Paper C
Health Education East Midlands - Governing Body
Supporting service transformation with changing education and training models;
funding considerations
Purpose of this paper
The Governing Body is asked to consider the recommendations for investment
priorities if there are unfilled medical training posts in the next financial year.
Why is it important?
It is important that the Governing Body agrees on priorities for investment as early
and proactive planning is needed to ensure any benefits in investment e.g. for
fellowships are optimised, as successful recruitment into innovative training posts is
dependent on the early advertising of these posts.
How it links to our strategic priorities
This paper links to our Medical workforce priority, to HEE’s Mandate, to the 5 Year
Forward View, the 10 point plan for primary care and HEE’s workforce strategy.
What are the implications/options/possibilities/risks/consequences/impacts?
There are risks to the provision of both current and future healthcare services if our
medical workforce intentions are not met. HEEM is also required to deliver against
the submitted workforce plan. Proactive management of possible gaps will mitigate
against the risks and provide clarity for local providers and CCGs on how HEEM will
address workforce issues.
Suggested resolution
The Governing Body is asked to approve the recommendations in this paper.
Professor Sheona Macleod
Postgraduate Dean HEEM
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Health Education East Midlands - Governing Body
Supporting service transformation with changing education and training models;
funding considerations
Executive Summary
The Governing Body is asked to consider the priorities for medical training investment in the next
year. Early and proactive planning is important to enable benefits to be optimised, recognising that:
 the agreed investment plan has been submitted to HEE based on provider plans collated by
each of the 5 workforce teams and on the anticipated medical training numbers required for
the future workforce.
 investment in innovative opportunities for medical trainees requires early proactive planning
to attract high quality candidates. Successful recruitment into innovative training
fellowships is dependent on us advertising these posts early as offers for training posts are
being made now.
 Some gaps in medical recruitment can be anticipated. In considering how best to invest
resulting underspend it is important to consider the area of workforce that this underspend
was generated from, to ensure we act to mitigate against the risk of inadequate workforce
supply in that area. The especially relates to general practice training.
 During the year slippage can create projected underspends in medical trainee investment
and provide opportunities for reinvestment.
 the amount of flexible funding is small and it important that we confirm our view on
priorities
The mandate is clear about the need to increase General Practice numbers and the 5 year forward
view (5YFV)and Building the Workforce – the New Deal for General Practice, the 10 point plan set
the direction for future delivery of care and for investment in General Practice.
The 5YFV also sets the direction for delivering care across traditional boundaries. This will mean
changes to training, to enable healthcare professionals to work in a different way, to enable service
change, and by moving training placements into the community, to support the transformation
agenda.
This paper is to enable the governing body to consider the principles for investment in medical
training and reinvestment of medical training underspend at the start of the year, to ensure the
greatest benefit from any reinvestment.
Proposals;
1 general practice
As it is likely that the East Midlands will not fully fill its GP training places for August 2015, at a time
when the region is already feeling the effects of insufficient numbers of GPs across the system. In
order to develop capacity in primary care, and to provide more GPs for the future, it is proposed that
for any GP training related underspend;
 Trusts continue to receive the funding for the GP training posts that they provide and that
these are advertised and recruited to as part of the pre-specialty training (GP) initiative,
which is being led by HEEM.
 Some of the Trust placements are used for after qualification (post-CCT) fellowships to
attract new GPs into the area and retain the region’s newly qualified GP workforce.
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Additional post CCT fellowships are created to attract and retain newly qualified GPs. These
will link with clinical commissioning and CCGs, medical education, leadership, frailty,
emergency care, and the third sector.
Support is provided with NHS England for the induction of international doctors new to the
NHS, and those returning from abroad or from a period out practice. This support would
assist us to both deliver the newly re-launched Induction and Refresher scheme and allow
the development of initiatives which might provide greater attractiveness to East Midlands
over other areas.
There is investment to support further development of practice nurses and the wider
primary care team.
Investment in the development of training infrastructure to improve education and training
in general practice across the region for undergraduate and postgraduate medical learners,
and the wider primary care workforce, is considered.
Specialty training
 Where there is likely under recruitment in medical training posts, it is proposed that;
o Funding remains with the Trusts. Those Trusts affected work with HEEM to create
attractive Fellowship posts rather than a locum for service (LAT). LAT posts are not
being sustained longer term, and fellowships can help address the challenge of
providing a future workforce in these specialties. There is some additional
investment required eg for attaining additional qualifications
o This informs workforce planning and investment in the alternative wider workforce,
as a multi professional solution will enhance sustainability.
