Training Surgeons for Future Service Requirements

A response from

February 2012

35-43 Lincolns Inn Fields London WC2A 3PE Telephone: 0207 973 0301 Fax: 0207 430 9235 Web: www.asit.org Email: president@asit.org Authors: Mr Goldie Khera (President) Mr James Milburn (Vice-President) Mr Joseph Shalhoub (Vice-President) Mr Edward Fitzgerald (Past President) On behalf of the ASiT Executive and Council

Contents
Section 1 Introduction p4

Section 2

Key points

p5

Section 3

Comments on the Background

p6

Section 4

Comments on Drivers for Change

p6

Section 5

Comments on Areas for Debate/ Discussion

p8

1.

Introduction

1.1

The Association of Surgeons in Training (ASiT) welcomes the review of the future of service provision within surgery by the Surgical Forum of Great Britain and Ireland and the opportunity to respond to the document, Training Surgeons for Service Requirements.

1.2

ASiT is an educational charity supporting the professional development of surgeons in training. Our association represents UK trainees from all nine surgical specialities and is one of the largest surgical professional groups with over 2,000 members.

1.3

Realising the requirements of society and the patient are the essence of our professional practice and the ultimate objective for all surgeons

1.4

The societal, fiscal, NHS organisational and political pressures leading to reconfiguration and continuing assessment have led to the best way to manage surgical practice coming under intense scrutiny.

1.5

This review is timely and ASiT acknowledges the need for consideration of how surgical practice may best fit the needs of the 21 st century patient.

1.6

However, ASiT has concerns regarding some of the recommendations of this statement and how they will impact upon current and future surgical trainees.

2.

Key Points

2.1

The role of the consultant as a skilled, independent individual providing surgical care is the best understood of all medical titles and should be maintained. ASiT believes that changes to the

consultant title without similar initiatives in all medical specialities would only worsen the publics understanding of the grades of hospital doctors.

2.2

The bulge of post-CCT (Certificate of Completion of Training) surgeons expected will not persist and there has been a reduction in international medical graduates (IMGs) arriving in the UK. This document does not consider that there will not be a large surplus of qualified surgeons in the future upon which many of the premises are built.

2.3

The current CCT permits practice of routine and emergency surgery in addition to specialist practice. Most surgeons feel that specialist skills are often acquired after CCT, often during fellowships and therefore the notion that this is a new concept is incongruent with contemporary practice.

2.4

Amalgamating the non-consultant grades with those post-CCT surgeons actively pursuing subspecialist training is detrimental to all individuals with their different goals and requirements.

2.5

The lesson from MMC was that quick, misguided workforce adjustments are disastrous for the medical profession. lesson should not be forgotten. This

2.6

We know the surgical landscape is changing rapidly. The uncertainty of the future means we must be ready and planning for uncertainty. This does not mean we should blinker ourselves to the fact that current knowledge prepares us for the future. 5

3.

Comments on the Background

3.1.

The pyramidal and apprentice models of surgical training alluded to were more relevant 10-20 years ago than in contemporary practice. They are no longer prevalent in the NHS and cannot be considered as current models of training on which to propose improvements.

4.

Comments on Drivers for Change

4.1.

Undergraduate medical places have expanded to ensure the UK is no longer dependent upon overseas recruitment, as the UK is now selfsufficient for medical graduates prior to full registration. In discussions of overseas recruitment, consideration should be given to trends of incidence not figures of prevalence. The figures in the paper reflect historical medical immigration and this is unlikely to be maintained.

4.2

Surgery is carried out by non-consultant surgeons known by a number of terms including associate specialist, staff grade, senior clinical fellow and many of these posts are held by IMGs. These posts often exist to maintain rota compliance through assisting consultants, not as autonomous professionals with their own operating lists and clinics. Many surgeons in these grades are highly skilled but few operate independently on anything but the most straight-forward cases.

4.3

There will shortly be a cohort of CCT-holders who may be unable to find jobs in the current climate. This has arisen as a result of MMC but, due to closer linking of trainee to projected consultant numbers will not continue in the long-term. A few years of a surfeit of individuals as a result of previous problems should not lead to wide-scale re-structuring of the entire training system. The notion that we are still fixed on the present trajectory in workforce planning is incongruent with the reality that there has already been significant course change in to avert this scenario persisting. This has 6

4.4

been driven by the GMC, Royal Surgical Colleges and the Centre for Workforce Intelligence (CfWI).

4.5

We disagree that the award of CCT marks the beginning of a surgical career and regard the journey as beginning in undergraduate or early postgraduate training. CCT reflects a milestone in development, along the perhaps half century of medical training. The term completion can be misleading, but attainment of competent independent practice is the principle test of a CCT.

