The two-year Foundation Programme was introduced in the UK in 2005. In this article, the original architects of the programme explain why it was ntroduced, the challenges faced when implementing it across the UK, why the programme is successful and what the future holds for the UK Foundation Programme.peer-reviewe

Carney, Stuart

Gallen, Derek

Moore, Carrie

English

OAR@UM

 Malta Medical Journal    Volume 21   Issue 01   March 2009The two-year Foundation Programme was introduced in the UK in 2005. In this article, the original architects of the programme explain why it was introduced, the challenges faced when implementing it across the UK, why the programme is successful and what the future holds for the UK Foundation Programme.Revolution and reformIn 2002, the need to reform training for doctors in the UK was identified. Patient safety was at the top of the political agenda and change was in the air as England’s Chief Medical Officer, Sir Liam Donaldson, stated his belief that the traditional training model of ‘on the job’ learning (sometimes unsupervised) was outdated and potentially unsafe. As a result, a major programme of change for postgraduate medical training in the UK (Modernising Medical Careers) was initiated.The reforms began, quite sensibly, with those doctors just finishing medical school and beginning to embark on a career in medicine. It was found that they struggled to put into practice the theories and concepts they learned in medical school. A particular difficulty was recognising and treating the acutely ill patient, particularly out of hours and when working in short-staffed A&E departments. The morbidity rate for patients treated by these doctors fresh out of medical school was comparatively high. Something had to be done.In 2003, the idea of broad-based, generic foundation training was hatched and the Foundation Programme began to take shape. Its aim: to provide a safe, well-supervised learning environment for doctors to put into practice what they learned in medical school. This programme would follow a set curriculum, where the specific skills and competences doctors need to practice safely were set out. All doctors would be assessed against the competences over a two year period. They would be supervised throughout the programme and required to attend regular classroom teaching sessions. They would have to maintain a portfolio of evidence to demonstrate their acquisition of required competence in each area. Until a competence was signed off, the doctor would not be allowed to perform that procedure (be it putting in a catheter or taking blood) on his/her own. The idea of a Foundation Programme was welcomed by patient groups as they could now be confident that all junior doctors were signed off as competent to perform procedures before treating patients unsupervised. Employing healthcare organisations were pleased that they would be improving services to patients through employing doctors with a minimum level of core medical skills. Medical students were relieved that they would be able to practice in a safe environment as they developed their clinical and professional skills. Consultants and senior doctors, however, were much more sceptical of the new training scheme.  The implementation of the programme required the development team to focus on engaging this crucial group of doctors and spending time allaying their fears through workshops highlighting the benefits and addressing the drawbacks identified during initial pilots.ChallengesWhile overall the Foundation Programme can be considered a success, implementing the programme was not without its difficulties.  It became apparent early on that a vast programme to raise awareness and understanding was needed for all of stakeholders – medical royal colleges, patients and public, nurses and other hospital staff, senior management at hospitals and GP practices, and the BMA, medical schools and students – basically a large proportion of the UK population. An extensive communications strategy was launched to increase awareness for all, with varying degrees of effectiveness. Carrie Moore, Stuart Carney, Derek GallenGuest EditorialThe UK Foundation Programme: past and presentCarrie Moore BScDirector, Strategy and CommunicationsUK Foundation Programme OfficeEmail: carrie.moore@foundationprogramme.nhs.ukStuart Carney MPH, MRCPsychDeputy National DirectorUK Foundation Programme OfficeDerek Gallen MMEd, FRCGPNational DirectorUK Foundation Programme Office*corresponding authorMalta Medical Journal    Volume 21   Issue 01   March 2009 9Many senior members of the medical profession did not understand why early postgraduate training needed to change. They felt that the training they had received was good enough. Of particular concern was the extra time they perceived it would take to implement the new assessment model on top of an already heavy clinical and educational workload. Fortunately, we had spent two years piloting different aspects of the Foundation Programme in several deaneries. The senior doctors involved in the pilots were able to respond positively to the concerns of their sceptical colleagues. Evaluation of pilots found that assessments took no more than an extra hour per consultant per placement. And the clinicians found them useful in ensuring their trainees were on track.Another concern was that foundation doctors would not learn as quickly if they could not attempt any procedures without first being required to watch someone else, and then be supervised carrying out the procedure themselves. Of course people learn more quickly through experience, but it also increases the risk to patients. There were concerns that as minimum standards of competence established, training was being “dumbed down” rather than aspiring to excellence. There has been no evidence to support this view. What did become clear, however, is that due to the requirement for regular assessments, struggling junior doctors were identified earlier and provided with the remedial training they needed.  The employing healthcare organisations also had some concerns. They were uncertain that they could cope with doctors changing placements every four months instead of every six months. They believed that as it takes two months in a post before junior doctors begin to contribute to service delivery, then service delivery would be compromised. In order to fulfil service obligations, the multi-disciplinary team rotas were retooled to ensure a mix of ability levels were assigned to each rota and that many of the administrative tasks traditionally assigned to junior doctors (such as searching for patient files) were redistributed to another member of the team. SuccessesThe introduction of a curriculum for the first two years of postgraduate medical training was a major step forward in both defining and demonstrating the level of competence required in these two years.  