18th June 2019
Dear Prof. Sheona McLeod and Dr. Paul Sadler,
Improving Surgical Training
The Association of Surgeons in Training (ASiT) and the British Orthopaedic Trainees Association (BOTA) are independent professional organisations that work to promote excellence in surgical training for the benefit of both surgeons and patients. In light of our shared commitment to surgical excellence we write this joint letter in response to the Higher Education England (HEE) ‘Improving Surgical Training’ (IST) correspondence dated the 30th April 2019.
The original aims of IST were welcomed by ASiT and BOTA.1 We support a programme which increases contact time between trainer and trainee, improves the balance between training and service provision, increases training opportunities and provides additional support to surgical trainees and their trainers. Despite documented concerns regarding the progression of surgical trainees and the need for additional resources, we supported the introduction of a pilot scheme.2 ASiT and BOTA also agreed for additional subspecialties to join the general surgery pilot, however only after a formal independent evaluation had taken place.
The communication by HEE on the 30th April 2019 stated that the IST pilot will expand to include 75% of Core Surgery posts by 2021 and 100% by 2022. The statement was sent to multiple stakeholders, including HEE Regional Directors, English Deans, Directors of Medical Education and Surgery Head of Schools. It is disappointing that our organisations were neither consulted in this decision nor included in this communication.
At present, we cannot support the expansion of the IST programme as outlined by HEE. We have concerns regarding the delay in the independent review process, inadequate resourcing, a dilution of the original objectives, and the progression of surgical trainees.
1. Independent external review
Excellent training and safe patient care should be maintained and this can only be ensured by a broad, comprehensive and independent review process. The need for a formal evaluation of the pilot was agreed by all parties at the introduction of the IST pilot. Stakeholders, including our organisations, were assured that an independent review process would identify and address any limitations or concerns and ensure that the objectives were being achieved.2
HEE now states that the full review will not report until 2021. This is not acceptable as 75% of trainees will have been enrolled onto the programme by this time. IST no longer constitutes a pilot and is set to expand regardless of external review. Premature expansion might negatively impact the engagement of stakeholders with detrimental consequences for the programme.
2. Resourcing and implications for the training environment
The value of the IST programme lies in the vision for an enhanced training environment and additional trainer support. Whilst some of the pilot sites have succeeded in implementing the necessary requirements, research completed by ASiT has demonstrated some pilot sites to be less successful: up to 45% of IST trainees surveyed have a call frequency more than 1 in 7, 53% have expressed dissatisfaction in the balance between service provision and training and 42% receive protected and structured teaching from consultant trainer once per month or less. Thus, expanding from a small-scale pilot to full implementation will require additional resources far beyond that detailed.
We are disappointed that the original objectives and scope of the IST programme have been reduced in both scale and ambition. Trainer programmed activities (PAs) are to be reduced by
half to 0.25 and more onerous on-call rotas are to be permitted, resulting in reduced trainer-trainee contact and reduced daytime training opportunities. The rushed expansion represents a rebranding of early years surgical training without meaningful improvements in the delivery of training or the training environment. A once in a generation opportunity to transform surgical training and prioritise training over service provision is being missed.
3. Progression through stages of training
The lack of clarity regarding progression through to Higher Surgical Training is of further concern. The processes for benchmarking at ST3 have not been adequately defined or tested. The balance between ‘uncoupled’ and ‘run-through’ training posts and the number of ST1 and ST3 positions requires careful planning and must not disadvantage trainees or create a two-tier training system. Our concern is that the proposed system may exclude trainees who get caught between core and Higher Surgical Training schemes or limit the opportunities available in specific deaneries. We support a scheme that will offer training opportunities and flexibility to undecided trainees, providing them with the experience to make an informed decision regarding their specialty of interest. We believe the optimal endpoint to be a ‘mixed economy’ offering both run through and decoupled training pathways.
For the reasons outlined above, we request for the recently announced expansion of the IST programme to be halted with immediate effect. In addition, we request that all stakeholders be afforded a role in future decision-making and planning. For example, the objectives and scope of the independent review must be agreed collectively from the outset.
Pending the results of the independent review, we request a robust plan for the structure of posts, progression criteria and programme funding. Annual ‘waypoint reviews’ must be implemented with all stakeholders (including ASiT, BOTA and the surgical Colleges) being consulted and presented with independent review data. In addition to halting the planned expansion, we request for the first waypoint review to report later this year, one year following the first IST cohort. These stakeholder reviews must enable the objectives and scope of IST to be critiqued and amended as required.
The surgical Colleges and trainee organisations have worked hard to support the IST programme. It is essential that IST delivers tangible improvements in the quality of surgical training, with
workforce morale, staff retention and patient care dependent on its success. This valuable opportunity to reform and improve surgical training cannot be wasted. All stakeholders are motivated to improve the provision of training and our organisations hope to work collaboratively with HEE to realise these aims once acceptable review and quality assurance processes are agreed.
1. Royal College of Surgeons of England. Improving Surgical Training: Proposal for a Pilot Surgical Training Programme (2015). 2. Evidence submitted to the Royal College of Surgeons of England ‘Improving Surgical Training’ Consultation: A statement from The Association of Surgeons in Training and The British Orthopaedic Trainees Association (2015).