background, drivers, implementation

Improving Surgical TrainingBackground, Drivers, Implementation

Ian Eardley

Vice President, Royal College of Surgeons of

England

Context

Context

Loss of Autonomy

Loss of the “Effort –Reward”

relationship

Loss of Support

Structures

“Many seem condemned to

spending years rootlessly

shuffling from one place to

another like lost luggage,

buffeted about by a

promotion system that

seems to be little more than

a lottery”

Professor Sir Simon Wessely

Context

71.3%67.0%

64.4%

58.5%

52.0% 50.4%

4.6% 6.1%9.4% 11.3% 13.1% 13.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2011 2012 2013 2014 2015 2016

Entering Specialty Training Taking Career Break

What about Surgery?

The Process of Surgical Training

Under-graduate Medical Training

• 5-6 years

• Entry at 18 years

• 60% female entry

• 27 UK medical schools

Foundation Medical Training

• 2 years

• Broad based training

• Registration after first year

• All Hospitals

Core Surgical Training

• 2 years

• Broad based or Themed

• All Hospitals

Specialty Training

• 10 specialties

• 5-6 years

• Regulated

• Certification at the end

• All Hospitals

Specialist Training

• 1-3 years

• Unregulated

• Sub-specialist practice

• No formal assessment

• Specialist Hospitals



• 5-6 years





• 2 years



• All Hospitals


• 2 years


• All Hospitals

Specialty Training

• 10 specialties

• 5-6 years

• Regulated


• All Hospitals

Specialist Training

• 1-3 years

• Unregulated




Examinations



• 5-6 years





• 2 years



• All Hospitals


• 2 years


• All Hospitals

Specialty Training

• 10 specialties

• 5-6 years

• Regulated


• All Hospitals

Specialist Training

• 1-3 years

• Unregulated




Selection points

Examinations



• 5-6 years





• 2 years



• All Hospitals


• 2 years


• All Hospitals

Specialty Training

• 10 specialties

• 5-6 years

• Regulated


• All Hospitals

Specialist Training

• 1-3 years

• Unregulated




Selection points

Examinations

500-600Per annum

400-500Per annum

The Cost of Surgical Training

• Annual cost to the NHS of a surgical trainee £198,000

University Hospitals of Leicester NHS Trust

Context: GMC survey (2014)

77.1%

78.4%

81.6%

83.4%84.1% 83.8%

85.6%

88.6%

70%

75%

80%

85%

90%

Surgery Medicine Emergencymedicine

Psychiatry Ophthalmology Radiology Anaesthesia General practice

Trainee Satisfaction

Context: GMC survey (2014)

72.1%

77.2%

86.5%

60%

65%

70%

75%

80%

85%

90%

Foundation Core Specialty

Surgical Trainee Satisfaction

Background

Oct 2013

• Publication of Shape of Training Report

2014

• HEE mandated to explore options for ShOT with Royal Colleges

Jan 2015

• JCST meeting with HEE

Early 2015

• HEE agreed to support an English College led review of surgical training

Improving Surgical Training

• HEE commissioned report

• Initiated in March 2015

• Report by October 2015

• Remit of the Report

• Potential ways of improving surgical

training

• Description of potential models

• Feasibility of a pilot

• Financial modelling

• Stakeholder feedback

• Recommendations for further work

• Recommendations regarding a pilot

Evidence: An Anecdote …..

