Health CommitteeWritten evidence from the Royal College of Surgeons (ETWP 50)


1. The Royal College of Surgeons welcomes the Health Select Committee’s inquiry into education, training and workforce planning. The College supports the emphasis on the multi-professional development of the entire healthcare workforce. There needs to be a national approach to the delivery of postgraduate medical education and training and workforce planning, to ensure that consistent standards exist. At the undergraduate level the College wishes to see a core national medical school curriculum and greater time spent in hospitals and other clinical care environments to ensure doctors entering postgraduate medical training have consistent skills. We also believe it is essential that the detail of the future of medical education and training is worked out within the next six months to ensure its delivery is not put at risk during the implementation of the health and social care reforms. The College believes there remains an unaddressed need for the independent setting, assessment and monitoring of national standards for education and training and impartial quality assurance both nationally and regionally.

2. If the changes proposed in relation to the Health and Social Care Bill to health education and training are wrong they will affect the stability of the healthcare workforce and impact ultimately on patient care. This response highlights specific areas of concern that need to be addressed in order to support the future healthcare workforce and deliver high quality care to our patients.

Surgical Education and Training

3. Education and training of healthcare professionals is fundamental to the delivery of quality of care and patient safety. For doctors training in the craft specialties, such as surgery where there is an emphasis on technical skills, it is the balance between education and training that is important. It is vital that the weighting given to training in the craft specialties is recognised and supported as this leads to the development and refinement of clinical judgement and technical skills which are essential for patient safety. This requires incentivising training throughout the service, making the most of training opportunities and ensuring sufficient time is available and that trainees and trainers are supported by the senior hospital management team. Effective working across relevant professional groups is essential to the delivery of high quality healthcare education and training and therefore patient safety.

4. In recent years many publications have suggested a reduction in the volume of practical training being undertaken by surgical trainees in comparison to those completing surgical training programmes prior to the full implementation of the working time regulations. Several such studies, based on reviews of logbook data, indicate that a direct effect of reduced working hours for surgical trainees has been a significant reduction in the volume of procedures performed and a dilution in experience and competency obtained at each level.

5. Surgical trainees are completing training and entering specialisation as consultants with diminished operative experience compared to previous generations. 77% of those trainees who replied to a recent Association of Upper Gastrointestinal Surgeons (AUGIS) survey stated that they would require additional training at the end of their programme with 95% of trainees wishing to undertake a fellowship after completion of training. Nationally the GMC’s 2011 training survey found that of all the medical specialties, surgery was the one where trainees were the least satisfied with their training and this position has changed little since 2006.

6. The College believes that professional bodies should have a greater role in setting specific standards for educating and training. Current quality assurance process is not sufficiently robust and should include independent professional groups such as Royal Colleges. Under the current education and training system the College is responsible for the training curriculum and for recommending trainees for accreditation to the respective regulator. The GMC sets and monitors standards for postgraduate medical training, scrutinises postgraduate curricula and examinations and quality assures training posts. The latter is based principally on an annual questionnaire/survey of trainees and trainers and triggered deanery-wide visits. At present, this system of monitoring and assessing training lacks the rigour of independent, specialist oversight. The medical Royal Colleges are ideally placed to provide this, as the bodies with ongoing responsibility for the curriculum.

Surgical Workforce Planning

7. The College as part of its commitment to maintain the highest standards of surgical practice and patient care supports the need for a clear workforce planning process for delivering the best possible care for the population. Workforce planning is necessary for making strategic decisions for the design and delivery of healthcare. Despite a wide range of workforce data being available, there is general agreement that this information is inaccurate and misrepresentative. A professionally led approach to collecting workforce data is the only reliable way to proceed to ensure robust data are obtained so that stakeholders can gain an in-depth understanding of surgeons’ working patterns and the services they deliver.

