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J R Soc Med. Feb 2008; 101(2): 59–62.
PMCID: PMC2254455
A healthcare curriculum for the 21st century: time for flexibility?
Olwyn MR Westwood,1 Samuel J Leinster,2 and Julius R Weinberg3
1 Professor of Medical Education, Barts and The London School of Medicine and Dentistry, Old Medical College Building, London E1 2AD, UK
2 Dean of Medicine and Professor of Medical Education, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK
3 Deputy Vice Chancellor and Professor, City University, London EC1V 0HB, UK
Correspondence to: Dr OMR Westwood. E-mail: o.westwood/at/qmul.ac.uk
The purpose of healthcare education is to provide appropriately skilled individuals to deliver the care needed by the population. However, curricula are shaped by the regulation of professional groups, professional accountability and demarcation issues. Current changes in the delivery of healthcare, in educational theory that advocates increased integration of theory and practice1-3 and in the international agreements on mobility of qualifications have challenged our traditional educational pathways.
This paper argues that delivery of an effective healthcare workforce for the future is dependent upon a radical rethink of our education system. Although we largely draw upon experiences within the UK, these issues could apply to most healthcare systems.
It seems unrealistic to expect that the majority of students entering higher education know the health profession they are best suited to, and that confining them to a particular profession will ensure their full potential is attained. Therefore we propose curricula with multiple ‘stepping on’ and ‘stepping off’ points. Stepping on would be appropriate to a individual's level of attainment, where they would acquire knowledge and skills within a professional area, or further knowledge and skills that, with the minimum necessary re-training, would allow transfer into another profession. Stepping off would be at a point which recognizes their level of attainment and provide entry into a clear role. Accordingly, an individual may step on as a member of one profession, but later step off as a member of a different profession, provided they have demonstrated appropriate skills and knowledge acquisition.
The key issue here is to promote judicious application of a relevant knowledge base.
The Bologna Declaration (1999)
This agreement,4 signed by EU Heads of Government, discusses the relevance of curricula to employment. It aims to influence change in basic and continuing professional education that include work-based, practice-based and life-long learning. The central ethos is a credit transfer system to facilitate student mobility between institutions for the development of professional qualifications. (A credit system is a way of describing an educational programme by attaching credits to its components.) If this was applied to all disciplines, including healthcare and medicine, it would facilitate progression to another profession without the need to ‘return to base’ to retrain.
The impact of Bologna on medicine is already being considered in many European countries. Some schools wish to remain outside the Bologna process, others are moving to a two cycle approach (i.e. ‘3-year +2-year’ or ‘3-year+3-year’) (see Figure 1), with the final award being a Masters degree.5 But there are practical issues for student mobility, not least agreement on the content and depth of curricula. For example, some medical schools have a clear separation between ‘preclinical’ disciplines and clinical practice, whereas others have an integrated curriculum with clinical contact from the first year.
Figure 1
Figure 1
How the Bologna Process could facilitate the step on-step off health care curricula. (Adapted from Kaiser 20055)
We argue that finding solutions to these issues presents an opportunity to both examine education pathways and formalize the mechanisms for student re-location and transfer.
The NHS Plan and curriculum planning
The government papers ‘The NHS Plan for England’6 and ‘Health Resources in the NHS Plan’7 proposed less rigid boundaries between health professions with respect to ‘who performs a particular skill’. Thus, designing an accelerated route into another health profession where there is overlap in two or more curricula (i.e. Bologna process) would fulfil the NHS Plan and provide obvious benefits to students, higher education and the NHS. The key issue is not to compromise knowledge and skills competences acquisition.
In response to current and future skills shortfalls, significant effort is under way to introduce new ways of working within the NHS. Higher education has been cautious in responding at the pre-registration level to the ‘revolution’ in emerging new roles within the NHS. Some curriculum content is common to some or all health professions. Although academic levels may vary, opportunities for credit acquisition in knowledge and skills need to be explored if the NHS Plan6 is to be realized. The ultimate prize is a better educated and adaptable workforce with greater career opportunities, allowing staff to fulfill their true potential8,9 and deliver better care.
Curriculum documentation
Scrutiny of the Quality Assurance Agency (QAA) benchmark statements for the health professions - that is, honours degrees (medicine and dentistry8) and academic and practitioner standards in health care subjects9 - allows areas of common learning to be identified.
With inter-professional learning, the appreciation of other roles is the key issue, whereas with common learning, the emphasis is on shared knowledge and skills competences. Obvious examples include patient-specific issues such as confidentiality, ethics, clinical skills and professionalism training. Mapping of the QAA benchmark statements for all health professional8-10 programmes would be the initial exercise, although some delineation of common and profession-specific curricula content would be necessary.
Professional Skills
As knowledge and skills needed for the professions overlap, boundaries have become less distinct. Indeed it has become increasingly difficult to identify the defining characteristics of a particular profession. We would agree with recommendation five of the Independent Inquiry into Modernising Medical Careers, led by Professor Sir John Tooke,11 that there is need for common understanding and clarity of the roles of a doctor - indeed we would suggest that this need extends across the contemporary healthcare team, along with acknowledging that these roles continually change. The best way to achieve this is through common training becoming the norm. For example, with skills acquisition such as prescribing, medical students qualify to prescribe as part of their GMC-accredited award. With changes in Department of Health regulations, other professionals now prescribe (e.g. nurses, pharmacists),12,13 but theirs is a post-registration qualification, rather than one integrated into their original academic award. The paradox here is that the various courses are accredited in order to allow health professionals to perform the same task (i.e. prescribe) yet their studies vary in content, practice development and academic level. This implies that there should be a streamlining of knowledge prerequisites and content of academic modules for learning how to prescribe safely.
