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There will be new joint training across the professions in communication skills and in NHS principles and organisation. They will form part of a new core curriculum for all education programmes for NHS staff. . . . A new common foundation programme will be put in place to enable students and staff to switch careers and training paths more easily.1
We believe it is important that the NHS . . . should work with higher education providers and accreditation bodies . . . to develop education and training arrangements which are genuinely multi-professional and which will enable students to transfer readily between courses without having to start their training afresh.2
These bold—and wholly laudable—statements are taken from two major documents published in the year 2000 on the future of the health service. The strength of the statements, and their inclusion within these two important documents, highlights the central role now being accorded to ideas of multiprofessional and inter-professional education in the development of the “new” NHS.
How is this to be delivered? To deliver on these aspirations, the NHS depends wholly on the ability of the education providers—universities and higher education colleges—to comprehend, embrace, and then provide interprofessional training. It is important therefore that education providers are an active part of this debate.
The first and most obvious point is the need to be clear about objectives; in turn that means being clear about definitions. In the health literature the terms “multiprofessional” and “interprofessional” are often used interchangeably, and sometimes they refer simply to team working.3–7 NHS publications adopt a multiplicity of definitions—and therefore of objectives.
Clarity of definition is not just important as a principle. Educators can deliver what the health service wants only if there is a clear statement of objectives, which at present is lacking. Without a clear definition of the desired “interprofessional” working practices, higher education cannot develop the pedagogical approaches which underpin it, a concern which I feel most keenly as vice chancellor of one of the universities designated as a site for a new medical school. As we plan for undergraduate medical education in these new environments, we need a clearer view of what interprofessional working within the health service will really mean.
The NHS wants students to be prepared for interprofessional working in any or all of the following senses:
Which of these does the NHS really want? Which of these can the education providers deliver? The first question needs to be answered elsewhere; I shall attempt, by considering each definition, to answer the second.
Most discussions of interprofessional education begin by acknowledging the historical divide between different occupational groups: “old fashioned demarcations between staff” as the NHS Plan puts it.1 The first step to overcoming these divides is seen as greater mutual knowledge and understanding. This is the framework adopted by the Centre for the Advancement of Interprofessional Education in its statement of its focus on “the ways professions learn with and about each other, foster mutual respect . . . overcome obstacles to collaboration.”8
Of all the objective versions of interprofessional education, fostering mutual respect seems the least threatening and is certainly widely accepted. Recent statements from the General Medical Council (GMC) advocate it: “[Interprofessional collaboration/training can] encourage professionals in training to learn from and about each other . . . encourage respect for the contribution each professional has to make to patient care . . . leading to mutual understanding of professional systems, cultures and roles.”9 This has a particular resonance for medicine, the profession that historically has policed these demarcation disputes most effectively to its own advantage.
For education providers, inclusion of “knowing about” other professions presents few problems since it can be incorporated quite readily into curriculum design. Whether, of itself, it can make inroads into the “old fashioned demarcations between staff” is another matter.
The value of working actively with other professionals, as part of a single care team, is well embedded in discussions of effective health care. Sir Charles George has described teamworking as “an essential prerequisite to modern clinical care”9 and in the GMC's guidance on maintaining good medical practice one of the key tests of a good team is that members can be “open and honest about professional performance” both together and separately. This requires a willingness to engage directly, across boundaries that have long been impermeable.10
Education and training can contribute to this endeavour in many ways, both before and after registration. Universities have found that after registration there is often a more local focus; needs can be more clearly identified and courses tailored to these. Though there are some problems of funding and of coordinating the professional requirements of different groups into a single training programme, this area could expand fairly rapidly if participation is encouraged by NHS employers.
From a university perspective, the barriers to shared learning at the preregistration stage are considerable:
It is not impossible to overcome these barriers, but the fact that experimentation has been limited indicates the level of difficulty.7 If this were to be pursued on a wide scale, it would be costly and would require considerable change—for example, on the part of professional bodies.
