DOI: 10.1308/147363514X14042954769915 SHAPE OF TRAININg

I M P L I C A T I O N S O F T H E

S H A P E O F T R A I N I N g

R E V I E W F O R S U R g E R Y

 Ann R Coll Surg Engl (Suppl) 

2014; 96: 357–359

HJM Feruson, JEF Fitzerald, AJ Beamish

on behalf of the Council of the Association of Surgeons in Training

Published in 2013, the Shape of

Training  review is an independent

review of postraduate medical

trainin overseen by Professor

David Greenaway.1 This review has

set out recommendations for the

structure and delivery of trainin

for the next 30 years,1 includin

a framework and timescale for

this reconuration. There is a

 wide rane of key themes, listed in

Table 1. The chanes proposed in

its 19 recommendations are far-

reachin, with implications for both

current and future surical trainees

in the UK.

The Association of Surgeons in Training

(ASiT) is a professional body and

registered charity working to promote

excellence in surgical training for the

benet of patients and trainees alike.

With a membership of more than 2,300

surgical trainees from all 10 surgical

specialties, ASiT represents a voice for all

surgical trainees. ASiT submitted written

evidence to the consultation component

of the review, addressing issues relating

specically to surgical training.

Report analysis

A summary of the key recommendations

made by the review is provided in Table

2. The broad goal of delivering trained

doctors who match the needs of the local

population is laudable. ASiT supports

the notion that postgraduate surgical

education must be able to respond to

changing demographics and patient

needs. Specic note and endorsement is

made of the recommendation to improve

the holistic nature of care, reinforcing

key aspects such as cultural awareness,

patients’ individual circumstances and

communication skills. The support of an

apprenticeship model for ongoing surgical

training is also welcome.

Concerns

The main concerns identied by the

ASiT are:

1. Run-through training as proposed in

the review has been tried previously

in surgical specialties and was rapidly

withdrawn.

2. The shortening of specialty training

 – such that a surgical trainee could

be considered a consultant surgeon

and practise independently, perhaps

only six years following graduation

 – fundamentally misunderstands

the rigours of surgical training and

the demands of being a consultant

in ever evolving craft specialties.

Furthermore, we do not believe the

NHS is nancially or organisationally

capable of delivering such training in

the time specied.

3. The proposal for the insert ion

of a year for additional career

development within training, as

opposed to an out-of-programme

period outside of training, further

reduces the available specialty

experience or possibility for formal

research and should be abandoned.

4. We feel that the term ‘Certicate

of Specialty Training’ (CST) implies

that CST holders will be ‘specialist

generalists’. If this is what is intended,

then these new specialist generalists

must be recognised as such in the

future NHS hierarchy as of equivalent

seniority to subspecialists. If a

‘non-specialist generalist’ is what is

desired, then we offer no support

to these proposals as it represents a

subconsultant grade by another name.

5. The award of a CST would result

in a generalist who may still require

supervision for all but the most basic

of procedures. This is incongruous

with the current Certicate of

Completion of Training (CCT) and

there is no support for the endpoint

of surgical training to represent

anything other than a fully trained

consultant surgeon, capable of fully

independent practice. As ASiT

has recently stated, it has never

previously been deemed acceptable or

workable to have a grade whereby the

357

 

THE ROYAL COLLEGE OF SURGEONS OF ENGLANDBULLETIN

overlap in duties and responsibilities

makes roles difcult to distinguish or

whereby despite undertaking similar

duties (eg operations), one is deemed

to be of lower responsibility or

requiring less skill. 2

6. The migration of subspecialty

‘credentialling’ beyond formal

postgraduate training raises

signicant nancial and organisational

questions, which appear not to have

been given consideration. Surgical

trainees should not have to bear any

further costs for their training as a

result of the delivery system.

7. The plugging of service gaps in the

emergency department by broadly

training surgeons fails to address

the root cause of these service

deciencies and risks further

decreasing hands-on surgical training

in the time available. 

Although it is outside of the remit

of ASiT, broad concerns have

also been raised regarding other

recommendations, including moving

General Medical Council registration

to the completion of medical school

training rather than after Foundation

Year 1. It is unclear how medical schools

can deliver this and it would al so open

up the foundation programme to

considerable competition from newly

qualied European doctors, who would

then be eligible to compete for posts.

Conclusions

The motivations of this review

are broadly laudable but the

recommendations are generally lacking

in sufcient detail to allow meaningful

abstraction on to future surgical

training. Furthermore, in a document

that seeks to improve the training

of the surgeons of the future, there

is disproportionate reference to the

improvement of service provision.

We accept that these two entities are

interdependent but feel that trainees

should not be the solution to service

gaps, nor should a subconsultant grade.

We have specic concerns regarding

the potential product of the proposed

training system in surgery. Although

it is commendable that the review

acknowledges that there is no appetite

for a subconsultant grade, this appears to

be the reality of what the reforms would

lead to in all but name. Within the term

‘subconsultant’ we include the possibility

of a consultant only in name, with a

different contract, pay and employment

opportunities from the subspecialist.

