December 25th 2017

December 25th 2017

It is Christmas Day and I so grateful to be celebrating this with my family. Our thoughts are not of religion but of family and love. We miss those who are no longer with us and celebrate the arrival of new bundles of joy. As we get older we realise that richness is not money but safety, health and well being. There is also great sadness realising that there are so many people who are not safe and have no access to healthcare.

Today of all days, just hug or talk to that someone special.

I want to say a special Merry Christmas to all of you. Thank you all for just being you!

With much love Stella


Will making new doctors work in the NHS for five years improve retention? BMJ Blog

Will making new doctors work in the NHS for five years improve retention? BMJ Blog

It appears from the language used in the consultation that there is a desire to seek justification prior to implementation. A recent poll on YouGov reminds me of the quote “you need to ask the right question to get the right answer.” The heavily biased question: “Under new government plans doctors could be forced to work in the UK for at least five years after completion of training or payback for some of their training courses. This is because many doctors leave the UK after training to work in other countries. It costs the taxpayer £230,000 to train a doctor over and above the fees paid by the individual. Do you think doctors trained here should pay some or all of this back if they leave the UK less than five years after training?” gained a 91% positive response.

H L Mencken wrote “For every complex problem there is an answer that is clear, simple, and wrong.” This feels like the wrong answer to the wrong question.

I think back to my early years post qualification. I worked over 80 hours per week doing a 2 in 5 rota. I was taught medical skills and enjoyed great camaraderie with my colleagues, spending time together, and working as a team. In my first house job, I was on the surgical on call rota and there were many more junior doctors on call in 1991 for a shift than there are now in 2017. My consultants took me under their wing and mentored me about my career plans. I spent four years deciding on my final career pathway and enjoyed my jobs. Although I was tired, I felt valued by the system. There is no doubt that the hours did not suit everyone and the reduction in hours was welcomed by the profession.

Now, trainees are working in an intense and underfunded system where staff do not appear to be valued. The environment developed has forced junior doctors to think twice about their long-term career options. Those that wish to stay are galloping through their first year of clinical practice, developing their portfolios to show baseline competence and a competitive CV for their chosen speciality. To achieve the essential criteria, they need evidence of leadership, management, teaching abilities, audit, and quality improvement projects. They need the ability to convene courses as well as be trained, and also be great mentors and colleagues. And of course, they need to pass the necessary exams. Within 18 months they need to have a concrete career plan and they need to achieve a core training post to have any incremental increase in salary. Team structures have been abolished and junior doctors do not feel part of the team.

It is no wonder that trainees feel demoralised and burnt out. They are coerced (outside of any goodwill left) to cover for absent colleagues due to rota gaps and often need a break after two years in a high-pressure environment. They take time out by going abroad, or explore career options in trust posts or as locums to allow them to test out other avenues whilst they decide on their final career pathway.

At present half of Foundation doctors (2 years post qualification) decide not to continue into a definitive career pathway in the UK. The Government suggests that conscription into five years of NHS service post qualification could improve retention akin to military training. The parallel to military recruitment and retention would be welcomed if the terms and conditions were similar. At present military medical cadets are paid a salary throughout medical school as well as educational fees. These trainees are valued by the military and are resources that are heavily invested in, to ensure they are equipped for service. If a military cadet wishes to leave, they can give notice and are required to pay back any expenses incurred. If similar terms were offered to medical students and doctors, because they are a valued resource which is worth investing in, retention would not be a problem and the discussion of conscription would not be necessary. Yet again, the Department of Health is trying to fix a problem with a sticking plaster rather than understanding the root of the problem.

Would a five year conscription improve the retention of junior doctors? Or will it cause an exodus of trainees after five years?

Are these the right questions, or do we need to ask “Why is there a retention crisis in the NHS?” We need to address junior doctors’ morale in order to solve this.

Stella Vig has been the foundation programme director at Croydon University Hospital for 10 years and holds many roles, including those of core surgery and higher surgery training programme director, JCST chair for core surgery, and general surgery SAC member. She is one of three clinical directors for Croydon and is keen to see efficiency and excellence in patient care within the NHS. 

Competing Interests: I am a member of RCS England Council and a trustee for the Society of Chiropody and Podiatry. 

Core Surgical Training

Core Surgical Training

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.

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.

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.

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.

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.