Evidence: An Anecdote ……

• Chance meeting with a core surgical trainee (urology) in the

interventional radiology suite during the last month of her 6

month attachment

• Problem

• During the 6 months, she was part of a “2 in 18” acute surgical

rota

• 5 CSTs, 6 Fellows, 7 gaps / locums

• Internal cover of gaps

• Result

• 18 days elective urology training in 6 months

The Problem

The need to be trained

The need to deliver the

service

Evidence: Full Shift Rotas ……

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

5 6 7 8 9 10

Numbers in cell

Daytime shifts

Extended days andweekends

Night time shifts

Evidence: Daytime Activities

13

15

7

86

104

106

83

16

70

9

2

26

13

11

19

13

10

4

60

53

62

103

16

30

33

34

67

16

54

19

Receiving bedside teaching

Attending formal/didactic teaching

Attending simulation teaching/training

Undertaking ward rounds

Completing discharge paperwork and admin

Other administrative tasks

Clerking and admitting new patients

In meetings (e.g. MDT, M&M)

Performing simple procedures on foundation…

Performing core surgical skills and procedures

In theatre as primary surgeon

In theatre as an assistant

In theatre observing surgery

In outpatient clinics

Undertaking audit, research or CPD

Foundation trainees

Surgical trainees

Chart 2: Mean amount of time spent during doctors’ last working shift (minutes)Base: 990 doctors in training

Foundation doctors spend significantly longer on ward rounds, paperwork and other administrative tasks, and performing simple practical procedures

Surgical trainees spend significantly longer clerking and admitting patients, performing core surgical skills, and in outpatient clinics

Time for teaching is low for both groups

Evidence: Logbook experience ……

• Appendicectomy

• E-logbook

• 2,032 core trainees

Mean Min Max

Assisting 6 0 49

Supervised scrubbed

6 0 61

Supervised unscrubbed

0 0 23

Performed 1 0 60

Trajectory of Training

0

20

40

60

80

100

120

140

160

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th

Nu

mb

er

of

pro

ced

ure

s

6 month block in ST3 - 8

Trajectory of Training - Indicative procedures

Carpal Tunnel Decompression [30]

Knee Arthroscopy & simple arthroscopicprocedures [40]Total Knee Replacement [40]

First Ray Surgery (Foot) [20]

Total Hip Replacement [40]

DHS [40]

Hemiarthroplasty hip [40]

Application of Limb External Fixator [5]

Operative Fixation of Weber B Ankle

Tension Band Wiring of Patella & Olecranon #

Intramedullary Nailing for Femoral or Tibial #

Tendon Repair [20]

Evidence: Achieved Competence

0

5

10

15

20

25

30

35

40

45

50

ST3 ST4 ST5 ST6 ST7 ST8No

. of

trai

ne

es

ob

tain

ig o

utc

om

e 4

Level of trainee when obtaining outcome 4 in TURP

Trainees obtaining 1st outcome 4

Trainees obtaining "competency"

• Review of all PBAs for

urology cohorts entering

training 2007-2009

• 3 consecutive PBAs at level

4 compatible with

competence

• Competency achieved

• At ST5 for inguino-scrotal

surgery

• At ST6 for TURP, TURBT,

Rigid URS

Conclusions

Imbalance of service and

training

Inadequate time for training

Inflexible training process

Especially in the early years of training

Main Recommendations

• Re-structuring of rotas

• Minimum of 10 in a full shift “cell”

• Use of a non-medical workforce within the on call rota at “core” trainee level

• Competence based progression with minimum and maximum duration

• Enhanced selection

• Run through progression

• Enhanced assessment and ARCP

• Enhanced training

• Time for training

• Enhanced trainer training

• “Apprenticeship” with longer attachments

• Curriculum modification

• Broader base

• Entrustable Professional Activities (EPAs)

• Embedded, enhanced simulation (boot camps)

• Surgically themed FY2

• Funded, QA, Nationally selected sub-specialist Fellowship training

Skill Acquisition

Experience

Skill Acquisition

Threshold for practice

Novice

[Advanced beginner]

Competent

Proficient

ExpertiseMastery

Who are the Extended Surgical Team?