4.6

The UK system of postgraduate training lasting 10 years leads to the acquisition of a highly trained individual. It is the envy of many developed countries and should not be eroded. Given the reduction in working hours, calls for this to be shortened may be unrealistic and indeed proposals to lengthen core training have only recently been rejected. A consultant delivered service is expensive does not reflect that the NHS does not have a service delivered by but one led by consultants. This is an important distinction as it recognises that a large proportion of service provision is not currently provided by consultants but rather by other grades. The notion that future trainees will require more training after they have gained their CCT particularly if they wish to specialise doe s not take into consideration past and current trainees undertaking fellowships to achieve this objective in many specialities. Specialist skills are therefore gained prior to appointment to a specialist role.

4.7

4.8

5.

Comments Areas for Debate/ Discussion

many surgical procedures are carried out each day in the NHS by surgeons who do not possess a CCT, which infers that the CCT as presently configured is not fit for purpose.

5.1

This

statement

seems

at

complete

odds

with

the

earlier

acknowledgement that a CCT ensures competence to operate unsupervised in the generality of their chosen speciality and provide emergency on-call cover. Some minor routine procedures may safely be performed by non-CCT holders but this does not translate to saying the current CCT is not fit for purpose or that it is not needed for general, specialist or emergency surgical practice.

5.2

Upon attainment of CCT, trainees have acquired a broad skill base and the ability to perform routine and emergency surgery. The assertion that they are too specialised may not be accurate when most will only have undertaken advanced specialist training during the final 2 years. The majority of specialities require experience in each specialist area before subspecialisation and are therefore equipped for the generality of practice.

It would make much more sense if sub-speciality skills were acquired after appointment to match the needs of the department, hospital and community where the surgeon is employed

5.3

This may be achievable locally if a senior consultant is qualified with a sufficient caseload to allow dual consultant operating and skill transfer. This is likely to be unrealistic outwith the major centres.

5.4

The surgeon is more likely to need to travel to another centre to learn these specialist skills. This would make it very difficult for employers to appoint if they were uncertain if they possessed the aptitude to develop

these skills. In a competency based system there would also be uncertainty when they may return to their base institution. Society perceives a consultant as the ultimate in trained staff which is a reflection of a long history of establishing this title. Although studies suggest many patients are uncertain of junior medical titles and roles, the role of a consultant as the named person responsible for a patient s care is well known. Any attempts to rebrand this role will confuse the publics understanding.

5.5

5.6

It must be remembered that surgeons make up a small minority of NHS medical staff. Construction of an additional grade if not consistent

across all other medical disciplines would lead to greater confusion among the public. It is very unlikely that all professions would agree to this abandonment of a uniform career progression structure.

5.7

The majority of routine work in the NHS is performed by consultants not using their specialist skills and therefore the argument that not all need to be subspecialised may be valid. However, the document only

proposes that a different title and increased salary be given to those who undergo subspecialist training. Is this not a disservice to the many skilled surgeons who are experienced and skilled but do not work in centres requiring subspecialists?

5.8

The amalgamation of the current non-consultant workforce with emerging post-CCT fellows to create a single tier between registrar and consultant has clear problems. Merging the two groups of those wishing to gain and not wishing further specialist training to bring consistency and uniformity to this role is contradictory to the expected outcomes for each group. Current non-consultant grades may not wish to take on the responsibilities of someone striving to attain specialist training and vice versa, especially in out of hours work. Many of this cohort may not wish to pursue further training for personal reasons and/or may not desire to work either full time or with requisite on-call 9

responsibilities. This would seem to immediately encourage a two tier level to this group which is at odds with the original aims of proposing this grade. This also seems in complete disagreement with the documents earlier encouragement of flexible and friendlier careers in surgery.

5.9

Currently there are calls to prolong training to compensate for reduced operative exposure. Any call to further reduce training time through shortening training will only prolong the time it takes to train either a generalist or a specialist and as a by-product will produce a trainee unable to provide a competent service to the NHS. If the duration of training is to be shortened then the structure of training must be radically altered to maximise opportunity within restricted hours.

5.10 The current broad base to surgical training through the historical Senior House Officer role and now Core Surgical Training provides the opportunity for experience in specialities with which the trainee may be unfamiliar, especially in interface disciplines. This is to be highly

commended and not withdrawn as the recent move away from runthough training has exemplified.

5.11 Frequently the term local employer is used including the governments proposed local skills networks but these proposals lose sight of national interests. Training numbers must be controlled nationally so training standards are maintained in recognised units. At what level is the local employer? In our foundation trust, region devolved state or country? Can a small foundation trust decide to train 10 ENT surgeons in specialist skills trying to become a national centre of excellence when a rival exists locally? Does this insinuate the Royal Colleges; CfWI and specialty associations have no role in assessing the future direction of national workforce numbers? This transfer of workforce decisionmaking to a local level is surely a retrograde step.

10