Socioeconomic provisions for specialist training in Italy and the UK: integrating the differences

Abstract

Despite new insights on objectives, programmes, standards, curriculums and assessment of European postgraduate medical education being published all the time, few papers deal with the social situation of doctors in training across all European countries. By comparing the socioeconomic provisions for specialist training in Italy and the UK, this work identified several determinants negatively influencing the environment in which junior doctors practise. Modernisation of European postgraduate medical education can be taken forward, provided some regulation and some consistency in socioeconomic provisions for specialist training can be promoted by competent authorities across all European countries.

Italy is a major economic power, but it underachieves in research.¹ In this scenario, postgraduate medical careers for young doctors seem to be particularly problematic. Provisions for specialist training could have a key role in considerably affecting the quality of postgraduate medical education. This paper aims

• to analyse the current social situation of young doctors in Italy,

• to acknowledge the new perspectives and major changes which have occurred in Italian postgraduate medical education and

• to promote a “by student to student” debate on the socioeconomic provisions of training influencing the overall quality of European specialist training.

Method

We qualitatively compared the socioeconomic provisions for specialist training in Italy and the UK. British postgraduate medical education was selected for comparison given its promising development and its exciting modernisation of medical careers.²

Results

Supervision of postgraduate medical education and specialist training

The Postgraduate Medical Education and Training Board is the new independent statutory body responsible for overseeing and promoting the development of postgraduate medical education and training for all specialties, including general practice, across the UK.³ In Italy, medical training is the responsibility of the universities, whereas the content of training is determined by national authorities (Ministero dell' Istruzione, dell'Università e della Ricerca, Rome, Italy). Despite these common guidelines, each Italian medical school pursues a distinct approach and develops specific interests, which strongly influence the type of training offered to postgraduate students. To date, in Italy, no single independent body is responsible for adapting specialist training to the changing requirements of modern medicine and establishing standards and requirements for postgraduate medical education and training.

Socioeconomic comparison

The few Italian doctors who are appointed by cumbersome competition⁴ to a psychiatric trainee position (lasting 4 years) start working fulltime in hospitals and public services.

Despite their clinical duties, they work as students (non‐employees), according to a labour contract established in 1991. Their substantial help to the national health system is given without cover for illness, maternity or pension rights, working flexibility or banding supplements, and they have to pay professional liability insurance on their own (table 1).

Table 1 Socioeconomic characteristics of specialist training for British and Italian doctors working in hospitals and public health services.

Characteristics			UK	Italy
Doctors/100 000 people (in 2002)			212.61	618.52
Supervisors of specialist training			JCGTGP	Universities
Training–employment contracts			Yes	No
European Directives 93/16 regulating specialist training enforced			In 1996	Never
Last labour contract renewal			2004	1991
Working time directives			Yes	No
Maternity rights			Yes	No
Pension rights			Yes	No
Earnings increase with training level			Yes	No
Banding supplements			Yes	No
Flexible working			Yes	No
Sponsorships			Yes	No
Tuition fee on final year in medical school			No	Yes
COICOP Eurostat salary in 2004			143	110
(€/month adjusted for COICOP)
Training level UK	Training level Italy
PRHO	Clinical training after degree	Min	1665	0
		Max	1772	0
HO	1st‐year training	Min	1665	879
		Max	1879	879
SHO	2nd–4th‐year training	Min	2078	879
		Max	2913	879
SpR	4th–6th‐year training	Min	2322	879
		Max	3526	879

COICOP Eurostat, cost of living comparison in the European Union (data as on 1 July 2004); HO, house officer; JCGTGP, Joint Committee for Postgraduate Training of General Practitioners; PRHO, preregistration house officer; SHO, senior house officer; SpR, specialist registrar.

Even though there are remarkable differences between the British and the Italian systems, Council Directive 93/16/EEC of 5 April 1993 states the mutual recognition of diplomas, certificates and other evidence of formal qualifications.⁵ Thus, as the British General Medical Council completely recognises the specialist qualification awarded in Italy is comparable to the British qualification. Consequently, a qualitative comparison between salaries is possible after adjusting for the cost of living (using the COICOP index published by Eurostat).⁶ Young Italian doctors receive neither a salary during the clinical working year after graduation nor an increase in pay depending on training levels or hours of work (fig 1). The ratio of the maximum British salary to the Italian scholarship ranges from 2:1 at house officer level (first year of training), to 3:1 at senior house officer level (2nd–4th year of training), and up to 4:1 at specialist registrar level (4th–6th year of training).

Figure 1 Monthly salary for doctors in training, adjusted for cost of living. HO, house officer; PRHO, preregistration house officer; SHO, senior house officer; SpR, specialist registrar.

Discussion

At undergraduate level, a medical career in Italy are still attractive. In fact, the proportion of doctors graduating per 100 000 citizens in Italy and the UK, respectively, are the highest and the lowest in advanced European countries.⁷ There are various reasons for this, including a strong altruistic culture in Italy, which fosters interest in medical careers. Despite the healthy status of undergraduate medical education, when compared with the UK, postgraduate specialist training is undermined by socioeconomic disadvantage and seems to be particularly problematic. The magnitude of such differences has forced the Italian government to enforce European directives,⁸ leading to new encouraging perspectives for junior doctors. Thus, in the 2006–7 Finance Act, some changes in the socioeconomic provisions for medical trainees are planned as follows: training–employment contracts, maternity rights, partial pension rights and a small salary increase.⁹ Further beneficial interventions would be: (1) research trainee schemes, (2) continuing professional development, (3) clinical audit, (4) sponsorship of specialist training and (5) better synergy and connections between national health bodies and professional education systems. At the international level, postgraduate medical training in the European Union should be supervised and certified by a common European board to ensure that common standards and requirements are met, and to develop and promote postgraduate medical education and training across European countries. In line with this, tentative contacts are taking place between Italy and the UK concening collaboration on postgraduate specialist training. A practical example is the long‐term partnership agreement between the South Essex Partnership Trust, UK, and the University of Pavia, Pavia, Italy, which includes recruiting and inducting junior doctors in Italy and promoting their professional development. We believe that such exchanges will increase international understanding, generate new ideas and contribute to overcoming cultural, clinical and socioeconomic differences in postgraduate medical education between countries such as Italy and the UK.

Conclusions

Socioeconomic differences between different types of European specialist medical training affect the quality of clinical work, undermine the quality of education, reduce creativity, weaken ideals and obscure the ethical principles inspiring healthcare.¹⁰ Currently, Italian junior doctors are going through a transitional period in which major changes are in force to standardise the provision of medical training at the European level. We believe that by creating opportunities for discussion concerning the social situation of junior doctors in training, we can help lessen the differences and harmonise the quality of postgraduate medical education in European countries.

Learning points

Questions to debate:

• Is the social situation of doctors undergoing specialist training (specialisation) standardised and satisfactory across all European countries?

• Which authority should be responsible for designing the training content and for supervising the specialist training: the national medical association, professional societies, universities or the state?

• Should postgraduate medical training in the European Union be supervised and certified by a common European board?

Abbreviations

COICOP - cost of living comparison in the European Union