training surgeons for future service requirements: asit response

7/29/2019 Training Surgeons for Future Service Requirements: ASiT Response

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Training Surgeons for Future ServiceRequirements

A response from

February 2012


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35-43 Lincolns Inn FieldsLondon WC2A 3PE

Telephone: 0207 973 0301Fax: 0207 430 9235Web: www.asit.orgEmail: [email protected]

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


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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


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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.


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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. This

lesson should not be forgotten.

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.


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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 self-

sufficient 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.

4.4 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


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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.

4.7 A consultant delivered service is expensive does not reflect that the

NHS does not have a service deliveredby but one ledby 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.

4.8 The notion that future trainees will require more training after they

have gained their CCT particularly if they wish to specialise does 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.


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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


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these skills. In a competency based system there would also be

uncertainty when they may return to their base institution.

5.5 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.

5.6 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


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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 run-

though 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 decision-

making to a local level is surely a retrograde step.

training surgeons for future service requirements: asit response

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