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We must improve our NHS - excellent training has to be key ingredient; High-quality education and training for doctors and nurses are crucial if we want to continue to improve our NHS. Here, Lowri Jackson from the Royal College of Physicians (RCP) explains how the next generation of Welsh medics are prepared for life working in our healthcare system.

Byline: Lowri Jackson

If there's one certainty in Welsh politics, it is that the NHS is permanently in a state of crisis.

Politicians, health professionals and the media all agree that change is needed: hospital waiting times are too high, our emergency departments are bursting at the seams and too many patients are struggling to be heard in a fragmented NHS.

But haven't we done enough talking? When is the time for action? Dr Alan Rees, the vice president of the Royal College of Physicians (RCP) in Wales, says it doesn't have to be like this.

He said: "Doctors all recognise that there is a need for change in the NHS.

"Of course, over the past year, the health service in Wales has been at the centre of political controversy, yet when I meet physicians and trainees, they are simply getting on with the job, doing their best for patients.

"Last year, the RCP published an action plan for the next Welsh Government called Focus on the Future. "We're asking politicians to listen to clinicians and let them work with patients to lead change."

As the population of Wales grows older, it is becoming more obvious that we need a new way of running our NHS.

We have to develop better multidisciplinary team working, fully integrate our health and social care services and improve communication between hospital and community health professionals.

And key to the success of this plan will be the NHS staff leading this change: the doctors, nurses, therapists, care workers and all the other thousands of health professionals who take responsibility for treating people and helping families every day in the Welsh NHS.

So how do we prepare for the unknown? What will the NHS of 2036 look like? Someone who has given this a lot of thought is Dr Steve Riley, director of the C21 Programme at Cardiff University's School of Medicine.

He said: "During 2010, the School of Medicine commenced a major curriculum review, not least as a result of poor performance in the National Student Survey and UK Foundation Programme data which showed us that Cardiff students were reporting lower levels of preparedness for practice and familiarity with practical procedures."

In response to this feedback, Cardiff University launched the Harmonisation Programme, which puts medical students at the heart of the action to prepare them for a life on the frontline of medicine.

Dr Riley added: "The Harmonisation Programme was designed to enhance the transition between undergraduate and postgraduate education with the express purpose of preparing Cardiff graduates for practice in the modern NHS.

"It blends existing knowledge and skills with those required by the Foundation Programme to prepare students for life after graduation. The key aims of the programme are based on apprenticeship principles.

"Medical students are embedded within clinical teams around Wales and take responsibility for patient care in a supervised and safe learning environment."

The pioneering project is the first of its kind in the UK and every year allows around 350 undergraduate students to experience the real world of a junior doctor before being thrown in at the deep end when they start their first job as a qualified medic.

The team at Cardiff University, led by Dr Riley and his colleague Dr Tom Yapp, has worked closely with Swansea University School of Medicine and the Wales Deanery to develop an engaging timetable of clinical placements.

"By matching medical students with postgraduate doctors for the eight-week Junior Student Assistantship (JSA), we are able to provide a supervised clinical placement that centres on the direct care of patients in acute settings," explains Dr Riley.

"The emphasis is on the final year students taking responsibility for patient care within this supervised environment.

"Students rotate between the hospital and the community to ensure a balanced view of the primary/secondary care divide."

In another innovative twist, not only do medical students get to shadow their postgraduate colleagues for two months, but the Wales Deanery and the universities have organised the Harmonisation Programme so that those students with a job offer in Wales get to spend their final placement - called their Senior Student Assistantship (SSA) - in the hospital where they will be working as junior doctors after graduation.

Students moving away from Wales are matched to a job that is as similar as possible to their job offer.

This allows students to get to know colleagues in their future workplace, familiarise themselves with systems and protocols and to better prepare them for life on the frontline of a busy NHS hospital.

Because around half of Welsh medical students stay in Wales for their first job, Dr Riley is convinced the system is having a powerful effect on the self-confidence of these new members of the NHS workforce.

"This final placement allows students to really work as part of the clinical team by directly managing patients under the supervision of hospital teams" he says.

The feedback speaks for itself: 93% of students rate the quality of teaching on placement good or very good and 91% thought that the quality of clinical supervision was good or very good.

"The programme has delivered what it set out to achieve," says Dr Riley.

"In the 2015 Foundation Programme Induction Survey, 80% of Cardiff University graduates agree or strongly agree that they feel prepared for their first post in a hospital."

As he points out, the next challenge is to demonstrate how this work will improve patient care, patient experience and patient safety - but it seems clear to Dr Riley that this is inevitable.

"The new structure ensures students are ready for their career in medicine, consolidating the skills and knowledge required to perform at the highest level within the NHS," he says.

"It demonstrates the commitment of the Welsh NHS to training the next generation of doctors."

But if only half of Welsh medical students stay in Wales, where will all the other doctors of the future come from? Dr Helen Baker is the associate director for secondary care at the Wales Deanery.

"We are passionate about the delivery of high quality training to our junior doctors here at the Wales Deanery," she says.

