What is LIFT?
The Longitudinal Integrated Foundation Training (LIFT) model aims to improve clinical progress and patient-centred practice, as well as the quality of the educational experience. As opposed to receiving one 4-month block of general practice training as Foundation Year 2 trainees, LIFT trainees experience two sessions per week (1 day) in general practice throughout their two years of Foundation training. This runs alongside 4 days each week in the traditional 4-month hospital block placements, experiencing 6 other placements across the 2 year training programme. The general practitioner supervising the trainee will be the Educational Supervisor for the whole two years of training.
This model was based on the work of Professor David Hirsh (Harvard Medical School) which showed the value of longitudinal integrated clerkships. For a greater understanding of the theoretical background, please view this short youtube video.
How do trainees benefit?
Trainees have benefited from the educational support and broader clinical exposures offered by experiencing primary care at this stage, and acknowledge the benefits of having a consistent supervisor for the two-year programme.
Practical skills such as consultation skills, developing management plans, communication and administrative activity have benefited from time in the primary care environment.
What do trainers think?
Supervisors consider LIFT trainees at FY2 to be “more aware of the patient journey” and “the primary and secondary care interface” than their counterparts who are following the traditional training route. They continue to have “surpassed expectations”, possessing superior consultation and communication skills, greater understanding of medical conditions from their early development and treatment by GPs through to acute stages requiring specialist care in the hospital environment, “excellent” clinical knowledge, are more able to treat patients “holistically”, and excel at providing essential referral and hospital discharge information. They are generally “more autonomous than a traditional FY2”.
“….. [they have] reached a level of independence so to speak, that we would not normally see from our foundation trainees in the old scheme…..”
LIFT trainees now additionally have a better understanding of the roles of the wider GP practice team than others. They are aware of their colleagues’ “strengths” and when it is useful to involve them in patient care. This can include the nurses, physiotherapists, and health visitors amongst others. The team gives pastoral support as well as their supervisor(s), having now “got to know them well”, developed friendships, and often formed social as well as working relationships with colleagues.
What are the challenges?
This scheme may not be for all trainees and is tailored for trainees who are looking at a career in general practice and there is evidence that trainees who train in a LIFT scheme are more likely to continue to GP training. Acute trusts can feel that they are losing manpower in FY1 but the rotations chosen allow them to gain manpower in FY2 and HEE is working with employers to design on-call rotas, maintain experience in FY1 and manage compensatory rest.
This is a novel programme aimed at trainees planning a career in general practice. It gives trainees benefits in terms of longitudinal experience in general practice and maintains the other skills gained in Foundation training.
LIFT Feedback Form: (Placement 2)
How does a FY1 trainee differ from a GP specialist trainee?
The FY1 doctors participating in the LIFT programme are not learning to be a GP so have a different curriculum and competencies. They are not independent practitioners so need a higher level of supervision. The FY1 trainee will be present in the community setting for 2 sessions per week.
Can FY1 LIFT trainees carry out home visits?
FY1 trainees should not be doing acute home visits at the request of the patient as these are felt to be too high risk for a doctor in the early stages of their training.
What about travel expenses for foundation trainees travelling to the GP practice?
Foundation trainees are employees of the acute trust. They are entilted to claim for travel from their base hospital to their GP practice. Claims for travel can be made via the local arrangements of the employing acute trust.
Who will be the foundation trainees educational supervisor?
The GP practices involved in the LIFT scheme have agreed to undertake the education supervision instead of the employing acute trust. You will have clinical supervisors in your placements in your employing acute trust.
Can an FY1 trainee carry out acute telephone triage?
Acute telephone triage is believed to be too high risk for doctors at this stage of their training in the primary care setting. They can undertake phone calls to patients that they are involved with on a more chronic basis if the trainee and supervisor believe this is appropriate.
What is a FY1 trainee?
FY1 trainees are doctors in their first-year post graduation.
They are provisionally registered with the General Medical Council (GMC)
They are enrolled on the Foundation Programme
The Foundation Programme is of two years duration.
FY1s are working on the knowledge, skills and behaviours that they must be able to show before being eligible to apply for full registration with the GMC.
The knowledge, skills and behaviours that FY1 doctors must be able to show by the time of annual review is documented in the GMCs guidance on the principles and standards of clinical care, competence and conduct.
These expected knowledge skills and behaviours are covered by the Foundation Programme Curriculum, found at https://www.foundationprogramme.nhs.uk/content/curriculum
Full registration is granted by the GMC if the year 1 requirements are met at the time of Annual Review of Competence Progression (ARCP).
The length of time doctors are allowed to hold provisional registration is limited to a maximum of three years and 30 days.
ARCPs happen annually around June time for FY1s to allow for the timing of the GMC application process for full registration.
