Aim: To obtain the views of specialist registrars on specialty care in the community.
Method: Specialist registrars from five Deaneries in England completed an online questionnaire about their views on employment prospects, the role of specialty care in the community, and the need for additional training in this area.
Results: One hundred and twenty seven replies were received over a four week period. Thirty (24%) viewed their future employment prospects as consultants as poor or very worrying. Seventy seven (61%) specialist registrars considered that as consultants they will need to work directly in the community. Thirty nine of these (51%) considered the need to work close to patients directly in the community as either a “bad” or “very bad” development. However, 102 (80%) specialist registrars believed that they should receive training on the delivery of specialty care in the community and 96 (76%) wanted this in the form of a university based degree.
- specialist registrars
- specialty care
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During the past year there have been dramatic changes in both the delivery of health care and the methods and programmes for training junior doctors. These changes are likely to gather pace over the next few years and lead to significant new training needs. Indeed by 2010 there will be a 50% increase in the number of medical graduates.1 In a subsequent report by the think tank, Reform, medical graduate unemployment was seen as inevitable.2 Such concerns have been well publicised in both the lay and professional press and are likely to affect career planning by doctors in training. Linked with these concerns is the shift of long term management of chronic disease away from hospitals and into the community. For employment and training this will mean a shift of personnel away from hospitals.
Specialist registrars in a range of different medical disciplines from five different deaneries were asked to complete an online questionnaire about job prospects and the role of specialty care in the community. The survey involved the deaneries of Leicestershire, Northampton and Rutland, Trent, North Western, Mersey and Yorkshire. It was conducted over a four week period in September 2006. Registrars working in gastroenterology, respiratory medicine, diabetes and endocrinology, nephrology, cardiology, rheumatology, infectious diseases, geriatrics, and acute medicine were contacted by email. The questionnaire sought the views of specialist registrars on their employment prospects, the role of specialty care in the community, and the desirability and format of additional training in this emerging specialty.
Replies were received from 127 specialist registrars. They were on average in the third year of their training programmes, with a range of first to fifth year. The largest groups were from geriatrics, gastroenterology, and respiratory medicine specialties. Thirty (24%) viewed their future employment prospects as consultants as poor or very worrying. Forty nine (39%) considered these prospects satisfactory (table 1). It was only among future cardiologists that all considered prospects of employment as a consultant were satisfactory or good. Interestingly, 77 (61%) specialist registrars considered that as consultants they will need to work directly in the community (table 2). Thirty nine of these (51%) considered the need to work close to patients directly in the community as either a “bad” or “very bad” development (table 2) This view was held most commonly among specialties such as gastroenterology and coincided with their belief that they were likely to work in the community in the future. Sixty seven per cent of cardiologists, who, as a group believed that they were unlikely to work directly in the community, regarded this development as “good” or “very good” (table 2).
With the changes that are in the process of happening 102 (80%) specialist registrars believe that they should receive training on the delivery of specialty care in the community (table 3). Ninety six (76%) believe this should take the form of a university based degree delivered by a distance learning programme, although only half felt that this would enhance their prospects of finding a post as a consultant (table 3).
The delivery of health care in the UK is coming under intense scrutiny by politicians. Central to their current argument is the concept that good quality diagnosis and management can be moved out of large hospital facilities and brought closer to patients.3 Such changes will inevitably place new responsibilities on doctors working in the community and reduce the need for large numbers of hospital based specialists. As a result, it is probable that the UK will see the emergence of office based practices,4 the development of polyclinics, and possibly, doctors chambers. For many trainees both the immediate and long term uncertainty generated by these changes has caused alarm. Although such concerns about the availability of consultant posts is not new,5 for some years the hope has been that there would be a close match between training programmes and vacancies. The changes that are now taking place cast some doubts on the likelihood that this will be achieved in the short term.
Against this background, together with the emergence of a significant independent health service provider network, many registrars see themselves as providing specialty care directly to patients in the community. Clearly, such a movement should be recognised and supported with appropriate training programmes. It is only then that we can ensure that the care patients receive will be of the highest quality and that it will dovetail with the services provided by family doctors and general practitioners with special interests. In effect anyone diagnosed with a chronic disease will be able to receive specialist care within the community by specialists whose specific training will make them “fit for purpose”. That this training should be delivered through universities on a distance and flexible learning programme, recognised through the award of a formal certificate, diploma or degree depending upon the length and nature of study, will ensure that there is an independent and robust assessment of candidates. Such a qualification will not be mandatory, but rather demonstrate a degree of excellence on behalf of its holder. It may well prove helpful in overcoming some of the professional reluctance to breaking down traditional barriers which exist between community and hospital based practice.6
We thank Jayesh Navekar in the web technical department of University Hospitals of Leicester NHS Trust for his help in developing the online questionnaire.