Author: stellavig

Consultant Vascular and General Surgeon Passionate about the NHS!

Waiting for an ITU bed

Waiting for an ITU bed

The national headlines recently have been alarming.

Hundreds of patients have had operations cancelled, many more than previous years as the NHS Crisis continues.

The John Radcliffe Hospital cancelled all non-urgent operations in Jan 2017 and is quoted as one of highest pressured Trusts.

These are just statistics and each data point represents a patient and their personal circumstances. As a NHS, we cancel patients every day and just shift them along a few days or weeks. These are difficult management and clinical decisions but must be taken as the NHS juggles elective and emergency care in the under resourced and under bedded NHS. However these patients are people and the NHS should not be in this position.

We try and ensure that patients with a cancer diagnosis are not cancelled nor patients with special circumstances or who have been cancelled before but the NHS cannot guarantee that this has been 100% delivered this or last year.

I do not have a Cancer, I am not an urgent or an emergency so I could wait if necessary. And I will if needed and I will understand. And the anxiety will increase just like any other patient. At best I will be cancelled one week, at worst…

And there is a huge personal cost to this wait, that is hidden from the NHS deficit. Each patient carries a personal cost, which is relatively small, but added up across the nation, must be huge.

Personally, I have suspended my work and have only just managed to finalise the business cases, delegated tasks and ensured I have handed over both clinical and managerial duties. I have planned a return to work date and the Trust are paying for a locum to cover me. Any delay with the date of surgery pushes that return date back as well as increasing the cost.

My husband has booked a week off work and has planned operations and appointments on his return. If my surgery is delayed, then these patients will either need to be delayed or a plan made for others to cover if possible, often on goodwill but potentially at a cost. He has booked somewhere to stay for a week and has paid up front. This is not available the week after and he will need to rebook and pay a further cost and will lose the money for the first week.

My sons have given notice at University for one week and have booked tickets and accommodation.

My sister has delayed a business trip and has planned to be around me initially and has arranged accommodation with my brother. She has arranged flexible leave with her company and will travel as necessary. My brother is flying in from abroad and is here for two weeks. He cannot rearrange his flight without a cost to him. He has also had to plan his work around his absence for a few weeks. All are using their precious annual leave. They don’t need to come but we lost our father last year and mother many years before that. As orphans, siblings bond even closer together and we have always been a great family unit.

I can be delayed safely and will not publish this until after my surgery as I do not want any special treatment.

I was supposed to phone at midday today but got a phone call at 11am telling me there will be a hospital bed. I am overjoyed as this is the first step. I can be admitted at 4pm and need a further CT scan to ensure that there is no change since my last scan.

I have naseptin, a nasal antiseptic containing chlorhexidine which causes an acute sniffly nose and I am sneezing everywhere! I am worried I might get cancelled by the anaesthetist but she sees me that night and tells me not to worry.

I am seen by the on-call registrar who informs me that there are 6 ITU beds for the morning and although he cannot guarantee a bed, things are looking good.

Lying in bed on the eve of surgery is scary. There is no going back once the operation is done. I will need to work hard to rehabilitate and get my balance and appetite back. I have read all the literature and have kept myself as busy as I can so I don’t think about it. I have washed in the special soap and will stop eating at midnight as well as stop drinking at 6am. I am dreading the surgery but know it needs to go ahead, so have signed the consent form.

I will not know whether there is a bed until tomorrow morning. I don’t know if any of you have seen the television true series called ‘the Hospital’. A gentleman was taken to theatre and was prepared for theatre with the access lines, catheter, monitoring etc and was cancelled at the last minute. My heart went out to him and his family as this is just not fair. I know that even if there is a bed that this could be cancelled at last minute and this fills me with fear.

I will wake up early and have a shower. I will follow all the instructions given to me and behave like a good patient. I have plenty of time now as I have nothing else to do. It is an odd time as the family are not here, I am a patient in a bed with nurses and patients around me. I am an ordinary person, stripped of all identification of who I am, waiting patiently for an ITU bed that will allow my surgeon to go ahead with necessary surgery.