 The planned investment in integrated training is used to create Fellowship posts to support
the transformation agenda in each LETC, to enable training to support a change in service,
without destabilising acute services.
 Fellowship posts support the transition of specialty training into the community as cross
organisational / integrated training posts for trainees are created. They would be based
mainly in the community with continued learning and contribution to service in the acute
setting. Gaining training approval for these placements would then enable the training
numbers and the trainees in the acute setting to shift over time, with appropriate workforce
planning.
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Health Education East Midlands - Governing Body
Supporting service transformation through changing education and training
models; funding considerations
Introduction
The health needs of the population within the UK have changed considerably since the foundation of
the Health Service, and will continue to change for the foreseeable future. There is now wide
acceptance that NHS services will need to change in order to provide appropriate care, including a
greater integration across all NHS systems and into social care. The Five Year Forward View clearly
signals that this is required.
HEE’s role, to ensure that the right workforce, with the right knowledge skills and attitudes is there
where it is needed to provide patient care, is key to enabling this service change.
The training of health care staff needs to evolve, both in preparation for the changed future service
provision and in response to the recognised failings highlighted by Sir Robert’s Francis and the advice
of Don Berwick. The Shape of Training review has signalled the direction of travel for postgraduate
medicine and the Shape of Caring review will guide future nursing education and training.
In HEEM we are actively exploring how best to adapt the current education and training of
healthcare staff, in order to deliver the future workforce that the East Midlands requires. All the
indications are for a more community focussed health service for the future, which provides the
opportunity to transform our current training to the desired future state, where the healthcare
workforce is increasingly trained across traditional boundaries.
There is only a limited amount of funding and much of how we ‘cut the cake’ is already defined by
national tariff for the current trainee workforce and benchmark price for education commissions.
Because the amount of flexible funding is small it is important that we are clear on the priorities for
spend so we maximise the benefits of any investment.
Investment planning
The investment plan has been submitted, this is based on provider plans collated by each of the 5
workforce teams.
This includes
 the planned spending on education commissions for non-medical training in our local HEI’s
 the SIFT spending on undergraduate medical education,
 investment in postgraduate medical training placements
The planned spend on medical training is based on;
 intake to replace the trainees leaving the training programme. This maintains a steady
output of CCT holders and to support service
 Increases or decreases in the intake based on workforce planning intelligence gathered in
the region
Changes in the medical numbers within the investment plan can affect the quality of training and
service, unless these have been effectively planned for.
The plans have been reviewed by central HEE and are aligned with the national workforce plan.
During the year there will be gaps in medical recruitment, some of which can be anticipated. When
these gaps are in specialty training or hospital posts for GP training, this leaves a gap in current
service and in the future workforce provision. Funding for these currently remains in the Trust.
When the placements are in General Practice, there will be slippage on the investment plan.
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It is important to consider the area of future workforce that any underspend results from, to ensure
we act to mitigate against the risk of inadequate workforce supply in that area. The especially relates
to general practice training.
1 General Practice
There are not sufficient numbers of junior doctors being attracted into GP training. The reasons are
multifactorial and this especially affects HEEM. The East Midlands is already feeling the effects of
there being too few GPs.
Building the Workforce, the New Deal for General Practice, the 10 point plan gives a clear direction
for investment some of which is the responsibility of HEE and some of NHS England. It focuses on
three areas, Recruit, Retain and Return
Recruit
1 Promoting general practice
2 Improving the breath of training
HEE and partners resource an additional year of post CCT training where it is hard to recruit trainees.
3 Training Hubs -pilot training hubs.
4 Targeted support
.Retain
5 Investment in retainer schemes
6 Improving the training capacity in general practice
7 Incentives to remain in practice
8 New ways of working
NHSE HEE and others identify key workforce initiatives to support general practice
Return
9 Easy return to practice
HEE and NHS England will publish a new induction and returner scheme, ,
10 Targeted investment in returners
*HEE responsibilities in Bold
It is likely that the East Midlands will not fully fill its GP training places for August 2015.