8. In 2010 the College, in collaboration with the surgical specialty associations, published the results of the first comprehensive census of the surgical workforce in England, Wales and Northern Ireland. The report provided data on workforce numbers as well as surgical subspecialty interests, working practices and retirement intentions. This information should improve workforce planning. It is essential that the Centre for Workforce Intelligence works in partnership with the profession and the proposed new structures with a remit to deliver education, training and workforce planning in order to achieve a step change in how workforce planning is undertaken and delivered. The Department of Health needs to recognise the cost of undertaking this work by the College and the value of the work to the CfWI and encourage closer collaboration.

RCS Concerns about the Impact of the Health and Social Care Reforms on:

(a) The education and training system

9. The College believes the proposed reforms of the education and training system have the potential to improve surgical training and address some of the fundamental problems that have been highlighted by both trainees and trainers, such as the availability of sufficient time in which to train/be trained.

10. Clinical representation on Health Education England—The College welcomes the establishment of Health Education England (HEE) and its responsibility for multi-professional development of the entire healthcare workforce. In the new system there needs to be strong independent clinical representation, standard setting and quality assurance from the professions through the Royal Colleges and those bodies responsible for the educational standards of colleagues in other healthcare professions.

11. Accountability of Local Education and Training Boards—We believe that at the local level the core functions such as contractual arrangements, rotations and running assessments need to be maintained. The core functions need to be laid out in the authorisation criteria and contractual arrangements with the Local Education and Training Boards (LETBs). There needs to be a specific consideration of research training for surgeons to ensure that all surgeons in training have an understanding of research and the option to participate further during their training. HEE will need to be assured that these functions are supported and delivered by the LETBs. It is essential that LETBs should involve a broad range of partners and be inclusive in their membership.

12. Delivering the Educational Outcomes Framework—The proposed Educational Outcomes Framework (EoF) has the potential to set standards and measure the quality of education and training. We believe there should be an enhanced role for appropriate Royal Colleges and other professional bodies in further developing this framework. The Colleges should be involved in the setting of standards relevant to training in a particular specialty within the EoF and this should be set in a context which includes consideration of the wider healthcare team and their respective educational standards. The profession, together with relevant partners, should also be fully involved in monitoring quality at both national and local level, for which both time and resource will be need to be provided. Robust externality is necessary to ensure the quality and consistency of national standards and delivery of training. Monitoring tools should include face to face feedback, surveys and logbook analysis. HEE should mandate the Colleges to do this work and fund them accordingly.

13. Funding of Continuing Professional Development—The College broadly supports the proposals that resourcing Continuing Professional Development (CPD) should become a responsibility of providers (employers) as well as remaining a responsibility of each individual surgeon. CPD is essential for the development of the existing surgical workforce in maintaining and improving standards across all areas of practice. Evidence of participation in CPD activity will be a compulsory requirement of revalidation in order for doctors to demonstrate continued fitness-to-practice. We support the proposed flexibility for providers to deliver this, such as collaborating with other providers. However we are concerned that funding for CPD does not appear to be protected and that funding for this is likely to be threatened by pressures on budgets. Providers will also need to provide time for CPD activities as well as funding. Oversight of CPD by HEE and the relevant Colleges/professional bodies is needed to ensure CPD remains accessible to the entire healthcare workforce.

(b) Workforce planning

14. It is our view that surgeons need to be trained to provide excellent patient care across the health service, not solely oriented to meet local workforce needs. Workforce planning is not sufficiently robust or sophisticated to ensure we train the right number of specialists to meet national, let alone local needs; freedom of movement by specialists between the trusts and devolved nations can only be supported if standards of training are uniform.

15. National partnerships with the Centre for Workforce Intelligence—The Centre for Workforce Intelligence (CfWI) should be accountable to Health Education England to ensure that it is fulfilling its role in data analysis and information provision. Many professional bodies such as the College have workforce data so it is essential that these organisations are suitably funded and are included in the work of the CfWI, rather than the CfWI duplicating data gathering that already exists. The CfWI should be open and transparent to ensure it has the confidence of the profession and can be effective in carrying out its role.

December 2011

Prepared 22nd May 2012