I feel sorry for the staff, surgeons and managers who have no real ability to manage this bed resource as it depends on the acuity of admissions overnight. Is the NHS funded correctly, are we using this resource wisely, is there enough social care funding to allow flow through the hospital, should we separate elective and emergency care? I don’t know but there is a NHS Crisis right now and I am now on the other side seeing it for myself.

The Surgeon

The Surgeon

December

I remember my December appointment. I had read all about my diagnosis. Google and medical text books are great but cause many anxieties instead of a sense of relief. My recommendation? Don’t look up your diagnosis! I am worried about all the complications discussed at my first appointment and a facial nerve palsy (loss of function with a facial droop) is definitely my worst fear. I have come to terms with a unilateral deafness but am still worried that if I am operating in a surgical theatre, I may not be able to hear my scrub sister and assistants. Or the medical student on the right of me. I am told that musicians go back to work after this surgery so I need to see how I feel.

My husband and I go to the appointment and instantly feel at ease as we enter into the clinic room. It really does matter how the room is set up. It is light and there is no noise. I sit near my surgeon, close to him without the desk as an artificial barrier between us. He sets the scene and immediately talks about my worst fears. How does he know? He must do this every day but for me the discussion feels personal. He treats me like an individual and addresses each of my questions. He explains the rationale of his approach and tells me how he will try and minimise complications or manage them if they do happen. He has pre-empted many of my concerns and treats me like a patient but with an understanding that I am a colleague. Importantly, he does not assume I know everything and explains the rationale with diagrams. I love explaining diagnoses and treatments to my patients with the aid of diagrams and therefore find this a very comforting gesture. Later I remember the diagrams,  as they stay fresh in my mind, when I am explaining the discussion to my sister.

A nurse walks into the consultation and I feel uncomfortable, as I don’t know who she is. I reflect on how I feel and the fact that nurses walk in and out of my clinic every day. I try and introduce each one but at times this is difficult when you are explaining a difficult diagnosis. Maybe this illness will make me a better doctor as I learn to empathise even more on my patients’ feelings.

We negotiate a plan of action for my operation. I feel confident as I can make my own informed decision but know full well that I have been steered and guided into the right decision by the experience and words of the consultant surgeon.

January

I am still wearing my heels as I go for my final appointment to make the decision for surgery. I am determined to be in them until I stop working (so I feel I am in control!). It seems to have been a long time since the original diagnosis in October.

I go with my sister and close friend to this appointment.

My husband cannot attend as he is working hard to manage his patients within the NHS. Clinic cannot be cancelled as he has the pressures of the 2-week rule for breast cancers. To explain, this means that patients must see a breast surgeon (as to whether they have a breast cancer or not) within two weeks. I cannot imagine how these patients must feel, finding a lump and not knowing what it is and fearing the worst.  I am so lucky that my mass is benign and not malignant. This additional diagnosis would have brought a huge additional burden and conversation and I can only imagine the professionalism of the entire multidisciplinary team at this difficult time.

My surgeon is obviously running a busy clinic but this all becomes irrelevant once we walk through the clinic door. He concentrates on my case. We are introduced to the specialist nurse. I introduce my sister and my concerned friend. The surgeon explains my diagnosis and goes through the scan. He is just as comforting but his words are the terms that my companions can understand. And they are really helped by hearing the information from him and afterwards tell me that I am in safe hands. What do we say that develops those feelings in our patients? I am still thinking and that will be a future blog!

I agree I need surgery and have a pre-assessment that day. How efficient. It is 10.30am and I have my ECG straight away. We are asked to go for coffee until my designated time with the specialist nurse who will see me and explain what I can expect. She is on time and she is so patient. She goes through my history and tells me about the pre and post operative course. I need blood tests and a nasal aseptic. I will be admitted the day before surgery and will need to shower with a special shampoo and body wash. I should not wear deodorant on the day. Really?? I will not be able to wash my hair for several days and certainly will not be able to dye my hair. I will be in ITU initially and will be in for around 10 days. (Immediately I set myself a challenge to be out in 5!). I am given patient leaflets and a guide to the hospital. Have I read them yet? No but I will before surgery. I ask about pain and wonder why it seems so natural to ask my nursing colleague and not the surgeon. She gives me her number and tells me to phone, anytime. And I believe her.