Progress

November 2015

HEE response broadly supportive

(but not to everything)

February 2016

Development of a business case for a

pilot in General surgery

April 2016

Funding secured for pilot to

commence August 2018

Currently

Exploring with HEE the possibility of

Vascular and Urology pilots

Current Status

• General surgery• Pilot to commence 2018

• Recruit into ST1

• SAC has agreed to support “run-through” with bench-marking at ST3

• Around 80 UK posts volunteered to be part of the pilot (including all Core posts in Scotland)

• Urology• Application made to HEE for de-coupled pilot to commence 2019

• Vascular surgery• Application made to HEE for run-through pilot to commence 2019

• Trauma and Orthopaedic• Exploring possibility of a run-through pilot to commence 2019/20

Timeline

No. Milestone – Decision/Delivery Point Target Date

1 Research from RCSEng Extended Surgical Team project published April 2016

2Support obtained from NHS England and NHS Improvement to principles of service changes/new service model

June 2016

3 Draft curriculum written September 2016

4 Pilot site recruitment commences September 2016

5 Pilot sites agreed February 2017

6 GMC approve curriculum September 2017

7 Recruitment of trainees commences November 2017

8 Trainee interviews heldJanuary – February 2018

9 Trainee offers made March 2018

10 Trainee places confirmed April 2018

11 Pilot training programme commences August 2018

Project Board

Reference Group

Working Groups

Pilots Sites

Focus Groups

IST: Governance and Consultancy

Leading & decision making

Advising & quality assuring

Producing

Delivering

Informing

33

IST Project Board

34

Commissioner HEE

Senior Education & Training Policy Manager,

Andrew Matthewman

Sponsor RCS Vice President, Ian Eardley

RCS Executive Director – Learning and

Quality, Stephen Hills

Senior user HEE Postgraduate Dean Yorkshire and the

Humber, David Wilkinson

Senior supplier Chair of JCST, Bill Allum

Project manager Megan Chard

Policy support Sam Lewis

Project support Sheena MacSween

IST: Project Working Groups

Workstreams

1a. Curriculum developmentGareth Griffiths (Director ISCP)

Maria Bussey (Head ISCP)

1b. Post-certification fellowships Gareth Griffiths

1c. Assessment processes

(& ARCP review)Bill Allum (Chair JCST)

2. Recruitment and selection Bill Allum

3. Trainer education developmentLouise Goldring, (Head Education RCS)

Nic Mitchell, (Senior Education Development RCS)

4. Pilot planning IST Project Board

5. Service and wider workforce planning

Jon Lund (Chair General Surgery SAC)

Clare Sutherland (Corporate Lead for Advanced

Practice, Derby NHS FT)

6. Communications

Meg Chard (Project manager, RCS)

Will Culliford (Policy, RCS)

Lydia Taylor (Communications RCS)

7. Project administration Meg Chard

8. Project evaluation TBC

Current Status: Pilot Sites

SchoolApplication

receivedNo. Pilot sites Locations

East Midlands Yes 2 Nottingham and Derby

East of England Yes 2 Cambridge and Norwich

North East Yes 3 Gateshead, Northumbria, Newcastle

North West Yes 2 Manchester, Liverpool

Scotland Yes Multiple To be confirmed

South West (Severn) Yes 1 Gloucester

Wales Yes 4 Swansea, Cardiff, Newport

Yorkshire Yes 4 Doncaster, Hull, Sheffield, Leeds

KSS Yes 2 East Kent, Medway

West Midlands No Expression interest TBC

London Yes 6 TBC TBC

South West (Peninsula) No Possible TBC

Wessex No Possible TBC

36

Issues and Concerns

• Practicalities of a Pilot

• Acceptance that it will run side by side with “conventional training”

• Availability of the non-medical workforce

• Advanced Clinical Practitioners, Surgical care practitioners, Physician Associates

• Competence based progression

• How to do it?

• Service engagement

• Rota re-design

• Time for training

• Funding for the non-medical workforce

• Run through training

• Role and effectiveness of ARCP

• Benchmarking

• Evaluation

Summary

• Surgical training in the UK currently delivers a good

product (at the end of training)

• The process of training is inefficient, costly and (often)

demoralising

• We can do something about it!

background, drivers, implementation

Documents