In order to provide more GPs for the future, it is proposed that Trusts continue to receive the
funding for the GP training posts that they provide and that these are advertised and recruited to as
part of the pre-specialty training (GP) initiative, which is being led by HEEM. This is being advertised
now and it is anticipated much greater interest than last year when the posts were advertised much
later on in recruitment.
Some of the placements could also be used for post- CCT fellowships to attract new GPs into the
area and retain the newly qualified GP workforce. In line with the 10 point plans it is proposed that
additional post CCT fellowships are created to attract and retain newly qualified GPs linking to
clinical commissioning, medical education, leadership, frailty, emergency care, working with trusts,
CCG’s and the third sector. Successful recruitment into pre-specialty training and post CCT
fellowships is dependent on us advertising these posts early. Offers for training posts are being
made now.
Post CCT fellowship proposals are in appendix 1
HEE will also support the induction of international doctors new to the NHS and those returning
from abroad or from a period out practice. This support would assist us to both deliver the newly relaunched Induction and Refresher scheme and allow the development of initiatives which might
provide greater attractiveness to East Midlands over other areas.
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HEEM continues to support the successful East Midlands retainee scheme which allows GPs to be
supported in limited part-time work when they would otherwise stop working because of personal
priorities.
There is a recognition that mainly secondary care based training for medical students and
foundation training is likely to be contributing to this. Both local medical schools are working to
address this.
There are also a high number of students leaving the area after graduating and work with local
communities and medical schools should focus on widening participation and encouraging local
application.
Recommendations
 Unfilled hospital GP training posts are advertised as Pre Specialty Training (GP) posts or
used as part of post CCT fellowships.
 Additional post CCT fellowships are created and funded to attract and retain newly
qualified GPs.
 There is support for the induction of international doctors new to the NHS and those
returning from abroad or from a period out practice.
 There is investment to support the development of practice nurses and the wider primary
care team and the development of a community infrastructure to support training for
general practice and community care (Community Education Provider Networks), managed
through the Primary Medical Services steering board.
Community based training in Postgraduate medical specialties
One of the main issues in carrying out transformation is that current medical training is not only
mostly based in secondary care but also contributing to the delivery of care in that setting.
The region has, for historic reasons, less training places per head of population than most other
regions and the increasingly frequent gaps in training rotations, compounded by recruitment issues
in some specialties, has resulted in significant pressures on postgraduate trainees.
However, our current model of mainly secondary care based training is not preparing the future
medical workforce for the kind of cross boundary working that will be required in the future.
Although it is relatively easy to redesign training placements to address this, that would require a
reduction of the number of medical trainees in the acute setting.
Workforce planning information, both regional and national, suggests that an increase in training
numbers in some specialties in the region, at the expense of other regions may be sensible.
However despite accepting we may be over producing doctors in some specialties, it will take time
for HEE to alter training numbers, as services depend heavily on the training workforce.
The investment plan for the next year has included funding some ‘integrated’ training opportunities
working across boundaries, including across primary, community and secondary care to enable us to
move trainees into the community to support the transformation agenda and to provide a more
community based future workforce.
Investment is required to attract doctors to fellowship training by providing added value incentives
eg certificates in leadership of Quality Improvement, as well as funding placements.
Creating innovative training placements in line with transformation plans will allow earlier
placements of trainees and support the development of plans to deliver services differently. HEEM
will pilot how future training could work and support medical students and junior doctors to have
increased exposure to community care, helping influence career intentions.
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There are a number of specialties where this could benefit current training quality, and the specialty
schools have offered to pilot innovative training places, which sit across traditional primary care
secondary care boundaries.
It is our intention to develop a selection of different posts to offer new opportunities for our junior
doctors. Some of these would involve working in the acute setting, e.g. Contributing to the acute
take, as well as in the community, seeing patients there and managing their care.
Integrated training placement
For specialty trainees eg in medicine looking after patients with diabetes or
rheumatological conditions, where much of the care is better suited to the
community, would work in community settings some of the time, returning to the
acute setting for case review and for continued involvement in on call. This would
allow maintenance of acute specialty skills, while developing confidence to work
both across the acute and community setting.
Trainees in Primary Care could, at the end of their three year placement, work part
time in a practice and/or an out of hours centre, while attending community clinics
in diabetes or rheumatology to become a GP with a special interest (GPwSI).