I am then asked to go for lunch as the senior house officer will see me at 2pm. We find an M & S restaurant and sit down and have a meal. I cannot remember the last time I had an hour for lunch or a sit-down meal in a hospital. Normally  I either eat on the run or forget to eat. This seems normal to me and my colleagues but my companions do not understand my comment on this and state that this must be so unhealthy and that I should know better. The NHS is so pressured and the workload is high. We all strive to get important jobs done in a timely fashion but the list is endless and this is an impossible task. We all give freely but I can feel the goodwill slowly seeping out of the NHS as the NHS staff feel more and more unvalued. We need to consider how we role model to our colleagues. What we did in the old NHS may not be correct now.

We rush back at 2pm and are told that the SHO is covering for a rota gap and has had to cover the ward as well as the preoperative clinic so will be back as soon as he can. I understand completely as this is happening across the NHS. We sit down and wait patiently. Time passes and it is now after 3pm and I enquire whether he is still busy. And yes, he is as there are sick patients on the ward. Of course I could clerk myself but this would not acceptable but I am tempted. Should patients be allowed to clerk themselves if we gave them a proforma? I wonder….

It is now after 4pm and he is still busy.  Now I am getting frustrated despite the fact I work in the NHS. I can imagine the car parking ticket when we finally get out of here. It will be expensive but it will be cheaper than hospital parking in London. My poor patients who must go through this everyday and are still so understanding and sympathetic.

At 4.30pm he finally gets back to clinic. He looks exhausted and is apologetic. He doesn’t need to be. I know he has been busy. Lucky for him, I give a concise history. He professionally clerks me in 20 minutes. I cannot resist asking him about his training and career plans. He is dedicated to neurosurgery but wants to take an extra year to make sure that when he enters a training programme to be a Consultant Neurosurgeon, that he has made the right choice. His passion shines through in that short period of contact. And I know he will be a great asset and future consultant in the NHS.

Finally, I can now go home. I buy the pre-assessment team some chocolates. Everyone loves chocolates. And they deserve a big thank you.

The GMC’s support for doctors during the NHS crisis is welcomed

Stella Vig: The GMC’s support for doctors during the NHS crisis is welcomed

3 Feb, 17 | by BMJ

Doctors have to make difficult clinical judgements about their patients on a daily basis and are trained to do so. This decision making develops with experience and the profession balances risk versus benefit on a case by case basis. Decision making, however, has changed rapidly over the last year with the added pressures brought on by the increasing demand on NHS services and the scarcity of resources. Decisions are now being made about whether operations are cancelled because there are no beds, or whether a trainee should be asked to stay when there is a rota gap, or how to deal with exception reporting.

Guidance from the General Medical Council (GMC), the Department of Health, and Health Education England has been confusing for both juniors and seniors over the last year. The medical profession’s ethics and morals have been challenged and a level of distrust has been established. The profession has breathed a huge collective sigh of relief with the publication of a recent letter by Terence Stephenson, chair of the GMC. The GMC has asked doctors to raise concerns about patient safety arising from the current pressures on the NHS. Therefore the GMC must recognise that patient safety may be compromised by the current situation. The GMC has stated it will “engage with employers” who failed to meet standards for doctor training and support. That suggests that there maybe employers that could fail to listen and respond to concerns.

The GMC will be investigating the impact of rota gaps this year suggesting that they believe there are rota gaps and there may be a negative impact. They also report “Health services across the UK are working harder than ever to deal with the fierce pressures of winter and emergency departments and primary care services are struggling to cope with demand.” In addition, the additional challenges of revalidation and the pressures of investigation are recognised with a desire to change.

