ASiT - the pursuit of excellence in training
at The Royal College of Surgeons
35/43 Lincoln’s Inn Fields London
WC2A 3PE www.asit.org
Telephone: 0207 869 6681
13th December 2019
Ms. Jane Cannon,
Assistant Registrar and Head of Operations, General Medical Council,
3 Hardman Street,
Surgical trainees across the UK and Republic of Ireland were profoundly disappointed with your correspondence of October 22nd, which withdrew General Medical Council (GMC) support for pre- CCT Training Interface Group (TIG) Fellowships. We are writing, as a group of representative organisations, to express our concerns and to request a reversal of this decision.
The current GMC approved TIG Fellowships in Cleft Lip and Palate Surgery, Hand Surgery, Head and Neck Surgical Oncology, Major Trauma Surgery and Oncoplastic Breast Surgery ensure the existence of a crucial subspecialist interface workforce and play a central role to supplement training programmes in plastic, breast, ENT, Maxillofacial, general and orthopaedic surgery. A new spinal TIG, due to start in 2020 will expand and advance this catalogue of excellent training and workforce development.
Pre-CCT TIG Fellowships are one of the greatest assets of UK surgical training for reasons including:
TIG Fellowships promote and deliver excellent patient care by providing structured, curriculum-based multidisciplinary training which is unique compared to other unregulated fellowships.1 For example, in Oncoplastic Breast Surgery, patients with breast cancer benefit from the expertise of surgeons that have been trained to deal with both the complexities of an oncological diagnosis alongside the need of a tailored reconstruction.2
TIG Fellowships reduce tribalism between parent surgical specialties, promote united team working and strengthen referral pathways. This is evident in Cleft Lip and Palate Surgery where TIG fellowships celebrate differing skillsets which ultimately culminates in collaborative working.3 Boosting communication and cross specialty working should be a priority to avoid isolated working patterns that do not serve the needs of the patient.
The interview processes for TIG Fellowships are fiercely competitive, which is a reflection of the fact that they are highly regarded both nationally and internationally. Indeed, the TIG scheme has been so successful that interface specialties such as Spinal Surgery, Sarcoma Surgery and Skin Cancer Surgery have recently bid to create their own interface fellowships. PLASTA surveyed UK Plastic Surgery Trainees in 2019 and 80% stated their ambition to apply for a pre-CCT TIG Fellowship.
Repositioning TIG Fellowships to a post-CCT time point has negative implications for patients, individual trainees, the overall surgical workforce and the health service.
Patients: The care offered to specific patient groups with pathology covered by a TIG fellowship will be threatened. TIGs were developed and approved, by the GMC4, to address areas where training within the parent surgical specialties was insufficient to provide the skills required to provide patient care in interface specialty areas. An example of this can be seen in Head and Neck Surgical Oncology, where the TIG Fellowships play a crucial role in this interface specialty training.5 Removing TIG Fellowships may have implications for patients with relevant conditions as competency in this area will not be guaranteed by the existing quality assured training provided.
Trainees: A post-CCT TIG Fellowship extends the duration of training for those who would meet the criteria and requirements to do it pre-CCT. Thus, removal of TIG Fellowships limit some of the flexibility in training previously promoted by the GMC - a retrograde step. The funding of such fellowships will be in jeopardy and may incur additional expense to trainees who already, personally invest £20,000-70,0006 in training. This, in turn, will limit diversity in the surgical workforce as only those from more financially secure backgrounds will be in a position to pursue this pathway.
Workforce: The interface specialties provide specialised care to a unique subset of patients but are not recognised by the GMC in their own right and therefore rely on TIG Fellowships for training and recruitment. In the absence of pre-CCT TIG Fellowships, trainees are likely to seek an alternative abroad at the point of CCT, and this will have significant implications for the retention of trained surgeons within the NHS.
We consider changes to the TIG Fellowship a further erosion of specialisation in surgery. We refute the position of the GMC Curriculum Oversight Group that a high level of specialisation is not required for a Day-1 Consultant. For example, the full gambit of skills acquired via a Trauma TIG are absolutely required by a Consultant on his or her first night on call in a major trauma centre. Trainee surgeons undergoing TIG fellowships are recruited directly into highly specialised areas, including to each of the various interface specialties, and would not be able to achieve sufficiently specialised training within the parent surgical specialty training programmes. This would leave the interface services with unmet needs and complex patients at unacceptable risk.
It is of great concern that the GMC has decided abruptly, without adequate stakeholder consultation to stop the pre-CCT TIG Fellowship scheme without designing, testing, and implementing a robust nationally funded alternative. We feel strongly that TIG fellowships should remain pre-CCT. However, if a post-CCT iteration is pursued, it must protect the foundations on which TIG Fellowships are built: a structured multidisciplinary curriculum, national appointment and national funding. Developing such an alternative will require time and careful collaboration with the JCST, ITOG Committee, interface specialty organisations, parent surgical specialty organisations, surgical trainee organisations and patient organisations.
Any proposed alternative must be trialled, appraised and validated before replacing what currently stands as an unparalleled training platform.
We are happy to engage with all stakeholders on this issue. We welcome the opportunity to meet to discuss this further and respectfully suggest that trainee representatives are offered seats at the JCST Strategic Planning Meeting and all other meetings related to this issue.
Deirdre Nally, President of the Association of Surgeons in Training (ASiT)
On Behalf of:
Rob Staruch & Matt Fell President and Vice President, Plasta
Dr Sarah Hallett Chair, BMA UK Junior Doctors Committee
Deena Harji President, Dukes‘ Club
Olivia McBride Rouleaux Club
Luke Forster Chair, BSoT Chair
Matthew Brown & Tricia Walker Outgoing and Incoming Presidents, BOTA
Mani George President, Association of Otolaryngologists in Training
Gina Weston-Petrides President, Mammary Fold
Fitzgerald JEF, Milburn JA, Khera G, Davies RSM, Hornby ST, Giddings CEB. Clinical fellowships in surgical training: Analysis of a national pan-specialty workforce survey. World J Surg. 2013;37(5):945-952.
Wyld L, Rubio IT, Kovacs T. Education and Training in Breast Cancer Surgery in Europe. Breast Care. 2019.
Drake-Lee A, Sandhu D. The future training of surgeons to manage patients with cleft lip and palate disorders. Br J Hosp Med. 2012;73(2):101-105.
Lees V, Henley M, Sandhu D. Interface specialty training in the UK. Ann R Coll Surg Engl. 2010;92:126-128.
Simo R, Robson A, Woodwards B, Niblock P, Matteucci P. Education of trainees, training and fellowships for head and neck oncologic and surgical training in the UK: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016;130(S2):S218-S221.
O’Callaghan J, Mohan HM, Sharrock A on behalf of the Council of the Association of Surgeons in Training. Cross-sectional study of the financial cost of training to the surgical trainee in the UK and Ireland BMJ Open 2017;7:e018086. doi: 10.1136/bmjopen-2017- 018086