Additionally both could have a remit to increase the education of staff about the
management of diabetes or rheumatology within the practice or CCG
There is also a planned reduction in the number of locum for training (LATs) posts that will exist in
the system over the next couple of years and fellowships will be created in collaboration with Trusts
to cover these.
Recommendations
 When there is specialty under-recruitment, funding remains with the trust but there is
investment in and collaboration with HEEM to create attractive Fellowship posts rather
than a locum for service,, which helps address the challenge of providing a future
workforce in these specialties.
 Investment in new Fellowship posts supports the transition of more specialty training into
the community.
 Investment in new Fellowship posts is used to support the transformation agenda in each
LETC.
3 Undergraduate Medical education and Clinical education and training
The career expectations and desires of medical students do not currently appear to match the future
workforce needs. Medical student training still occurs mainly in secondary care, despite the fact that
many of patients are no longer cared for in that setting. Greater exposure to community based care
is required, in order to increase the awareness of, and recruitment to General Practice and
community based specialties. Currently both the Medical Schools in the East Midlands are reviewing
their student curriculum and placements.
With the move to increased care in the community, opportunities for further development of the
skills of community practitioners in specialised areas will be needed.
Increased training placements will be required for undergraduate nursing, midwifery and allied
healthcare professionals in the community.
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Consideration should be given to the effective development of new workforce groups such as
Physician’s Associates and Advanced Care Practitioners, who will play an increasing role.
Addressing these challenges also provides the opportunity for greater inter-professional and multiprofessional learning opportunities. Training placements in postgraduate and undergraduate
medicine across primary and secondary care, will be most effective at creating future integrated
thinking, if they also link to undergraduate and postgraduate non-medical training across both
settings.
.
Recommendation
New postgraduate placements, as described above, should be developed in line with opportunities
to increase the capacity for teaching undergraduates in both medicine and other healthcare
careers. Investment should support the development of a training infrastructure that will improve
general practice across the region for both undergraduate and postgraduate medical education,
and the wider workforce
The Primary Medical Services steering board reviews;
 the post CCT fellowship initiatives taking into account training capability and quality,
service requirements from regional transformation plans, CCG proposals and proposed
service changes
 suitable community providers encouraging them to plan for future placements from the
postgraduate specialty schools, Medical schools, and HEIs.
Future plans
Pat Oakley’s work with HEEM, which started with an ‘agenda setting’ meeting on the 5th February,
will help focus activity on ensuring we have the medical workforce we require.
The 5 development goals identified are:
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providing excellent training places, supervisors and clinical tutors, and trainee support so
that junior doctors feel East Midlands is a “place of arrival” for both their training and career
development;
supporting hard-pressed recruitment areas with joint training posts and rotations so that
Trusts and GP practices which can recruit trainees help those in trouble;
developing innovative training posts which further the development of care in the
community;
recognising centers of practice innovation and supporting their networks to other centers
outside East Midlands so that trainees feel they are in a “happening place” as they develop
their post-graduate careers locally;
working with the East Midlands’ county councils and local authorities to develop a long-term
strategy to funnel bright school children to the region’s universities and to brand the region
as a “place of arrival”.
The workforce planning cycle this year will focus on integrating medical and ‘non- medical’
workforce planning.
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Funding implications
Total GP training budget in LDAs with Trusts
£10m
Total budget for GP Practices for training
£28m
Total number of GP trainees
708 (within practice and hospital)
Total foundation training budget going into trusts
£29m
The total number of foundation posts
990
Total specialty training budget going into trusts
£67m,
Total specialty training posts
2005
The estimated cost for fellowships next year
£1.753m plus non pay costs.
Costs below for post CCT GP fellowships, transformation fellows and cross boundary integrated care
fellowships
Grade
No of
Posts
2015/16
(8
months)
£
2016/17
(12
months)
£
2017/18
(4
Programme
months) Total Cost
£
£
Post CCT GP
Fellowships for
2 years
ST4
30
539,280
808,920
Integrated Care
Fellowships to
allow a gradual
movement of
specialty
training posts
ST4
30
898,800
449,400
1,348,200
ST5
10
315,187
157,593
472,780
1,753,267
1,415,913
Transformation
Fellows; to
support service
transformation
programmes
269,640
269,640
1,617,840
3,438,820
If we only recruit 200 GP trainees from August 2015 (instead of 280) this will lead to an under spend
of £1.1m against the GP training budget next year.