At last there appears to be a body representing the profession who believes the situations which are witnessed by doctors every day and which cause great anxiety. The request from the GMC to report concerns will be read with great relief by many clinicians.

The Ghosts in the Machine

Jeremy Hunt says that the 4-hour A&E target is only meant for urgent cases. Perhaps he is right as this is what clinicians have been saying and perhaps we need to listen to them.

Each target introduced by government has been developed based on excellent evidence and for a reasonable purpose at the time.  A prime example is the four-hour target set nationally for A and E. This is reported nationally and is used as a bench marking tool of the performance of Trusts.

Initially this target was introduced by the Labour Government in 2004, as it was identified that there was a requirement to promote improvements in A&E departments, which had suffered underfunding for a number of years. Initially set as 98% of patients seen must be treated, admitted or discharged in under four hours, this was amended to 95% in June 2010.

The target, accompanied by extra financial support, was a key plan to achieve the improvements. This was laudable and brought about dramatic changes, 52% to 98.2% within 2 years, but had dropped to 91.8% by 2014 as funding was removed.

So what has been the impact of this target? The initial monetary investment is no longer in the system and public perception, demand and access to healthcare has changed over the last ten years. There has an unprecedented rise in the older population, long term conditions alongside an increasing population base. The increased need for emergency services has led to professional management of the hospital bed stock. There has been an increase in bed managers, whose role is to ensure patients are placed promptly in appropriate beds; in addition to discharge coordinators to help overcome obstacles to patients being discharged when ready.

There are further elective targets introduced by subsequent desires to improve patient experience and safety. The 2-week rule for cancer patients ensures that patients suspected of a possible cancer are seen within this time period but some patients reflect that this increases anxiety and it relies on the expertise of the referring clinician. There is an 18-week target from referral to treatment for elective patients of any type. In addition, any patient waiting more than 52 weeks incurs a breech, reportable centrally. There are penalties  and fines attached to breaches of any of the targets.

So how are these targets achieved? Clinically but also there are numerous layers of managers keeping track of the data in archaic databases that are not reliable and therefore require checking by hand to reduce inaccuracies.

There is a tension in these emergency and elective targets as these are within the same bed base and by the same clinicians.

In parallel, the reduction in the number of NHS beds by 17% (21k) has been facilitated by the change of pathways to day case management. The closure of beds and the reduction of associated staffing is also a prime opportunity to save money and so is championed but are unique opportunities, as budgets are then reduced. incurring a cost pressure if extra beds are needed.

So what are the ramifications of these targets?  There is no doubt that there was an initial improvement in clinical care but this has not been an easily sustainable effort. Currently there is a great deal of management, clinician and financial investment to ensure that these targets are not only achieved but also reported.

The real ramifications are the loss of trust and value of each other. There is a feeling that the public and patients do not respect the NHS as there are high non-attendance rates not just as outpatients but also of elective surgery.  It appears that the public have become used to the NHS just offering another date if they don’t attend. The lost opportunity is compelling as it blocks another patient from attending on that date but also the Trust from claiming an income for that time period.

There are many managers and NHS clinicians working very hard and often putting in extra (unpaid) hours to make sure they deliver the best. They wish to drive excellence but sadly we communicate by email and have lost the relationship with each other. The managers are responsible for managing all aspects of hospital care and that includes staffing. And managers are employed to manage these managers. The top heavy approach with central targets has pushed to try and add another couple of patients into an already overbooked clinic so that it can be achieved. NHS professionals of all specialities are often short staffed but always go that extra to deliver a high standard of care and therefore do not understand or accommodate this pressure.

There is a distrust of clinicians, so a desire to encourage an extra ward round to discharge a few more patients is requested and due to the pressure managers may resort to doing extra rounds on a clinician’s behalf. There is a loss of value, respect and trust between clinicians and managers but both are working to the same goal.

And this is now developing at pace.

