Training in the Community

1. Training in the Community Dr Mark Cottee STFS associate Director

2. Pilot research project • Broadening Foundation Training • Discussion

3. What is the effect of brief experience of community patient care on foundation year one doctors understanding of and orientation to primary care? Dr Sarah Eccles, GP ST4, Medical Education Fellow South Thames Foundation School Dr Mark Cottee; Care of the Elderly Consultant St Georges Hospital, Associate Director South Thames Foundation School Professor Paul Booton, Professor of General Practice and Primary Care, St Georges University of London

4. Project Background • Longstanding clinical and political imperatives to push more care into community settings • Junior doctorsneed to have a good understanding of patient care in community settings • Majority of undergraduate and foundation programme is hospital based • Literature shows benefit of community experience for junior doctors

5. Benefits & Drawbacks Described in Literature • Benefits • Improved understanding of primary care • Improved understanding of patient needs • Improved communication between primary and secondary care • Gave insight independent of career goals • Educational benefit for trainers and trainees • Better supervision and assessment of learning needs • Drawbacks • Differences in educational requirements • Limitations of year one doctors e.g. prescribing, less clinical experience • Strain on GP practices accommodating very junior doctor • Anxiety returning to hospital posts 1 Richardson M. Bond A Hume N (2007), Report of a pilot second year Foundation Programme including an attachment in general practice, Education for Primary Care. 18: 471-79 2 Firth A. Wass V. (2011), The impact of general practice attachments on foundation doctors: achieving the goals of Modernising Medical Careers. Education for Primary Care. 22(5) 3 Williams C, Cantillon P, Cochrane M (2001), The clinical and educational experiences of pre-registration house officers in general practice. Medical Education 35: 774-81 4 Wilton J (1995), Pre-registration house officers in general practice, BMJ 310: 369-72

6. Community experience in the Foundation Programme • 2005 aimed to provide a GP placement to 55% of trainees (80% by 2007)1 • Evaluation after 5 years • Curriculum too heavily reliant on the care of acutely ill patient2 • “…all foundation doctors must have opportunities to understand community care provision and the majority should be offered community placements…” • FY2 rotations 2012 • 44% GP • 2% community specialties 1 Department of Health (2004), Modernising Medical Careers 2 Medical Education England (2011). Foundation for Excellence - an evaluation of the Foundation Programme

7. Project Outline • Recruit 12 F1 doctors • Conduct focus group discussion and survey to evaluate opinions and experience to date • Deliver community experience • Community visit to a patient whom they have been involved in discharging • Meet with patient and GP separately • Discuss and evaluate discharge and subsequent community input • Repeat focus group discussion and survey to evaluate experience • Survey of South Thames foundation school trainees (1500 Drs) on community experience

8. Participants • 12 Foundation Year One doctors working at St Georges Hospital • 5 male, 7 female • Age range 23-35 • Range of: medical schools; undergraduate and graduate entry • Current F1 Jobs: • Acute Medical Unit (3), Upper GI (2), Breast Surgery (2), Gastroenterology (1), Respiratory (1), Paediatrics (1), Liaison Psychiatry (1), Community Psychiatry (1) • Career aims: • GP = 2 • Hospital Specialty = 6 • CMT (1), Genetics (1), Psychiatry (1), Opthalmology (1), Anaesthetics (1) Broad based training (1) • Don’t know = 4

9. Focus Group Results

10. Community experience to date • Majority felt they had had adequate amount of communityexperience so far in training • Overview of experience • Majority undergraduate • 3 doctors doing F1 jobs with community experience • Majority from GP • short contact early in course • longitudinal patient follow up • longer placement in final years • Less community speciality experience • short placements community clinic or hospital • psychiatry & paediatrics

11. Understanding of community • Although felt they had good amount of community experiencedid not translate fully once working • Felt lacked knowledge of wider role of the GP “….even though we had loads of experience and I've seen a lot in general practice, I still don't know when I am asked to discharge a patient, what is appropriate or not to ask the GP to take on …” • Felt lacked wider information about community services “..when you are an F1, because you're often leading certain packages for someone's discharge, and you're trying to arrange for community follow-up and arrange for there to be continuity of care, but you don't really have that good an understanding about what there is available..”

12. Understanding of community • Lack of confidence regarding discharge letters (TTO) • Unsure what to cover “…I'm not precisely sure what is useful or not on a TTO…” • Lack of feedback “…I have absolutely no idea whether I write good or bad discharge letters because we don't get any feedback from anyone….”