"One of our key aims is to improve both recruitment and retention of doctors in Wales."

Dr Alan Rees agrees and added: "As doctors, our priority is excellent patient care. We desperately need a long-term plan for the future of the health service in Wales, and national leadership from the next Welsh Government.

"Patients must be put at the very centre of care."

That's why the RCP has been calling for a national medical workforce and training strategy which ensures that staff and trainees are part of the solution, now and in the future.

"Crucially, we need to focus on attracting and encouraging junior doctors to train and work in Wales," he adds.

Luckily, the Wales Deanery has identified the same set of challenges.

The Deanery, based at Cardiff University, is responsible for delivering postgraduate medical and dental education to around 2,800 doctors and dentists across all of Wales.

It works with health boards and trusts to make sure junior doctors balance the job of helping patients with passing exams and on-the-job training.

In a stretched NHS, with too few staff and too great a workload, this is easier said than done.

"In order to ensure we can recruit and retain high quality trainee doctors in Wales, there is a need to improve the quality of training on offer to trainees," says Professor Derek Gallen, postgraduate dean at the Wales Deanery.

"Specifically, we need to protect teaching time, provide opportunities to attend outpatient clinics and provide theatre time."

But with so many rota gaps in so many hospitals in Wales, how do we make sure that trainees are able to work, learn and still have time to enjoy life outside medicine? The solution, says Dr Rees, lies in protected teaching time.

"Every hospital in Wales depends on its trainees, and there are huge implications when a hospital loses its training status. Hospitals need to ensure clinic time and dedicated teaching time."

And that's exactly why the Deanery is launching a new education contract for junior doctors in Wales.

This joint partnership between the Wales Deanery, the Welsh Government and NHS Wales means that junior doctors in Wales will be the first in the UK to get ring-fenced time for learning written into their contracts from August 2016.

It's a pioneering piece of work, mapped against GMC standards and curricula, which means that for the first time, trainees will have the right to attend outpatient clinics, theatre sessions, teaching sessions, ward rounds and other educational opportunities.

Professor Gallen has high hopes for the new contract.

He said: "We are investing in the educational environment.

"The aim of this new contract is to lead to an improved culture across NHS Wales which supports learning, education and training."

The new system will be introduced over the next two years.

Dr Daniel Baker, a trainee GP doctor, says he is optimistic about the changes.

He said: "Training doesn't just stop at medical school. Dealing with increasing complex medical conditions involves career-long learning and it is innovations like this which mean doctors can keep up to date and play their role in continuously improving our service to keep the NHS going."

Indeed, one of the most pressing challenges for the Welsh NHS is how to provide safe, high quality healthcare to patients while also giving trainees the time to learn and develop their skills as doctors.

Trainees will be asked about their experience of the new education contract during their annual review process.

They will also be asked to give feedback at the end of specialty placements.

Health boards and trusts in Wales will also be required to provide data on how the system is working, and if they are not fulfilling their end of the contract, the Wales Deanery will take action.

"Service planners must make medical education and training a priority when designing health services," says Dr Rees.

"The RCP believes that workforce planning should be a key priority for the NHS in Wales.

"Trainee and medical undergraduate numbers should be increased, and junior doctors and medical students must be supported and encouraged to stay in Wales by offering them innovative new training pathways, an improved workload and more opportunities to take part in clinical leadership and quality improvement programmes."

So will the new education contract make a difference? Dr Baker thinks so.

She said: "The fact that this new education contract, with its promise to ring-fence training time, is unique to Wales should help us attract and keep trainee doctors.

"It will help us to guarantee that all our trainees get the breadth and depth of experience in the curriculum to enable them to be the best possible doctors."

The only thing we know for sure is that the medical students of today will be the consultants of 2036 - and they will be working in a very different NHS.

"In the future, safe, effective care should be organised around the patient. We need to make it easier for hospitals, GPs and social care teams to work together rather than separately," says Dr Rees, noting that future changes to medical training will need to reflect the needs of patients.

"Good care in the future depends on good training now," he adds.

"We want to ensure that Wales is a leader in postgraduate medical education and to guarantee that all trainees have the same high quality training," Professor Gallen explains. "It is a laudable ambition - and it is reassuring to discover that while the political debate rages on in Cardiff Bay, doctors in Wales are focused on preparing the newest members of the medical workforce to lead the NHS of the future."

Dr Rees concludes: "What's important now is that politicians show national leadership and support innovative solutions to keep our hospitals sustainable.

"Clinicians must be listened to and allowed to lead. That's how we'll make sure that Wales becomes a world leader in patient care."

The new structure ensures students are ready for their career in medicine, consolidating the skills and knowledge required to perform at the highest level within the NHS


<b training. doesn't stop at medical school

Junior doctors in Wales will be the first in the UK to get ring-fenced time for learning written into their contracts from August 2016.

<"The Harmonisation Programme was designed to enhance the transition between undergraduate and postgraduate education
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Publication:South Wales Echo (Cardiff, Wales)
Geographic Code:4EUUK
Date:Jun 8, 2016
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