The CST holder of the future will lack

the in-depth knowledge and operative

experience of current trainees owing

to the shortened and broadened

training structure proposed. While the

review intends these trained surgeons

to provide the majority of generalised

care, it is clear that they will be working

at a lower level to that of the current

CCT consultant. This is not in the best

interests of future patient care in surgery.

Patient expectations for their care

continue to rise. At the same time, the

complexities of surgical care together

with the focus on surgeon outcomes

are driving the profession towards ever

GREATER FLEXIBILITY MUST BE GIVEN

FOR CRAFT SPECIALTIES TO ACHIEVE

THE TECHNICAL, PROFESSIONAL

AND KNOWLEDGE-BASED SKILLS

THAT THEIR FUTURE CONSULTANT

CAREERS WILL NECESSITATE

 

Five themes were identied that the review focused on:

 > patient needs

 >  balance of the medical workforce – specialists or generalists

 >  exibility of training

 >  the breadth and scope of training

 > tensions between service and training

KEY THEMES OF THE SHAPE OF TRAINING REVIEW

TABLE 1

1. Full GMC registration should move to the point of graduation from medical

school.

2. The FP should continue as a two-year programme, facilitating broad-based

learning in community and secondary care settings.

3. Following the FP, doctors will enter ‘broad-based specialty training’ in a general

area of practice. (Child health, women’s health and mental health are

specically mentioned.)

4. This training will proceed for 4–6 years.

5. There will be the option of a single year to be taken within training to expand

management/educational/clinical experience.

6. The CCT will be replaced by a CST.

7. The future CST holder will be eligible to apply for consultant-level posts in the

generality of their training area.

8. Subspecialty skills will be acquired after obtaining the CST by a process of

‘credentialling’.

9. All changes in training (and therefore the products of the proposed training

system) will be based on the local needs of the population.

 

GMC = General Medical Council; FP = Foundation Programme; CCT = Certicate

of Completion of Training; CST = Certicate of Specialty Training

SUMMARY OF THE REVIEW’S KEY RECOMMENDATIONS

TABLE 2

358

 

THE ROYAL COLLEGE OF SURGEONS OF ENGLANDBULLETIN

increasing specialism. In parallel to this,

factors discussed previously by ASiT3–7 

are conspiring to substantially reduce the

operative experience of current surgical

trainees. ASiT therefore nds it difcult

to see how the generalist model proposed

in this review can be reconciled against

these pressures and be of benet both to

patients and trainees. Greater exibility

must be given for craft specialties to

achieve the technical, professional and

knowledge-based skills that their future

consultant careers will necessitate.

With regard to post-CST training,

ASiT does not support the notion

of subspecialty credentialling in the

ten existing surgical specialties. The

migration of subspecialty credentialling

beyond formal postgraduate training

raises signicant nancial, organisational

and gatekeeping questions, which appear

not to have been given consideration.

ASiT believes that the ‘one-size-ts-

all’ approach to postgraduate training

taken in this review is inappropriate for

surgery. Even in the unlikely event that

the NHS were able to commit signicant

nancial resources to undertake

a complete reconguration of the

current model of postgraduate medical

training, it is difcult to see how these

recommendations could be implemented

in surgery.

The respective royal colleges have

been challenged to deliver their future

plans for surgical training based on the

recommendations of the Shape of

Training  review. We look forward to

engaging with the profession, patient

groups and other stakeholders to

ensure the highest standards in the

shape of future surgical training.

Further information

 > Shape of Training  webpage: 

www.shapeoftraining.co.uk 

 > Full ASiT response to the review: 

www.asit.org/resources/articles/

shapeoftraining

References1. Greenaway D. Securing the Future of Excellent Patient

Care. London: GMC; 2013.

2. Shalhoub J, Giddings CE, Ferguson HJ et al .

Developing future surgical workforce structures:

a review of post-training non-consultant grade

specialist roles and the results of a national

trainee survey from the Association of Surgeons in

Training. Int J Surg 2013; 11: 578–583.

3. Association of Surgeons in Training. Aspir ing to

Excellence: Findings and Recommendations of the

Independent Inquiry into MMC – Response by the

 Asso ciation of Surgeon s in Training.  London: ASiT;

2007.

4. Association of Surgeons in Training. Optimising

Working Hours to Provide Quality in Training and

Patient Safety. London: ASiT; 2009.

5. Fitzger ald JE, Marron CD, Giddings CE. The

inuence of specialty, grade, gender and deanery

on the implementation and outcomes of European

working time regulations in surgery. Br J Surg 2011;

98: 21.

6. Fitzger ald JE, Giddings CE, Khera G, Marron

CD. Improving the future of surgical training and

education: consensus recommendations from the

Association of Surgeons in Training. Int J Surg 2012;

10: 389–392.

7. Wild JR, Lambert G, Hornby S, Fitzger ald JE.

Emergency cross-cover of surgical specialties:

consensus recommendations by the Association of

Surgeons in Training. Int J Surg 2013; 11: 584–588.

Submit a technical video

Videos should be around 1 minute long andaccompanied by short explanatory text.

For more details, visit

www.rcseng.ac.uk/publications/submissions

or email annals@rcseng.ac.uk

The Annals is inviting submissions of short video-based Technical Tips and Notes for the ever-popular

Technical Section.

359