Cognitive skills
The QAA and the Bologna Declaration emphasize the importance of generic and cognitive skills acquisition, for example in self-directed learning, research or in-depth study for presenting a specific topic. Within UK medical programmes these outcomes are addressed in the student selected components (approximately 25-33% of the curriculum content10). Thus it would be plausible for students with evidence of these competences to be exempted from ‘repeat-learning’ upon transfer to another programme. A credit transfer system would help to facilitate this.
For step on-step off curricula to work, the depth, competences and learning outcomes of each part of a programme need be explicitly defined and academic credits assigned. Whilst this may be an administrative upheaval, the integration of the different streams of academic activity, and student mobility between institutions and programmes, would then be a real possibility to allow the step-wise process for requalification.
The modular system facilitates credit transfer of learning. Within any programme, there may be defined modules with specific content required by a professional regulator for registration to practice. This is achievable for shared modules and discipline-specific modules - it has been a feature of the Physiotherapy and Occupational Therapy degrees at the University of East Anglia since 1990.14
The problem-based learning (PBL) approach lends itself to multi- and inter-professional education, mirroring the ‘world of work’ within multi-disciplinary teams. In shared PBL sessions, some outcomes may be core to all professions (A) while others are profession-specific (B). At the time of undertaking these shared sessions, students can opt for an appropriate profession-specific component. But if they subsequently wish to train for another profession, they may transfer the credit outcomes and competences for (A) yet would need to acquire the additional credits for outcomes and competences (B) for their new role. Learning technologies (web, simulation, self-directed learning) may be used where appropriate to ‘fill in the gaps’ in knowledge and skills competences.
We recognize that these proposals carry significant challenges to healthcare education and its professional boundaries - the key issue is defining learning outcomes, competences and credit values. Gaps in knowledge and skills competences may be viewed as a barrier to change. Yet there is little agreement on the level of detail for disciplines needed for each health profession. Variation in emphasis in UK medical schools is welcomed, but tempered by the General Medical Council who accredits the award and quality assures the knowledge, skills and professional attributes achieved for confirming fitness to practise as a doctor. It might be argued that the skills of decision-making, diagnosis and breadth of training makes medicine different to other health professions - here again, skills may be learned within profession-specific modules and breadth through exposure.
A common foundation curriculum would aid flexibility in moving between programmes. But prior declaration and enrolment for a specific programme (e.g. physiotherapy, radiography, medicine) would be essential if competition between students for the professions was to be avoided. The aim is not for everyone to become a doctor, but to acknowledge and credit areas of common learning to allow ease in retraining for another profession in the future.
The medical school in Brunei suggests a good working model: a common foundation programme of multi-professional and specialist modules in the initial three-year integrated medical programme. Students then complete the final three years of medicine within partner medical schools with independently-developed curricula in another country, for example the UK, Canada or Australia.15 This is much the same as when UK medical schools with an integrated curriculum accept students from a traditional medical programme with limited integration for their ‘clinical years’, but without evidence of compromised standards.
This concept of credit transfer is not radical, as academic transcripts already allow mobility between degree programmes (including medicine) on a case-by-case basis. University registries regularly deal with students who, owing personal circumstances, transfer mid-degree to another programme or institution. Why not use the same system to transfer from one profession to another? Academic regulations on the use of credits would overcome the issues surrounding knowledge retention and skills for transfer to another programme.
The NHS was created to meet the needs of the population in the 1940s, when the traditional professions were well established. Demographic change has dramatically altered the demand for, and the supply of, services in terms of volume and type. The potential impact on the supply and shortage of appropriately qualified professionals is a real issue. Hence we need to maximize the benefits for those we are able to attract by providing flexible career structures. As healthcare delivery evolves, new packages of care appear; innovations in training and commitment to retraining are therefore essential to ensure that roles can be filled appropriately. Clearly such a move will not happen immediately, but could begin with partnerships between education providers which allow flexibility for healthcare and medical students to move between programmes.
We suggest that current boundaries are too rigid, and silo training is not the most effective way to educate the health professionals of the future. The external pressures of Bologna, demographics and workforce planning are driving change in the professions. Even with inter-professional learning, such pressures can create protectionism and defensiveness over professional boundaries that anyone involved in professional body review of academic programmes will know.
This paper is intended to challenge - we would like to see modularized programmes for health professions providing multiple pathways that lead to accreditation in a variety of health professions. But does anyone have the courage, and do the professional bodies have the vision, to support it?
Notes
DECLARATIONS
Competing interests None declared
Funding None
Ethical approval N/A
Guarantor OMRW
Contributorship All author contributed equally
Acknowledgements To Mrs Trudi Patchett for her administrative assistance, and to Professors Richard Hay & Lambert Schuwirth for invaluable insights when commenting upon an early draft
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