Understanding the needs of doctors in training
Our research and expert advice highlight the case management model as best practice for supporting the needs of doctors in training.
Case management is defined as: 'A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet [...] health and human services' needs. It is characterised by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.' As an approach, it has similarities to multidisciplinary teams in medicine.
Using that process flow can help create an action plan for supporting each disabled doctor in training.
This process applies for disabled doctors at any stage of training. The same stepwise approach can be considered for assessing doctors in training with new or evolving health needs.
All doctors in training should have access to occupational health advice. Doctors may acquire a condition or disability at any stage of their career. If a doctor in training has a long-term health condition or disability, they may need specialist occupational health advice through an accredited occupational health physician, to make decisions about training and working.
The deanery or NHS England local teams with the doctors' employers can use and adapt the process as they feel is appropriate, for example by using some of the steps included, depending on the specifics of the case.
Process map for supporting doctors in training
This process gives an overview of what can be done; not all steps will be appropriate for all doctors in training, but it can be adapted to each individual case at the discretion of the postgraduate deanery/NHS England local team and the doctor's employer. All doctors should have access to occupational health advice. Doctors may acquire a condition or disability at any stage of their career. If a doctor has a long-term condition or disability, they may need specialist occupational health advice through an accredited occupational health physician, to make decisions about training and working.
Step 1 Sharing information
Doctors in training share information about how their condition or disability might affect their practice with their deanery/NHS England local team and employer. The doctor in training does not need to share the nature of their condition, they can focus on how it affects their practice and what support or reasonable adjustments they would need.
Step 2 Postgraduate dean as gatekeeper
The postgraduate dean or nominated representative (for example an associate dean or the foundation school director) can arrange the next steps for considering what support the doctor in training needs.
Step 3 Form support network
Depending on decision by postgraduate dean or nominated representative, they can gather individuals to provide advice on how the doctor in training can be supported. We will refer to the people involved as the doctor's 'support network'. The doctor's support network could include:
- an accredited occupational health physician with current or recent experience in physician health, from the occupational health services where the doctor is/will be based
- the deanery or NHS England local team
- the foundation school (if applicable), for example through the foundation school director
- the doctor’s training programme director
- the director of medical education or nominated representative at the local education provider where the doctor is or will be based
- the doctor’s named educational and clinical supervisors (one person could be doing both roles)
- the Human Resources team from the doctor's employer
- the Professional Support Unit (if available)
- the disability support office (if available).
The doctor in training could be invited to some of the support network discussions. It is good practice to offer the doctor in training options for a few dates, and also the opportunity for them to bring a friend or representative for support.
Step 4 Decide key contacts
It is good practice for disabled doctors in training to have a key contact they can liaise with for anything related to their support. The support network can assign the key contact(s) with input from the doctor. It may be practical for the key contact to be someone seeing the doctor on a regular basis, such as their educational supervisor.
Step 5 Confidentiality arrangements
When handling information about individuals, organisations must do so lawfully. Organisations must provide doctors in training with material regarding how their information will be used, and their rights in respect of that information. This will help to make sure any information shared by the doctor in training is not misused. It will also give doctors in training confidence in providing such information.
The Information Commissioner's Office provides guidance on what to include in privacy information, including a checklist (in Panel A10 of the Appendix). The Information Commissioner's Office sometimes offer free advisory visits to organisations to give them practical advice on how to improve their data protection practice.
An organisation might want to consider the following when collecting information from doctors in training about their health.
- Keeping a clear audit trail of decision-making for supporting disabled doctors in training as this is likely to help organisations make sure they have taken appropriate steps to provide reasonable adjustments.
- Keeping a record of all conversations between the support network and the doctor in training. It is good practice to agree the method of recording such conversations and for the doctor in training to see a draft record of any discussions.
Step 6 Occupational health assessment
It could be helpful for a disabled doctor in training to have an occupational health assessment. A high-quality assessment could be very valuable in informing support for the doctor in training. It is good practice for:
- The assessments to be done by an accredited occupational health physician, with demonstrable current or recent experience in physician health, and an understanding of the requirements from doctors in training.
- The assessments to be done through an in-person meeting between the occupational health physician and the doctor.
- If an agency has been hired to provide occupational health services, they provide details of who among their staff will be doing the assessments. It could be helpful for the service to confirm that one or a small number of physicians meeting those criteria will provide the advice for continuity purposes.
The occupational health physician can make an independent assessment of the individual doctor's needs and ways to enable them to progress through their training. The occupational health physician will decide if they need an opinion from an independent specialist or a specialist organisation as part of their assessment. Organisations can also consider any requests from a doctor in training for a second opinion or a referral to another occupational health service.
The Government has published guidance on employing disabled people, which includes advice from specialist organisations for a number of specific conditions such as mental health conditions, hearing and visual impairments and hidden disabilities (in Section 5 of the Government guidance).
An organisation can use or adapt the sample forms included in the appendix of the guide (panels A8–A9) as a starting point for requesting an occupational health assessment for a doctor in training, and for occupational health reports. The support network can decide if it is necessary to proceed to the next step and call a case conference or joint meeting, or if an action plan can be agreed straight away (step 8).
Step 7 Case conference joint meeting
The support network can discuss the recommendations from the occupational health assessment.
The discussions will be individual to each doctor in training, but broadly they may cover:
- An outline of the doctor's health condition or disability – to help understand the impact on their training and practice.