How is an FY1 trainee different from a GP specialist trainee?
he FY1 trainee is fundamentally different from a GP trainee.
The FY1 trainee is not learning to be a GP.
The FY1 trainees are not independent practitioners and need a high level of supervision.
The FY1 trainee needs support in gaining competencies from the Foundation Programme Curriculum; https://www.foundationprogramme.nhs.uk/content/curriculum
The GP specialist trainee is covering a different curriculum.
The aim of the longitudinal Foundation training placement in a community setting is to give the FY1 trainee a meaningful longitudinal relationship with patients and the health care team, to advance workforce transformation and promote compassionate patient-centred care.
The FY1 trainee will be in the community setting 2 sessions per week.
Who decides which doctor will come to my practice?
The Foundation teams at the employing Trusts allocate the trainees to the practices
Co-operation with the local trusts Foundation training faculty is paramount to ensure trainees are allocated to practises to match practicality and training needs/desires.
The first year of LIFT will see 18 trainees in a longitudinal training programme
What about medical defence cover?
FY1 trainees must have the appropriate level of medical defence cover. FY1 trainees will be covered by Crown indemnity as they are employed by the acute Trust. It is however, recommended by the GMC that they need to belong to a recognised defence organisation, at their own expense (this expense is tax deductible). The “minimum” defence organisations cover provides indemnity for “good Samaritan acts” and is advisable for all doctors.
Can FY1 trainee sign prescriptions or repeat prescriptions?
Prescribing in GP by FY1s is covered in the GP educational supervision document. Repeat prescriptions should not be signed by FY1 doctors.
To help with the educational need around prescribing in primary care, it is a worthy topic for an early tutorial. If you have a local friendly pharmacist, why not utilise this resource as part of your GP induction programme? It could be a way of learning how to do an effective medication review.
Can an FY1 trainee carry out acute telephone triage?
No – this is felt to be too much of a risk for doctors at this stage of training in the primary care setting. They can carry out phone calls to patients they are involved with on a more chronic basis if the trainee and trainer feel this is suitable.
Can the FY1 trainees carry out home visits?
Mindfulness should be given to the purpose and requirements of the home visit; in addition to the educational value of this visit for the trainee.
FY1 trainees should not be doing acute home visits at the request of the patient. These are felt to be too high risk for a doctor in the early stages of training
The FY1 trainee can do some carefully selected and supervised home visits if felt to be acceptable by the patient and educationally valuable for the trainee.
Home visits are not a Foundation Programme Curriculum competency.
Joint visits with a more senior practitioner can be an excellent educational experience and are the recommended method for experiencing home visits.
If a trainee does not have a car, it is possible to use public transport or walk/cycle to home visits in many practice areas.
They can carry out home visits to patients with chronic illness and those being discharged from hospital as long as there are clear objectives for this work.
What about FY1 trainees traveling?
Foundation trainees are employees of the acute trust. As such they are responsible for their own travel arrangements.
They may be eligible for a cycle to work or car share discount scheme through the trust employment benefits scheme.
If they are using their own car for travel as part of their work, it is advised that they inform their motor insurance company so that they are aware that their car is used for “business”
Travel expenses are included in the education contract with the Trusts from HEE.
Foundation trainees are entitled to claim for travel from their base hospital to their GP practice and also for any travel needed for work e.g. home visiting.
Claims for travel are made via the local arrangements of the employing acute Trust.
The rate used for mileage claims is that of the Public Transport Rate pertaining at the time.
FY1s are not required to travel with patients in ambulance services admitted from GP clinics. If doing so, they must act as observers rather than be responsible for patient care during transfer.
What about FY1 Study Leave (S/L)?
FY1 trainees are not entitled to formal S/L.
They are mandated to attend the formal Foundation Teaching Programme at the acute hospital site with their peers.
They are entitled to take up to 5 days to attend tasters in other specialities over their 2-year Foundation Programme.
The Foundation Programme Training Guide and Operational Guide details the rationale and delivery of the generic foundation teaching sessions, and study leave for F1 & F2s. https://www.foundationprogramme.nhs.uk/sites/default/files/2019-10/Found...
Study Leave and Taster Guidance are also on the YHFS website.
Professional leave for educationally viable tasks as part of professional development can be agreed between supervisor and trainee.
The Foundation Programme Director must authorise requests for S/L for taster weeks. The Foundation Programme Administrator locally will record the study leave taken.
Professional leave for educationally viable tasks as part of professional development can be agreed between supervisor and trainee.
What about FY1 Annual Leave (A/L)?
The GP placement will run longitudinally over the entire year.
It is assumed that limitations to A/L will predominantly be from rota co-ordination and acute hospital provision of staff.
