The past few years have seen a proliferation of literature from the Department of Health. Much of the emphasis is on restructuring the SHO grade. The key papers were Unfinished Business and papers relating to Modernising Medical Careers. In addition, another batch of papers concerned the establishment of the Postgraduate Medical Education and Training Board (PMETB) and the definition of its functions. The PMETB will take over the legislative functions of the Specialist Training Authority (STA) in October 2004.
The implications of the proposed changes have been discussed widely within the Committees of the Royal College of Ophthalmologists over the past two years. We are now in a position to produce an outline of changes and how we propose to implement them.
Presently in the UK the minimum time required to produce a consultant ophthalmologist would be 6.5 years. This would comprise 2 years of basic specialist training (BST) and 4.5 years of higher specialist training (HST). This minimum time period assumes that a trainee will move between basic and higher specialist training at the first opportunity and pass all four examinations in a timely manner. This happens rarely and it is more common for trainees to spend up to 3.5 years in basic specialist training. Some trainees may well take the opportunity to have time out of the programme to pursue research. The current quality of BST is variable. The quality of HST is much more consistent and this is monitored by the RITA system.
The Foundation Years
Up until now a trainee would graduate from university and then enter the Pre-registration House Officer year. After obtaining registration with the GMC at the completion of the first year, the trainee would then enter basic specialist training. In August 2005 the first Foundation programmes will begin. These will encompass the pre-registration year but also provide a second year of more broadly based experience in acute medical specialties. Attachments may extend from 3 months to possibly 1 year, although in practice it is much more likely that there will be either eight 3 month attachments or six 4 month attachments. The duration of the attachments will be determined locally. It is likely and indeed desirable that ophthalmology becomes part of the Foundation year experiences in a number of programmes. The advantage to the profession is that many more individuals will get more comprehensive exposure to ophthalmology and therefore an increased understanding. The disadvantage of this system is that these individuals will not necessarily be productive during the short-term attachments and there will be three or four such individuals in every clinical year. Trainees will be expected to acquire and demonstrate competencies in areas of the Foundation Programme Curriculum. This will be a generic curriculum. There will be no formal examinations during the Foundation programme. It is possible that if an individual does a 3 or 4 month block in ophthalmology, that this may be counted towards the time in the run-through grade. This is an issue that needs to be resolved but is not of particular importance, as there will be many more significant milestones to pass during the run-through grade.
The Run-Through Grade
A trainee would expect to progress from a Foundation programme to a specialist training programme by a selection process. In time this may include aptitude tests as well as interview. In ophthalmology this will be a particularly competitive process, as we shall lose many SHO training posts from our current numbers. We do not anticipate that examinations, such as MRCOphth Part 1, will form part of the selection process for ophthalmology. Participation in a Foundation programme, including an ophthalmology module, will not be essential for entry into the run-through grade.
It is envisaged that the duration of training will remain close to the current minimum of 6.5 years. It may be that the minimum duration of training would be 6 years with some latitude beyond that, depending upon the individual’s personal circumstances. One curriculum will cover the entire training programme. Progression will be dependent upon the demonstration of competencies. It is likely that the examination structures will be revised with a Part 1 examination being taken at the end of Year 1. It is envisaged that a trainee will have three opportunities to pass the Part 1 examination (12 months, 18 months and 24 months). If the trainee fails to pass the Part 1 examination after three attempts, then the trainee would progress no further in the run-through grade and leave the training programme at that point. A second examination is likely to be taken during Year 5. Success in the examinations will be essential for progression.
The methods for assessment of competencies and examinations will need to be robust and defensible. This will be necessary to satisfy the PMETB that our structures are fair. Examinations and assessments will need to be ‘fit for purpose’. It is not envisaged that all entering a training programme will pass successfully through it. It is anticipated that the major hurdle is likely to occur around the end of Year 2. By this time, it should be apparent whether a trainee has the aptitude, skills and knowledge necessary to become an ophthalmologist. If a trainee overcomes that hurdle then there is every expectation that he/she should progress to become an ophthalmologist. This is very similar to the current situation where there is very little wastage of trainees once they have entered HST.
The run-through grade will select trainees who will be expected to become consultants within a fixed period of time. The number of training posts at the SHO grade (Years 1 and 2) will reduce by approximately 50%. The opportunities for doctors coming from abroad to acquire experience in ophthalmology at the SHO grade will be drastically reduced. Doctors from overseas will be able to compete for entry to the run-through grade without discrimination. Realistically, however, we shall be unable to accommodate the large numbers of overseas doctors that we have in the past.