- Reaching a shared decision about what support to put in place to help the doctor in training overcome any obstacles.
- If the support network has any concerns about the feasibility of the recommendations in the report, they may consider raising these with the occupational health physician who completed the assessment.
- The Equality and Human Rights Commission gives advice on factors to take into account when considering what is reasonable. These factors are outlined on the panel below.
- Working together with the doctor in training is best practice to reach a reasonable, balanced and evidenced-based decision.
- The doctor in training is the best person to explain how their health condition or disability affects them day to day.
- The support network members are experts on educational and employment aspects of being a doctor in training.
The discussion could cover the different parts of training and practice, including:
- accommodation and transport
- facilities, access and equipment
- working hours and rota design
- procedures and tasks
- interaction with colleagues and patients
- care arrangements.
An action plan of how the doctor will be supported going forward can be formed from the discussions.
Panel 16: Factors to consider when deciding what support to provide
- Have we considered this case individually, about the specific doctor in training and their unique circumstances?
- Have we explored treating the doctor in training better or 'more favourably' than non-disabled people as a part of the solution?
- Is/are the proposed adjustment(s) effective in removing or reducing any disadvantage the disabled doctor in training is facing? Have we considered other adjustments or changes that can contribute?
- How easy or practical is this adjustment?
- How much does this adjustment cost? Have we considered other sources of funding like Access to Work?
- Is there advice or support available? Have we explored getting expert advice to support balanced decision making? Could we contact specialist organisations?
- Do we believe this/these adjustment(s) would increase the risks to the health and safety of anybody (the doctor, other doctors, staff, patients etc.)? If yes, have we done a proper, documented assessment of the potential risks?
Panel 17: More information on Access to Work
A worker is offered support based on their needs, which may include a grant to help cover the costs of practical support in the workplace.
An Access to Work grant can pay for items or services the doctor in training needs, including:
- adaptations to equipment
- special equipment or software
- adaptations to the doctor's vehicle so they can get to work
- taxi fares to work or a support worker if the doctor can't use public transport
- a support service if the doctor has a mental health condition – this could include counselling or job coaching
- disability awareness training for a doctor's colleagues
- the cost of moving a doctor's equipment if they change location or job, which is a part of training in medicine.
Access to work can also help assess whether the needs of a doctor in training can be met through reasonable adjustments by their employer.
Step 8 Action plan
The action plan formed by the support network will be implemented by members of the network and the doctor's employer.
The purpose of any support implemented is to help the doctor in training achieve the level of competence required by the Foundation Programme curriculum or the specialty curricula – and not to alter or reduce the standard required.
The action plan could address a number of areas where the doctor in training can be supported. Some examples are below. These are not exhaustive and if a doctor in training has an action plan it will be individual to them.
Accommodation and transport
- If the doctor is living in hospital accommodation: have reasonable adjustments been made to make it accessible?
- How is the doctor travelling to work? Have reasonable adjustments been made to help with transport (eg taxis, parking spaces)?
Facilities, access and equipment
- Are the premises and facilities accessible?
- What, if any, equipment does the doctor need to navigate the?
- What, if any, specialist equipment does the doctor need to work?
Working patterns and rota design
- Would the doctor in training benefit from working hour arrangements?
- Can the employer make adjustments to working hours (eg training less than full time, reduced or flexible hours, reduced daytime / night / weekend on-call duties)?
- The doctor could consider temporarily working in a non-training grade.
Procedures and tasks
- What, if any, procedures or tasks does the doctor need support in performing?
- What reasonable adjustments have been made for the doctor to perform these? For example, lumbar support to perform surgery or speech-to-text software to write notes.
- Can the doctor not perform certain tasks or procedures in their role?
Interaction with colleagues and patients
- Does the doctor need help in their communication with colleagues and patients?
- What reasonable adjustments have been made for the doctor? For example, an educational psychologist could support a doctor with an autism-spectrum disorder in their communication skills.
- Would the doctor benefit from increased supervisory support?
Leave and care arrangements
- What, if any, pre-arranged leave does the doctor need to attend medical appointments?
- Leave for medical appointments must not be taken out of doctors' annual leave.
- What follow-up does the doctor need from occupational health services?
It is good practice for the action plan to be developed in collaboration with the doctor on training as much as possible, and for the final action plan to be shared with them.
If there are concerns about the doctor in training demonstrating the required competences despite support, this can be handled through the educational review and Annual Review of Competence Progression (ARCP) processes. It is good practice for the support network to collaborate with the doctor's educational supervisor and members of the ARCP panel on this.
Step 9 Monitoring and review
The support network could appoint someone to be responsible for monitoring the action plan implementation, ideally a person in regular contact with the doctor in training.
There is a shared responsibility for implementing the action plan:
- The individual responsible from the support network could meet regularly with the doctor to monitor the plan, for example through a termly or annual review. This could be incorporated into existing reviews. The support network can also give a contact for the doctor in training to raise issues in case they are not happy with the support provided.
- The doctor in training should be encouraged to engage with the support process and implementation of the action plan.
Ongoing communication with the doctor in training will help understand if the reasonable adjustments and support in place are effective. The Equality and Human Rights Commission says that it may be that several adjustments are required in order to remove or reduce a range of disadvantages for a disabled person.
Disabled doctors will make an individual decision about whether they want to share any information about their health with colleagues and patients. Postgraduate education organisations may support the doctors' decision and empower them to share information if they choose to.