The FY1 A/L will be subject to six weeks agreed notice period to allow cancellation of clinical commitment.
The FY1 trainee A/L should not be restricted by service needs of the GP practice.
What about FY1 leave other than A/L or S/L?
FY1 doctors occasionally face additional difficulties.
Support pathways for doctors with additional difficulties are well established within the local trusts Foundation programme governance systems. Transparency of information about trainees is thus paramount between faculty members of the supervising educational team.
FY1 trainees have the right to amended work duties to support their progression.
The maximum permitted absence from training, other than annual leave or study leave, during the F1 year is four weeks (or 20 days) – after which their progression may be affected.
Any additional leave should be recorded and reported to the Foundation Programme Administrator and the employing Acute Trust HR department.
Should a FY1 trainee do GP out of hours shifts?
FY1 trainees are not required to work out of hour’s shifts at GP centres. However, if this is educationally valuable and agreed by both GP clinical supervisor (for direct supervision) and trainee it is possible. European Working Time Directive (EWTD) and funding for supervision would need consideration.
What hours should an FY1 trainee work in GP?
FY1 trainees in the LIFT pilot will work 2 programmed activities (1 day) in the GP setting per week.
They must not work over 40 basic hours a week overall (including the hospital component of the training).
If shown by hours monitoring to be working over 40 hours the doctor could be entitled to financial remuneration.
The maximum of 40 hours must fall between the times of 7am-7pm Monday to Friday.
Travel time during working hours must be accounted for.
The actual timetable is able to be practice-specific within these guidelines.
Timetables of activity should be submitted to HR at the local trust for consideration and work monitoring
How does the FY1 document their progression with the Foundation Programme curriculum competencies while in GP?
Progression of competence is documented and assessed through the Horus e-portfolio
Training on Horus and required documentation will be given to both the FY1 trainee and the GP trainer.
The trainers should complete the relevant sections of the Horus e-portfolio including the structured learning events
An Educational Supervision initial induction meeting is required at the start of FY1. Educational Supervision reports are required at the end of each themed placement.
GPs can form part of the Foundation ARCP panel of reviewers but not for trainees they directly supervise.
Who are the people that will support me and my FY1 in the LIFT project?
The local GP Associate Dean would be available to give advice about educational issues in General Practice. Your local Foundation Programme faculty can tell you who this is for your area.
Each employing trust has a Foundation Programme Director and an administrator, with whom you will work closely. Details of Foundation Programme Directors and Foundation Programme Administrators can be found on HEE (North West) web site.
Has it increased applications to GP schemes in Manchester?
Yes, it has, and it hasn’t only benefited GP but other specialties too.
What was feedback from Foundation trainees who have been through the programme – what went well and what was challenging?
The most challenging of all was the rotas. Concerns such as not feeling part of the team or a part of the practices disappeared quite quickly. Another challenge was being able to track patients. There were some goals which did not work and wasn’t possible to reach. The positive is that the scheme didn’t collapse, and it has now expanded to other specialties now.
What was the feedback from GP trainers about how the training went when delivered 1 day per week?
We are unsure however we have deliberately gone down from 1 ½ days to just 1 day to minimise the impact on the manpower within the Trust.
What was the feedback from hospital supervisors about how the training went in ward-based specialties?
The feedback was that they were a bit sceptical as they were worried that trainees wouldn’t be engaged with what was going on and that they would lose contact due to being out for a day per week however, this didn’t happen and they found that FY2s in particular had experience from FY1 so they had a head start so it was overall positive from trainers.
What happens with exception reports?
Exception reports will still sit with the Trusts but would advise to make ES and HR aware of this so this can be managed appropriately.
Did the Foundation Drs contribute to on call throughout programme as per their Foundation colleagues?
We felt it was important to maintain their on-call and the trainees in Manchester wanted to keep it this way and it has worked fine.
Did the Manchester pilot have a specific requirement in terms of % attendance at GP placements?
Did any of the LIFT trainees struggle to achieve the required competencies in hospital specialties?
No, in actual fact it was noted that the LIFT trainees ePortfolio’s were better than non-LIFT trainees, but this could be down to the individuals themselves and could be unrelated to the programme.
What would happen in the event of a LTFT trainee struggling to achieve the required competencies?
There haven’t been any problems previously, this was quite the reverse but this is dependent on the individual, as oppose to the programme.
The Manchester pilot was supported by additional funding for FY1’s (LIFT 1 pilot) and Physicians Associates (LIFT 2 pilot). Is there any funding available for backfill of the Yorkshire pilot?
No, we are not doing this yet. This is cost neutral, so we do not have funding available for backfill.
FY1 LIFT pilot begins with new intake in August 2019, and involves the 6 trainees in each of the above 2 complete rotations, the first FY2 year with LIFT posts will therefore be 2020 – is this correct?