There was no national curriculum at this level before.Feedback from both foundation doctors and consultants acting as their educational and clinical supervisors has been excellent. A clear message is the belief that the training and support provided is much better than that previously provided. The structured training means that trainee doctors know what is expected of them at each point in their training; and the assessment model allows them to track progress and to identify areas for improvement. From the 2006 intake of foundation trainees, the UK has run a national recruitment process for the Foundation Programme. A key factor of this is the use of one nationally agreed application form which has successfully reduced the bureaucratic burden on deaneries, trusts and medical students. From 2007, the national recruitment process moved online. This open, transparent and equitable process has been effective in providing geographical flexibility and appointment based on merit. Applicants are able to rank the foundation schools in order of preference and allocation is based on their preferences, together with their overall application score. Once allocated to a foundation school, applicants rank the programmes available within that school. They are then matched locally to either one or two year rotations, depending on the school. Each doctor undertakes two years of training, usually split into three four-month placements per year. Over the two years, they have experience of six specialties which provides a greater breadth of exposure in a range of settings across the NHS than previously.The types of placements available have also broadened under the programme. The UKFPO coordinates the Foundation Programme nationally, and was able to secure funding for academic foundation programmes, community placements and placements in those specialties that traditionally have trouble recruiting.It was hoped that a better supervised and more structured training programme with access to careers’ advice would reduce the risk of another “lost tribe” of medical graduates. Foundation doctors are encouraged to reflect on their career aspirations, consider their strengths and attributes and attempt to match these to the needs of the service and future employment opportunities. Providing realistic information about workforce planning and the anticipated changes in consultant need for certain specialties also helps focus their career planning.Operational structuresA number of structures have been set in place to facilitate the delivery of the Foundation Programme. The Foundation Programme CurriculumThe Foundation Programme curriculum was developed to underpin the training programme. It follows a spiral model, with the second year building on the experience and knowledge gained in the first year. Each outcome is broken down into knowledge, skills, competences and attitudes. The outcomes primarily relate to the generic medical and professional skills required of all junior doctors with a particular focus on the acutely ill patient. Operational frameworkThe Operational Framework was introduced to provide guidance to foundation schools on how the Curriculum should be implemented from a practical, operational point of view. The Operational Framework includes details of the various 0 Malta Medical Journal    Volume 21   Issue 01   March 2009roles related to the Foundation Programme such as clinical and educational supervisors, foundation training programme directors, and the foundation doctors themselves.  At the end of the first year, doctors are “signed off” by their foundation training programme director confirming they have met the requirements laid down by the UK’s General Medical Council (GMC) and the Foundation Programme Curriculum. They may then apply for full registration with the GMC. At the end of their second year, they receive a “Foundation Achievement of Competence Document” which enables them to take up specialty/GP training programmes. If a doctor is found not to have reached the appropriate standards, they cannot progress to the next level of training. Foundation schoolsDuring the pilot stage, it became apparent that a specific administrative group should be developed within the deanery to develop and administer foundation training locally. It was agreed that “foundation schools” would be developed, with nominally 300 foundation doctors allocated to each one. There are currently 26 foundation schools across the UK. However, the number of foundation doctors each looks after varies considerably from less than 100 to more than 800 doctors.Foundation schools in the UK are not bricks and mortar institutions, but rather a conceptual grouping of relevant organisations, which is supported by an administrative team. The foundation school brings together medical schools, the local postgraduate medical deanery, trusts and other organisations (e.g. hospices) to offer foundation doctors training in a range of different settings and clinical environments. UK Foundation Programme Office (UKFPO)The UK Foundation Programme Office (UKFPO), established in June 2007, exists to facilitate the operation and continuing development of the Foundation Programme across the UK (this role was previously carried out by the MMC programme teams in each of the four UK countries). The senior management team of the UKFPO was involved in the initial development and implementation of the Foundation Programme within England and is committed to a programme of continuous improvement. While the actual number of staff within the office is small, the UKFPO has developed a number of stakeholder committees and groups, each with a specific focus. One of the major strengths of the Foundation Programme has been the UKFPO’s ability to keep the major stakeholders engaged and to arrive at a consensus with regard to the rules and procedures governing the delivery of the Foundation Programme across the UK. What next for the UK Foundation Programme?There are several areas that we are continuing to develop within the programme.  The Foundation Programme Curriculum is currently under review and will be revised in time for the August 2010 intake. This will be accompanied by a revised Operational Framework.  We are working to ensure that a UK-wide electronic portfolio is available to all foundation doctors and a consistent set of assessment tools is used by all foundation schools.  We would also like to investigate ways to implement the government’s vision of more care delivered in the community by increasing the number of foundation placements in community settings (such as family medicine). Currently, there is a vast discrepancy between the number of community training posts available and the strategic direction of travel for training in the community.We are encouraging foundation schools to develop comprehensive, fully integrated two-year programmes to maximise the educational effectiveness for foundation trainees. The UKFPO is also working with the foundation schools to develop minimum standards for “taster weeks” in specialties that foundation doctors would not otherwise have exposure to during their foundation training.The four UK health departments have recently shown their longer-term support for the UKFPO by issuing a Memorandum of Understanding to March 2012.  We are confident that we can continue to work with our many and varied stakeholders to develop and improve the UK Foundation Programme even further.

The UK Foundation Programme : past and present

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The UK Foundation Programme : past and present

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