13. Understanding of community • Uncertainty regarding time frame and feasibility a) “I think I understand what they (GPs) can and can't do, but I don’t know, in terms of their workload, how much they can cope with b) especially for stuff that needs to be done in the next couple of days…. I don't know how quick the process is, do they see it (discharge letter) the next day after the patient gets discharged? • It's put in the post. b) It's put in the post? a) I shouldn't think it's first class b) so I mean … actually, maybe I've given inappropriate follow-ups…”

14. Understanding of community • Would like more guidance on discharge letters “…..it probably would be quite good to have some teaching at the beginning from a GP, ….just to give us kind of some realistic ideas and what they want to hear from us, what's important….” • From GPs “….I think we did have one talk about TTO's but it was by one of the AMU doctors, so maybe it would have been better coming from a GP….” • More beneficial if taught once working “….I think that it would have just fallen on deaf ears as a student because you don't really take ownership. Until they're your patients it doesn't really mean anything….”

15. Importance of community experience • Felt important for junior doctors to have community experience “……you're isolated in a ….., a huge majority of care in the UK goes on in primary care, so you need to have an understanding of how it works…” • Irrespective of career aims “…. probably the people who are going to steer away from it (community job) the most are potentially the people who need to be in the community the most at some stage to appreciate what goes on out there….” • Not necessarily long duration “….four months is quite a long time to spend in GP, especially if you know you don't want to do anything community based, but it would be good to get at least a taster of it….”

16. Community experience as F1’s Some concerns: • Need for service provision “…F1's are needed in the hospital, we're kind of essential on wards....” • Lack of experience “…I still have so much to learn that I think it would just be almost like an extension of being a medical student because you would have to run everything by the GP…” • Prescribing limitations “…..I'm not sure how you'd sort of be having it in F1 because I know we can't prescribe outside of hospital….”

17. Community experience as F1’s But appropriate experience would be positive • Teaching day “….in the same way we have F1 teaching days, every now and again, I don't know, maybe some of them should be more community based….” • Ward release “….even if it was just a couple of weeks and, as an F1, you had your own community clinic….” • Split posts “…if they could create posts that were sort of half GP and half something else and people could swap over after two months. That might be a good idea….” • Autonomy important “….a taster would be really useful, as long as they were given some sort of responsibility, so even the people who weren't keen would have to work hard….”

18. Summary • Reported good undergraduate community experience but focus groups suggest not adequate for needs as F1 • Feel community experience as a junior doctor important but concerns about feasibility • Feel F1 community experience would be beneficial

19. Next Steps • Deliver community experience • Community visit to a patient whom they have been involved in discharging • Meet with patient and GP separately • Discuss and evaluate discharge and subsequent community input • Repeat focus groups • Survey of foundation school • Potential to repeat with larger sample

20. Broadening the Foundation Programme (February 2014)HEE

21. summary • Reductions in surgical foundation doctor (FD) posts • Increase in community posts (such as general practice, community paediatrics, palliative care, public health or community psychiatry) • Potential developments of integrated community placements, which must include a supervisor based in the community • Increases in psychiatry posts (some of these are community based, so can contribute to both targets) • Most medical posts will need to include community-facing experience

22. There are three major consequences • Consequences of redeployment. • Requirements for backfill. • Consequences for STFS

23. Risks of implementation • Shortfalls of doctors in trusts creating service pressures, resulting in: • Patient safety concerns • Impact on other trainees, to whom the workload then falls • Cost pressures on trusts • Development of inadequately supervised community posts resulting in patient / doctor safety concerns • Inability to identify sufficient community posts

24. Overall post reconfigurations to meet targets 2017

26. Recommendation • Foundation doctors should not rotate through a placement in the same specialty or specialty grouping more than once, unless this is required to enable them to meet the outcomes set out in the Curriculum. Any placements repeated in F2 must include opportunities to learn outside the traditional hospital setting.

27. Current (2013/14) surgical posts *including some specialties eg ENT but not ophthalmology

28. Current (2013/4) medical posts

29. Recommendation 3 • At least 80% of foundation doctors should undertake a community-based placement or an integrated placement from August 2015. • All foundation doctors should undertake community-based placement or an integrated placement from August 2017. It should be noted that both community and integrated placements are based in a community setting, and that an acute-based community-facing placement is not a substitute.

30. Current community posts

31. summary • Reductions in surgical foundation doctor (FD) posts • Increase in community posts (such as general practice, community paediatrics, palliative care, public health or community psychiatry) • Potential developments of integrated community placements, which must include a supervisor based in the community • Increases in psychiatry posts (some of these are community based, so can contribute to both targets) • Most medical posts will need to include community-facing experience

32. Comments • Ideas • Good practice