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Training and learning for the future: making change happen
  1. Robert E Klaber
  1. Correspondence to Dr Bob E Klaber, Imperial College Healthcare NHS Trust St Mary's Hospital, The Bays Building, 16 South Warf Road, London W2 1PF, UK; Robert.Klaber{at}

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Healthcare is changing. There are increasing numbers of people with multiple comorbidities, ageing populations, stark health inequalities and rising patient expectations about quality of care. As access to personal healthcare data, technological advances and changes to patients’ expectations as to how information is shared1 continue to develop rapidly, healthcare systems across the world are struggling to adapt.

There are also significant concerns about the ability of the global healthcare workforce to meet these demands. The potential impact of a health workforce crisis is greatest in emerging economies. However, there is a strong argument that more advanced economies also need to respond, both to the impact of economic austerity and to the combined problem of an ageing population and ageing health workforce. Buchan and Campbell suggest that as new models of care emerge this is both an opportunity for transformative thinking and a threat to the status quo.2 They argue that the aspiration for universal health coverage will not be achieved without a shared commitment to a transformative health workforce agenda across the globe. Across all countries and in all health systems there is “no health without a workforce”.

If healthcare is changing, education and training programmes need to adapt and change too, so that a future workforce can deliver high quality care in these new settings. In the UK, the Shape of Training Review3 has proposed a new approach to education and training which aims to ensure that doctors are trained to the highest standards and can meet these changing patient needs. Shape of Training highlights that patients and the public need more doctors who can provide general care in broad specialties across a range of different settings. It encourages the development of flexibility in training, where local workforce demands, and patient needs, can lead to doctors taking up opportunities to train, or obtain credentials in new areas. The report also highlights a need to move towards a culture of lifelong learning.

Perhaps the first place to challenge the status quo might be the structures of our rotations during undergraduate and postgraduate medical training. Most clinical learning occurs in blocks of time in specific specialties in hospitals, yet if we are to take a more patient-centred approach to our learning the sort of longitudinal approach to education being adopted by Hirsh and colleagues at Harvard Medical School4 is one that we should examine more closely. The opportunity to “follow the footsteps of our patients” as they navigate their way through our healthcare systems is often invaluable, yet this is an approach scarcely used, or not at all, within the vast majority of educational programmes. If we are to understand how our patients obtain information to enable them to self-manage, how they relate to friends, family and social media contacts for peer support, and how they want to communicate and interact with us as health professionals, we need to radically change the lens through which we view them.

This change is difficult, and for many healthcare professionals uncomfortable. The professional and ethical frameworks which underpin our work can be challenged by these new approaches to how our patients are asking us to deliver healthcare, which is all the more reason why these concerns need to be addressed in our training programmes. Patient centredness sounds as if it is a skill that every healthcare professional should automatically be brilliant at, but the development of skilled communication approaches, the understanding of co-production techniques and the leadership and self-awareness to be able to take this approach to patient care require significant support and development.

As ‘out of hospital’ models of care develop and take on a much wider scale, the need to move our workforce out into the community will increase, yet there is little sign that our training rotations and educational programmes are leading the way in this transformation. To meet this future demand we need to introduce programmes of learning and development that train ‘in and for’ integrated models of care, and healthcare outside hospitals. Too often new models of care are developed and implemented without the associated workforce development and educational thinking. If we are to achieve the desired effect of these new approaches to healthcare delivery then this is something that needs urgently to change.

Lifelong learning is a concept that healthcare professionals, employers and indeed patients recognise is important yet continue to struggle with. The patient who stated that “I don't want any learners looking after me” before sending away the consultant who had responded “We are all learners here” is a good example of this. Although lifelong learning is strongly supported, little progress has been made beyond the tick-box approach to collecting points and certificates for continuing professional development that has dominated medicine in the past 5–10 years. Techniques of reflection, critical appraisal, peer learning and review are slowly becoming more widely used and are adding depth to continuing professional development.

In introducing the concept of ‘credentialing’ the Shape of Training review opens up new approaches to lifelong learning with the opportunity to learn more formally and develop new competencies long after training has been completed. Credentialing is defined as a process that formally accredits a doctor attaining competence (including knowledge, skills and performance) in a defined area of practice.3 For our workforce to develop flexibly and adapt to emerging models of care the introduction of this proposal will be crucial. Whether or not healthcare providers feel able to give their workforce the time away from work and financial support to take on this more formal learning remains to be seen.

The Shape of Training review highlights that over the past decade, there have been six major inquiries about aspects of the structure, function and effectiveness of medical education and training in the UK. These reviews concluded that the current system is slow to adapt to patient and service needs. In May 2013 the UK government gave Health Education England a mandate to “develop the right people with the right skills and the right values”.5 As the approach to healthcare evolves rapidly, delivering on this mandate will be a real challenge but one that deserves our total focus.

To date the system has been largely slow and unresponsive to education and workforce changes, and there is significant risk that yet another inquiry will come along before change takes place. Our best chance of countering this is to put training and learning in healthcare at the centre of every discussion about the future—we all have a responsibility to do this.



  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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