And we have a healthcare system with GP practices and social care. They are also suffering the need to demonstrate target achievement. For General Practices, this has incurred income losses as these run as small businesses. The partners of several practices have not drawn a salary for several months to ensure the salaried staff get paid and some sadly have shut.  On the brink of chaos with staff shortages, the current request to ensure 7/7 deliverability will demoralise the NHS workforce even more.

The intangible outcome is a sick NHS, a claustrophobic environment which is constantly under scrutiny.

The NHS should now be allowed to deliver targets set locally to achieve excellent care. The Five Year Forward view is very laudable and the Vanguards, if allowed to develop local solutions, may succeed. The NHS needs to be funded with a long-term strategy and we need to eliminate the wastage of money that currently occurs.

There is only one aim within the NHS. That is to deliver the best care within a financial envelope and deliver this free at the point of care. Let’s assume that all NHS Clinicians will do their jobs as that is what we are trained to do. Let’s assume that managers will manage the service and developments. Let’s assume that the public and patients value the NHS.

Put that trust back in the system and get rid of the ghosts and we may well succeed.

Me and My Acoustic Neuroma

Me and My Acoustic Neuroma

I have been a consultant vascular and general surgeon for ten years and am always busy. I have been tired but I have never been so exhausted as now, finishing a long theatre list on a dark October night.

I walk back to the car and feel unbalanced, especially in my trade mark high heels. Maybe I have just got to the age when I need to wear flats. My trainee comments that I am walking like I am drunk. Alarm bells start to ring.

I pop into the neurology clinic the next morning and explain my worst fears: ‘I think I have a brain tumour’. It is probably just vestibulitis after an awful cold, but it is not getting better. Instead, my symptoms are worse. I have headaches and I report that my right eye feels dry.

The neurologist reassures me but arranges a scan. She phones MRI and they can fit me in straight away. I have my scan and realise, because they need a second scan with contrast, that they have found something in my head. I am a professional but in those few minutes become a worried patient. I think the worst: what type of brain tumour, how large and where is it?

I find the neurologist waiting for me to explain the scan findings. They have found something. I have a 3cm mass in my cerebellum which is compressing my brain, causing the dizziness. It is not malignant but couldn’t have been sited in a worse place. I cry. The neurologist explains that I will need to see a neurosurgeon and their team. I have an acoustic neuroma.

Within two days, I am referred locally and told I need surgery; there is no other choice. I will need three months away from work. Then it gets worse. I will lose my hearing, there is a 20% risk of damage to the nerve supplying the movement of my face, a risk of damage to the sensation of my face, and to my ability to balance. I will feel sick after the surgery and, of course, there is the pain.

I listen and make my decision: I am not having surgery, there must be other ways.  Perhaps radiotherapy or just wait for it to settle. I become an expert on acoustic neuromas overnight. I read all the literature. The patient leaflet explains that if I do have surgery ‘it will attempt to preserve my quality of life’. Great.

I seek a second opinion and am reassured by the surgeon. I finally understand what I teach. To have compassion and to gain your patient’s absolute trust. In his explanations of the surgery, his words are comforting as he has pre-planned management of any complications that might be expected. I explain my own fears; I would struggle with a facial nerve palsy. He listens patiently and discusses all options with me. I take all the advice and it slowly dawns on me, I really do have no choice but surgery.

I start thinking about the cost of care and how fortunate I am in the NHS. I start calculating the cost in America and it mounts up to hundreds of thousands of pounds. I cannot imagine having to make sure that I can pay before taking advice, or letting the cost of care drive my decision making. I have my efficient and thorough pre-assessment and get a date for surgery in February.