The Dual Sponsorship Scheme will continue to exist. The numbers of trainees within that programme is relatively small (up to 15 per annum). It is likely that there will be more Fixed Term Training Appointments (FTTAs) for overseas doctors. If the run-through grade is created and senior trainees (Years 5 and 6) go out of programme, there will be no pool of qualified SHOs to take up Locum Appointment Training (LAT) posts. Opportunities will then exist for overseas doctors to fill the gaps of 6 months to 1 year. FTTAs may well be a highly suitable way to do this. Few FTTAs are made currently, largely because gaps can be filled by UK trainees undertaking a LAT post.
By 2010 we estimate that 1260 consultants will be required within the UK. This represents an increase in consultant number of 5% per annum. To work towards that number we require 100 SpRs to acquire the CCT (Certificate of Completion of Training) annually. We calculate therefore that 100 trainees would be required in each year of the run-through grade. We anticipate providing an additional 20% of posts during Years 1 and 2 to allow for eventualities such as failure to progress, or individuals dropping out to pursue research. The total number of Year 1 and Year 2 trainees would therefore be 240 (20% headroom) with the number of Year 3-6 trainees being 440 (10% headroom). These are UK figures.
The direct consequence of this is that for strictly training purposes we will require approximately half the number of SHOs that are currently in post.
Current SHO and Specialist Registrar Numbers in England, Wales, Scotland and Northern Ireland in 2004
SHO NUMBERS - 423
SpR NUMBERS - 333
SHO NUMBERS - 24
SpR NUMBERS - 13
SHO NUMBERS - 44
SpR NUMBERS - 49
SHO NUMBERS - 8
SpR NUMBERS - 12
Alternative deployment of current SHOs
1. Integration into Foundation programmes.
2. Creation of a number of medical ophthalmology SHO posts in Foundation programmes.
3. Creation of run-through medical ophthalmology programmes.
4. GP registrar posts (6-12 months duration).
5. Service grade SHO posts.
6. Possible creation of a new community ophthalmology training programme.
The loss of SHO posts will be a considerable anxiety for all departments. The potential loss of these individuals will have service implications and also implications for compliance with the European Working Time Directive (EWTD).
The Royal College of Ophthalmologists and the Ophthalmic Trainees Group have expressed a strong desire to have subspecialty training retained within the run-through grade. Individualised subspecialty training to a more advanced level will be retained in the new run-through grade. It is our belief that the current product (the newly qualified consultant) is at an appropriate level and that the newly qualified consultant is able to practice their subspecialty skills.
The fear is that if the subspecialty training is lost from the programmes, it may be lost for ever and that Trusts may be unwilling to fund subsequent training for consultants.
The first trainees will be exiting from the Foundation programmes to enter the run-through grade in August 2007. The various Committees and Sub-committees within the Royal College of Ophthalmologists are currently at work devising curricula for the Foundation Programme, GPs and the run-through grade. Robust methods of competency assessments will need to be established and piloted. The objectives and methods of examinations will need to be redefined.
The proposed changes provide an opportunity to improve upon the quality of training, particularly during Years 1 and 2. Quality assurance of our trainees will become more robust. Ophthalmology has always been a competitive specialty. The significant hurdles are now encountered far earlier in a trainee’s career. In the past the most significant step was between the registrar and senior registrar grades. This then moved to the hurdle between SHO and Specialist Registrar and in the future the principal hurdle will be entry into the training grades at the Year 1 level. We shall need to develop our counselling structures. Good quality advice will need to be given to trainees during the Foundation years. Not all trainees wishing to enter ophthalmology will be able to do so. How will trainers identify the best candidates for our training programmes? Regional Specialty Training Committees will need to become adept at breaking bad news when Year 2/3 trainees fail to progress into the latter years of training. Exit strategies for these individuals will need to be devised.
The postgraduate deans are likely to take ophthalmology SHO posts, which are currently in existence, and make some of them into Foundation posts. In many ways this will be helpful. We have never been able to place all SHOs in BST programmes into HST programmes. There has always been wastage. Many of these trainees have had unrealistic career aspirations. The aspirations nonetheless exist. When Foundation posts are created we will begin to get our numbers more in balance. We will need a period of transition to get SHOs who are currently in training (not all) into higher specialist training programmes. We shall need to gradually increase our recruitment into the run-through programmes from 2007. There will clearly be a period of transition where HST and the run-through grade run in tandem.
Many difficult challenges lie ahead for us all.
Stuart Cook/June 2004
Note: This report is available on Royal College of Ophthalmologists website as a pdf document ( http://www.rcophth.ac.uk/docs/college/TrainingInOphthalmology-TheNext10Years.pdf ). It has been made available here for informational purposes to answer the several queries regarding the future of ophtha training in UK we have been receiving since inception of MMC.