Yes, F2 LIFT doesn’t happen until 2020.
Because of the above, the FY2 year commencing August 2019 will be unchanged- is this correct?
Is the above still the pilot, and if so when is the roll out planned?
Yes, we would want to carry this forward and is something we will continue to do.
After the pilot in the NW was there an exit questionnaire and did it seem to improve GP recruitment? If not, why are we doing it?
Yes, there was an exit questionnaire.
Do the teaching GP practices know that this is on the not too distant horizon? STH couldn’t opt out, so if this programme is for overall GP benefit, why can training practices opt out?
Yes, the GP practices do know this and overall, it is a GP benefit but it can also benefit the Trust too. We asked practices who were interested / keen to come forward initially to avoid the idea of “forcing” practices to do it.
Where does the funding sit? Do GPs get any funding to train the FY1s?
The funding for FY1 LIFT is the same as for FY2 / FY2 LIFT and is outlined in the YHFS Payments Guidance
Because the trainees are only with their practices for one day per week, do GPS then absolve themselves of any ES duties which will be picked up by the Trust trainers who are down by 1 trainee for one day each week?
Yes, the GP will be the ES.
They still do the Out of Hours with the Trust, and if a zero day they don’t go to the practice-is this right and do the GPS know?
The zero days have to be equitably split in line with their attendance.
From where do they claim any additional travel expenses?
Foundation doctors should specify a base for the two-year programme, and they are then entitled to travel expenses beyond their base (not from their home to their base) however if the GP practice is closer than their base, they cannot claim. Expenses will be claimed from the Trust, and be reimbursed by HEE.
By the time study leave, annual leave, zero days, night are brought into the equation I worry that GP practices and Trust departments alike, will have little clue who to expect on which days. How will trainee movements and attendance be tracked?
There are processes in the Trust for tracking absences and the Trust will be aware what days the trainees will be at their LIFT post. It is down to the Trust to track this as the Employer.
Will HORUS be updated as for each placement there will be two CS reports, I guess?
There will be two reports to be done for the first placement but not thereafter. There is a combined ES and CS on Horus however this would not be used for LIFT trainees.
Will the LIFT trainees be able to prescribe independently?
Only when they are in FY2 – this is unchanged. FY1’s cannot prescribe independently but they should have 100% in house supervision so this should never be a problem.
Have you any suggestions as to how the timetable should look within the practice?
It should reflect a WTE timetable, but on a LTFT basis. This should be looked at the same way you would look at a LTFT trainee.
What sorts of things do you expect a LIFT trainee to do in a GP practice?
This should be the same as FY1 / FY2.
When will we find out the details of the trainee who is coming to join us, and their rota?
All current practices should have this information now. In subsequent years this will be sent with the allocation information, once allocations are completed.
Are there any requirements about numbers of assessments that should be done in primary care?
It is recommended that the LIFT trainee do more than the minimum, but we cannot enforce this but would be good practice.
Looking at the allocations, we have at least one LIFT trainee in EM from second placement in December onwards, as you know there are many ‘out of hours’ shifts in ED, particularly twilight and night shifts; I would like to know the school’s suggestion on the best way to arrange GP placements during weeks when a trainee is on a block of night or twilight shifts?
The trainees cannot be in a GP practice during the day then going on to do a twilight / night shift so would be helpful to manage this as you would if a trainee is working less than full time.
Will it be acceptable for the trainee to attend the GP placement for two days in a week when they are on day shifts and none during the night / twilight shifts? We will make sure the trainee is able to attend the required days of GP placement if this is agreed
Yes, this would be acceptable as they would not be able to do a GP practice during the day then a night shift afterwards.
Some doctors are doing locum shifts whereby it is unknown to the HR department and the HR team were not looking at what duties they were doing and think they should be aware that locums may be in breach and nobody is aware.
F1’s can only do locums within their employing trust and only at FY1 level. They are not fully registered and cannot work unsupervised. It would be very unusual for them to take on too many locums as they are very busy as F1s already.
F2’s are different because they are fully registered with the GMC and they can do other locums that are related to their training. However, FY2 should take on locums shifts only as appropriate and as long as they do not contravene their rest time. This can be seen as a probity issue in certain circumstances.
What if find that trainees are in breach of the REST guidance?
This would be unacceptable and if this happens then the trainee is to be sent straight home and the deanery as well as the TPDs need to be made aware immediately via email. If this is done while they are on their annual leave, then this would be fine.
Do the Trust not let the trainees take leave in their last 7 days of their post?
Trusts confirm that they do restrict leave in the last week for shadowing purposes but there is no concrete rule. This would be a decision for the employer, the trust, to make.