In my rapid journey from being a professional to a patient, I have had so many worries. I have however been lucky about one thing. I am in the NHS

Core Surgical Training

Core Surgical Training

The future of core surgical training

Stella Vig, Bill Allum
Volume: 99 Issue: 1, January 2017, pp. 20-22
DOI: http://dx.doi.org/10.1308/rcsbull.2017.20
Published online: December 24, 2016

The technical and clinical skills developed in the early years of surgical training are pivotal to the career progression of surgical trainees. The recent discussions arising from the Shape of Training review have highlighted the need for a review of core surgical training (CST). The reduction in surgical attachments both at medical school and foundation-training level has resulted in a lack of exposure to surgery for medical students and junior trainees. Satisfaction levels among foundation trainees (FYs) and core surgical trainees (CTs) are the lowest across all medical specialties. Despite these concerns, applications to CST still outstrip the number of posts available in training programmes. Recent discussions within the Joint Committee on Surgical Training (JCST) have identified a need to consider the value of the CST scheme and re-visit the experience it offers to trainees.

Background

The surgical specialty registrars are the consultants of the future. The outcomes of the GMC National Training Survey 2014 indicate that they are largely satisfied with their training – respondents in specialty surgical training posts report an 85.5% satisfaction rate with their current post. By contrast, CTs and FYs recorded a 77.2% and 72.1% satisfaction level respectively.

In addition, responders identifying as less than full-time CTs reported difficulties accessing teaching and training on ward rounds, outpatient clinics, elective operating lists and simulation training. Many use unpaid clinical sessions to ensure they meet the requirements set out by training programmes and ST3 recruitment panels.

The aim of CST is to ensure that all CT2 trainees are awarded an outcome 6 at final Annual Review of Competence Progression. Currently 78% of trainees complete CST in two years, with others completing after an extension to training arising from failure in examinations, change of career path and other reasons. Indeed, 10% of CSTs fail to complete the MRCS within their two-year training programme, whereas another 3% resign before completion of core training.

In 2015, 43% of CT2 trainees were appointed to an ST3 post immediately following completion of CST; 20% were employed in Locum Appointment for Service (LAS) posts, research and trust surgical posts; and 15% took a year out of training for personal reasons, such as a career break, time to travel or other unspecified factors. Trainees also used their acquired surgical skills and knowledge to progress to other competitive careers

JCST trainee survey 2014/15 findings

  • 33% reported that routine clinical work prevented the acquisition of new skills;

  • 24% reported missing training opportunities to cover for absent colleagues and fill rota gaps;

  • 12% reported attending fewer than 2 consultant supervised operating lists per week;

  • 47% reported attending fewer than 2 consultant supervised outpatient sessions per week;

  • 20% reported being unable to attend emergency theatre on a regular basis;

  • 16% reported not regularly seeing new patients in an outpatient setting.

How to improve CST

  • Quality of training posts: Appropriate external quality assurance adhering to the JCST QIs for training posts.

  • Programme design: Flexibility of programmes, including generic or themed, run-through or uncoupled.

  • Improving basic skill: Establishing educational induction as part of learning agreements/timetable.

  • Simulation: Embed simulation within training.

  • Optimising opportunities: 12-month posts in a single trust. Dedicated operating theatre and outpatient clinic time.

  • Curriculum: Definition of outcomes of training with appropriate incorporation into curricula.

  • GMC recognition and approval of trainers: Trainer recognition with inclusion of training PAs into job plans.

Current challenges
The key struggle for CTs is the need to provide service at the expense of training opportunities. Gaps in services are common, with CTs covering absent colleagues and rota gaps. There is often no distinction between CTs, FYs and non-training grades in hospital rotas, causing difficulties in appropriately targeting training opportunities. This is largely a reflection of the origins of many posts from the former SHO tier, which were often simply for service.

This balance needs to shift to ensure trainees gain the necessary knowledge and clinical and technical skills, as well as the experience to be eligible for ST3 posts in a given specialty. Furthermore, despite curriculum-defined requirements, there is a lack of consistency applying these standards across programmes and posts. The quality indicators (QIs) defined by the JCST for posts are variably met, reflecting a lack of external input into quality assurance. In addition, service pressures result in limited contact, guidance and supervision from their trainers.

