the training schemes across Europe. A formal consultation on some of the key questions is planned for October 2004. This will include other royal medical colleges, the GMC, GPC and other major stakeholder organisations. .

Questionnaire surveys of stakeholders have also formed an integral part of the review process. A number of different questionnaires have been produced, building on the feedback from the consultation meetings.. The first two were targeted at GP Registrars and general practitioners on HPE programmes. Others have been produced for use with GP trainers and course organisers. Collaboration with COGPED has been valuable. The COGPED GP Registrar Exit Survey has been made available to the team. The result of the first survey of GP Registrars in the West Midlands has been submitted for publication.

The Structure of the New Curriculum
While the consultation with stakeholders continues, the Education & Training Group have been working on documentation that will form the Guide to the Curriculum for GP Training that will be presented to RCGP Council for consideration later in 2004.This will include a number of Curriculum Statements which will form the main detailed learning resources for trainers and trainees alike. Although members of the working groups include DPGPEs, more detailed work in partnership with COGPED will be required soon. The JCPTGP has been asked to review the existing Vocational Training Regulations and feed into the Curriculum Review Process generally while the PMETB and DoH's Modernising Medical Careers teams are regularly informed of progress.

The Steering Group has examined different approaches to structuring the curriculum. Recognising the increasing significance of developments in the EU, it invited a sub-group (Dr Justin Allen, Dr Arthur Hibble and Professor Hywel Thomas) to examine the feasibility of using the WONCA Europe (2002) document as a basis for the structure of the curriculum. This was subsequently agreed while acknowledging that the whole curriculum would also be referenced to the General Medical Council's Good Medical Practice. The Education & Training Group have acknowledged the excellent MRCGP Examination Syllabus that the RCGP Examiners have produced which is mapped to Good Medical Practice. The Syllabus is a key document that will be used in fashioning the Curriculum Statements and the Guide generally.

RCGP Curriculum Statements
A provisional set of RCGP Curriculum Statements has been agreed by the Education and Training Group and presented to RCGP Council. . The first statement covers the core competencies required to become a GP and constitutes the elements of the discipline which distinguish it from others. Further Statements cover specific areas relevant to the training of the future general practitioner:
1. Being a Family Doctor
2. Care of children and young people
3. Care of older adults
4. Gender specific health issues
4.1 Woman's health
4.2 Men's health
5. Sexual health
6. Care of acutely ill people
7. Care of people with cancer
8. Palliative care
9. Mental Health
10. Primary care in the NHS
10.1 Clinical governance
10.2 Patient safety & managing risk
10.3 Primary care management
10.4 Improving quality
11. Healthy people: promoting health and preventing disease
12. Personal and professional development
12.1 Practice based learning & critical thinking
12.2 Evidence based medicine
12.3 Research and scholarly activity
13. Clinical management
13.1 Cardiovascular problems
13.2 Neurological problems
13.3 Skin problems
13.4 Metabolic problems
13.5 Respiratory problems
13.6 Rheumatology and conditions of the musculoskeletal system
13.7 Trauma
13.8 ENT and facial problems
13.9 Eye problems
13.10 Digestive problems
13.11 Minor surgery
14. The consultation
15. Valuing Diversity

The Statements are being sent out for consultation across the UK. Each Statement has a champion from the Education & Training Group who will consult with local general practitioners and experts using statements 1 and 13.3 and the Royal College of General Practitioners Examination Syllabus as guides. The Education & Training Group will then review the outcomes of the process and edit the final documents.

[A1]
Next Steps
The consultation on the Curriculum Statements and the production of the Guide continues. Discussions are about to take place with the RCGP Honorary Secretary regarding a formal consultation on some of the key issues that will help form the final submission to the PMETB in early 2005.

The curriculum review is a truly open process. We welcome comments and suggestions and are particularly keen to receive any offers of help! - Please forward any suggestions to my colleague Mike Deighan via email - mike@worcestervts.co.uk

1 This document is derived from a full draft of the literature review and will provide the basis for a further document that will be longer than this summary but briefer than the existing draft. [A1]I suggest this is omitted as nothing has happened since the last report.

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