There is also the fundamental question of whether shared learning is the most effective learning for each of the professional groups. Recent research in Dundee, on limited shared learning between medical students and midwifery students, suggests that this may not be so. Even though the groups had gained in mutual tolerance and understanding, effective learning for each of the groups may have been compromised.11
Interprofessional working as “substitution” is strongly advocated in the NHS Plan.1 It flows from the commitment to redesign the health service around the needs and concerns of patients, to end the “demarcation lines,” especially those between doctors and other health professionals. According to the secretary of state's introduction to the plan, “For the first time, nurses and other health professionals will be given the bigger roles that their qualifications and expertise deserve. The Plan envisages a major role for education in this task of ‘breaking down the barriers’. . . . Radical reform is required in NHS education and training to reshape care around the patient.”1
This will include some common training programmes (with communications skills, and NHS principles and organisation, being the most immediate need) plus the development of training that will enable non-medical professional groups to undertake new tasks: midwives moving into public health; nurses prescribing certain drugs; pharmacists developing a comprehensive community service. All of this implies a major educational agenda at preregistration or postregistration level, or both.
In this definition of interprofessionalism, it is clear that the first big challenges are to working practices within the NHS itself. Education cannot lead these changes; if we were to do so we could find ourselves preparing students for a future that might never exist. Providing common modules on issues such as communication skills is relatively manageable, but supporting the more radical changes is a substantial challenge, involving major curriculum redesign and possibly an overhaul of programme provision.
It is also less than clear how these changes might affect medical education specifically: is the implication that doctors simply give up the monopoly of some of their roles, or are they themselves to take on new roles, hitherto the province of other health professions? Clearly major changes in the medical curriculum would be a matter for the GMC, but when planning a new medical school one is inevitably thinking long term. These questions must be settled quickly if the education providers are to gear up to support radical change in working practices in the NHS.
Recent NHS documents emphasise inter-professionalism as “moving across” in career terms. The aim is to facilitate movement from a career in one health profession to another, during the course of training and afterwards. This model presumes that educational routes to different professional qualifications will remain distinct, at least in their later stages, but that it will be much easier to move between these routes without having to start from the beginning. Thus an individual might begin training for midwifery, then switch to medicine, or vice versa.
Universities are familiar with this kind of flexibility in the early years of other degree programmes, and most are geared up to delivering it. Capacity to do so in the health professions depends on the views of accreditation bodies. Mechanisms to support this flexibility are needed—for example, conversion courses to enable students who wanted to “move across” to be brought up to speed in disciplines new to them.
Given the right conditions, universities could rise to this challenge of greater flexibility with some enthusiasm. I am much less sanguine about the particular mechanism envisaged in the NHS Plan for delivering flexibility: the common foundation programme. It is difficult either to embrace or to criticise this idea with any degree of confidence, since the plan says so little about it. The problems of creating elements of shared learning within existing programmes (described above) would be accentuated if the higher education sector were truly called upon to deliver a completely common programme for the first year (or more?) of training for nursing, medicine, and all the therapies.
This particular idea should not form the centrepiece of future discussions about educational change. It would be much more productive for the NHS to invite universities and higher education colleges to produce proposals to support the kind of career flexibility which the NHS desires, rather than prescribe the form that this should take.
Universities stand ready to support the NHS, and other health providers, by adapting and developing their educational programmes. Those with programmes in nursing and professions allied to medicine as well as in medicine will find it easier than other providers to plan for interprofessional education in all its forms. Even so, some versions will be easier to deliver than others, and some have long lead times.
In a spirit of partnership working I suggest that universities, as the experts on education within this partnership, might be invited to think laterally about how best to support NHS objectives once these have been clarified. This is likely to produce more effective and sustainable solutions than when the NHS tries to specify the type of education which it wishes to see.
In this spirit of lateral thinking, I offer one particular thought on a topic which has been little discussed but which seems to have considerable merits. When we talk about shared learning, as part of professional programmes, the impression is usually given that this takes place in a classroom. Why? All professional programmes have substantial fractions of time spent in clinical placements, and for the most part the same health service facilities are used to provide clinical experience for all groups in training.
Would it not be more effective to envisage a substantial amount of interprofessional learning taking place in clinical settings, where students are dealing with real life circumstances; where they can see the contributions of the different members of the team; where they can learn to work together and can indeed take over each other's roles where appropriate? Clinical placements which delivered this kind of learning would require a close and sustained partnership between educators and health service supervisors, across a range of professional groups. The organisational challenges would be considerable—but the gains could be enormous.
This is an edited version of a presentation at the Millennium Festival of Medicine in London, 6-10 November 2000.
Based on a presentation from the Millennium Festival of Medicine
Competing interests: None declared.