Improving core surgical training

These elements have recently been discussed at length by the JCST. The educational aims of core training placements must be robustly defined. This definition is inherent within the QIs but these can only be evaluated by regular review. This should be achieved by appropriate internal review by specialty training committees with external input from the Core Surgical Training Committee (CSTC). We anticipate that the approved change in status of the CSTC to the Core Surgical Training Advisory Committee will reinforce this externality to benefit the quality of core training.

There has been a longstanding debate about generic or specialty-themed content of CST programmes. The evolution of run-through training in neurosurgery and pilots in cardiothoracic surgery and OMFS has re-focused this debate. In addition, the need to increase flexibility in training, which has been highlighted in the discussions on the new junior doctors’ contract, has identified an impetus to allow trainees to tailor their training according to their career aims. The JCST has taken the view that there should be a mixed economy of run-through and uncoupled entry. These different models will not only allow those who have decided their career path to proceed with their chosen specialty but also allow those who are undecided to pursue a more generic path with progression into their specialty at ST3. A key issue for run-through is to ensure equivalence at entry to ST3. We hope the recently announced review of the ARCP process by Health Education England will improve on what is currently an inconsistent process.

The main priority when new trainees start work is the maintenance of patient safety, and implicit within this should be a set of core knowledge and skills. To this end, the use of Educational Induction (‘boot camps’) should be developed as a standard for all those entering core training. This should take place as a dedicated week, which should be embedded within the first two months of starting a programme. A fundamental component of such induction is simulation. There is now approval to include simulation as a training tool in the current core curriculum. This has been enabled by all Schools of Surgery developing simulation training opportunities. We hope that this will enable trainees to learn and practise key skills that they can then progress in the clinical setting to achieve the required competences with confidence

Timetabling for many CST posts partly reflects their origin from former SHO posts and partly the design of programmes, which is dictated to support service provision. As a result, posts have been restricted by short-term attachments that have limited training with reduced exposure to and support from trainers. This adds to the frustration of moving hospitals frequently. Twelve-month attachments should become the preferred approach to provide stability while including internal specialty/subspecialty rotations. In addition, timetabling must ensure protected scheduled access to the operating theatre and outpatient clinics, with defined education outcomes. There are a number of examples of dedicating training opportunities that should be spread across CST. Furthermore, trainers should have dedicated sessional time for one-to-one/small-group teaching at least weekly, thus ‘professionalising’ their role.

The GMC is revising its standards for curricula and assessment, with an emphasis on outcomes. This is a deliberate move away from the ‘tick-box culture’ that has evolved during the past few years, reflecting the granular nature of curricula and workplace-based assessments. The definition of an outcomes curriculum is based upon those tasks (alternatively referred to as ‘entrusted professional activities’ – EPAs) that form part of the working week. An example is the ability to manage an on-call duty of unselected emergency admissions. Satisfactory completion of such an EPA would be underpinned by the knowledge, clinical and technical skills to manage the variety of patients admitted. The assessment is intended to be a more global view using existing WBAs as required to evaluate specific concerns. This will require definition of those EPAs specific to core training, which should be embedded in a more modular design of the curriculum, thereby increasing individual flexibility.

Finally, there needs to be appropriate support for trainers with time for training in job plans, the lack of which is a consistent feature in the JCST trainers’ survey. This will be facilitated by the GMC approval process but employer recognition in providing educational PAs is essential. It is also incumbent on trainers to ensure they are up to date with their understanding of these evolving processes and appreciate their responsibility to the trainees under their supervision.

Conclusion

The challenges facing surgical training have been exacerbated by the various pressures within healthcare. These have resulted in significant levels of dissatisfaction among trainees, which have potential adverse effects on the future workforce. The majority of surgical trainees have decided on a surgical career to combine patient care with the practical craft aspects of the specialty. The proposals described in this report are intended to improve the quality and experience of surgical training. Some will be straightforward to introduce but others will require a collaborative approach with educational stakeholders. However, it is hoped that these will address the discontent among trainees and ensure surgery remains a popular career choice.