Post CCT fellowships could be funded 3 days per week with the other 2 days funded by other sources
(CCG/ Trust/ Medical School) for a 2 year fellowship programme
We have £1.75m earmarked for fellowships programmes for cross specialty fellowships to develop
straining and allow gradual movement of some existing specialty training posts.
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The Governing Body is asked to;
approve the recommendations in this paper.
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Unfilled hospital GP training posts are advertised as Pre Specialty Training (GP) posts or
used as part of post CCT fellowships.
Additional post CCT fellowships are created and funded to attract and retain newly
qualified GPs.
There is support for the induction of international doctors new to the NHS and those
returning from abroad or from a period out practice.
There is investment to support the development of practice nurses and the wider primary
care team and the development of a community infrastructure to support training for
general practice and community care (Community Education Provider Networks),
When there is specialty under-recruitment, funding remains with the trust but there is
investment in and collaboration with HEEM to create attractive Fellowship posts, to help
address the challenge of providing a future workforce in these specialties.
Investment in new Fellowship posts is used to support the transformation agenda in each
LETC.
Investment in new Fellowship posts supports a gradual transition of specialty training into
the community.
The primary care group reviews the post CCT fellowship initiatives taking into account
training capability and quality, service requirements from regional transformation plans,
CCG proposals and proposed service change.
New postgraduate placements, as described above, should be developed in line with
opportunities to increase the capacity for teaching undergraduates in both medicine and
other healthcare careers.
Professor Sheona Macleod
Postgraduate Dean HEEM
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Appendix 1 Primary Care Fellowship Proposals
This document is summary of the current position with regard to Primary Care Fellowships. The
embedded documents are of suggested fellowships drafted by a variety of interested parties based
on a simple template which include some basic person specifications.
The basic outline for Primary Care Fellows is as follows
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Post CCT
1 year full time contract (10 sessions) held by practice/LMC/CCG as agreed
2-2.5 days spent in practice as salaried doctor funded by practice
1.5 to 2 days delivering an “activity” (see below) This may be funded by HEEM or by other
organisations e.g. CCG
1- 1.5 days Educational activity e.g. postgraduate certificate related to topic of activity
funded by HEEM
Academic support via institution of educational activity
Overall support for other issues via an Associate postgraduate dean and programme director
With funding the preferred model would be
 Post CCT
 2 year full time contract
 2-2.5 days in practice as above
 1.5-2 days delivering activity
 1-1.5 Education to Masters level
Activity type
Aims/Project outline
Clinical – diabetes management Improve management of complex diabetes in the
community
Respond to challenges of diabetes in the Asian population
Managing diabetes in an impoverished population
This was a suggestion for Leicestershire as it has an
Academic Community Diabetes Centre but they have
indicated the CCGs would be unwilling to part fund, so we
would have to examine what value this represents against
other areas where CCGs may part fund.
Educational1
Post CCT Fellowship programme – Medical Education
Quality improvement
This is written as supporting GP training but could work
equally well in the context of a CPEN and multi-professional
teaching
Primary Care QI Fellow Draft – OH edit
This is a very generic model that could work in a variety of
settings and shares many attributes of the transformational
model below
1
One year proposal could be extended to 2 to enable MA Med Ed. Educational remit can be multi-professional
to support PCEN.
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Transformational working – care
in the community
Educational - Rural Track
Educational Research– early
intervention support
Clinical – frail elderly care
Clinical – remote frail elderly
Clinical –frail elderly nursing
homes
Proposed timetable for Post CCT Fellowship
This would be working with CCGs, gaining a better
understanding of how they work and looking at leadership
as academic component.
UoN is developing a “Rural track” module which will enable
high quality teaching to occur in Lincolnshire.
Fellowships will support development of the practices to
allow a positive educational environment
The LETB is supporting a project called “Perfect Day” using
an intervention for GP trainees to try and improve
performance early in training to improve number of
trainees completing in standard three year programme.
The educational fellow would help to deliver the
intervention and assist with its evaluation.
Hardwick fellowship proposal
Area of the Lincolnshire coastline and North Lincolnshire
have a highly deprived ageing population with significant
co-morbidity and recruitment issues. This fellowship would
look at developing the care of frail elderly using a multiprofessional model around RCGP model of “Patientcentred Care” which increases the ability of patients to
manage their own health problems.
Significant and increasing pressures on hospital services
have been encountered despite the successful
implementation of a variety of admission avoidance
schemes. These fellowships would focus on education of
practice and nursing home staff using the RCGP model of
“Patient –centred Care” to develop meaningful care
planning, including end-of-life management to decrease risk
of recurrent/inappropriate admission.
Moving forward
There are a variety of submissions which are worth considering both in their specifics and in their
general outlines which could be offered to other parts of East Midlands.
If funding is agreed we will send out to all areas for expressions of interest using the basic models
above asking for projects and contact details for interested “host” practices and organisations.
We will then offer 6 QI fellowships where we have worked to develop a number of projects of
relevance to different localities so the potential fellow will be able to choose where they want to be
plus choose what interests them.
Many areas have the same issues and may differ in detail but they are essentially the same in
content. eg the Lincolnshire& Northamptonshire frail elderly and the Hardwicke frail elderly
proposals
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With a “library” of posts then we can start a recruitment process that can then match successful
candidates to posts with three elements
 The practices
 The projects/secondary activity
 The academic qualification
In order to ensure these are supportive environments, we would propose confining these to training
practices, members of a PCEN, or other recognised training environments.
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Appendix 2: Proposals for integrated (secondary care) fellowships
Introduction
The HEEM integrated secondary care Fellowship Programme are designed to afford doctors in
training in the region a range of development opportunities that are fully integrated with their
clinical training. They allow junior doctors training in secondary care to experience practising their
specialty in primary and community care settings. HEEM fellows can also obtain a Post Graduate
Qualification and additional competencies beyond their speciality curriculum.
HEEM has a track record of supporting the provision of diverse fellowship opportunities as have
many of the Trusts in the East Midlands.
Programmes and Posts
From 2015 HEEM will expand the range of Fellowships offered across training programmes in the
East Midlands focussing on different areas of development.
These include:
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Medical Education and Medical Leadership and Management Programme–Development of
HEEM academic pathways for both with 1 and 2 year fellowship opportunities intercalated
with clinical training and opportunity to gain a higher qualification in the course of the
fellowship.
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Quality Improvement Fellowship Programme -The introduction of a network of 1 year
Quality Improvement Fellowships for medical trainees working across the East Midlands.
Local Education Providers will host the Fellows ,identifying a sponsor (Medical /Clinical
Director or Chief Executive level) who will provide an initial shadowing period ,ongoing
support and mentoring throughout the course of the Fellowship including identification of a
suitable trust Quality Improvement project.
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Some projects focus on high quality care for older people including those with dementia,
reducing avoidable admissions and preventing unnecessary hospital stays.
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Trainees will work towards a higher qualification in the course of the Fellowship.
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Quality Improvement Fellows will be working at CT/ST2 or above and progressing
satisfactorily through Speciality Training
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Quality Improvement Fellows will continue in speciality training for 50% during the 12
month period and work as a QI Fellow for the remaining 50% of the time.
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Some specific frailty projects for specialities aligned to improve the quality of training in
health care of the elderly for a wide range of training programmes. These will pave the way
for better training for doctors in the care of older patients with multiple co morbidities to
improve patient outcomes.
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One year clinical fellowships for trainees who have completed core training and wish to
develop enhanced competencies in the care of older people before entering higher
speciality training.
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One year Out of Programme (OOP) opportunities for NTN holders to equip these doctors to
care more effectively for an ageing population.
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Fellowships in Psychiatry are being developed by the Specialty School with Local Education
Providers to attract ,retain and develop trainees working in this hard to recruit to
programme. These include fellowships which are part of a regional network of
undergraduate and postgraduate teaching posts in psychiatry and fellowships for Post CCT
GP training in mental health. Integrated practice opportunities for speciality trainees in
psychiatry include those in emergency and liaison psychiatry, neurodevelopmental
psychiatry, primary mental healthcare and eating disorders.
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In Emergency Medicine a programme of Intercalated Fellowships are being developed as pre
ACCS training for those doctors who may wish to explore working in Emergency Medicine
after Foundation Training to inform their future career intentions.
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Post CCT fellowships can develop doctors with specific capabilities to meet a future medical
workforce need in the East Midlands. For example, a post CCT fellow in heart failure and
palliative medicine to improve training in the community for both GP and secondary care
trainees in cardiology.
Examples of the opportunities and experiences gained by current and past fellows are
illustrated below:
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