Surgical training has come a long way in a short time. I type this as I take the fast train up to London this morning, where I’m joining a meeting to review the new curriculum for general surgery with PMETB.
The curriculum, the ISCP website, and the Schools of Surgery supporting training in England, have all done much to revolutionise surgical training in recent years. Arguments remain about trainees shouldering the costs of this, and considerable frustration surrounds the hoop-jumping, user-unfriendly ISCP training website. However, there can be no doubt that surgical training has now been pushed to its rightful place at the top of the agenda.
The elephant in the room remains the working hours in which this training package is delivered, and the deleterious impact of the Working Time Directive. The arguments surrounding WTD have been recited many times - that frequent handovers and the lack of continuity of care harms training and patient safety, and that the skeleton (increasingly non-resident) cover does likewise. The rise of the shift system takes trainees away from both their firms and also core day-time training opportunities, amplified by the unnecessary forced ‘zero hours’ following on-calls.
Surgery finds itself in a particularly vulnerable position. As a post-graduate craft speciality, the apprenticeship model falls short when restricted working hours prevent trainees from learning their craft. Despite what some non-surgeons argue, no amount of high-technology simulation can replace this (and in any case, no-one is proposing to fund this).
So trainees now find themselves stuck between a rock and a hard place. Although the framework that supports surgical training has seen major development in the past decade, at the coal-face there has been little change in how hospitals facilitate training on a day-to-day level within the NHS. A reduction in working hours against this backdrop is disastrous.
The volume of survey responses received by ASiT and BOTA is testament to the strength of feeling generated amongst surgical trainees by this issue. They value their training, and they see it deteriorating in front of them day-by-day. Worse still, they find themselves in the unenviable position of skating around the rules and coming in to work on days off in order to progress their training. This unregulated ‘grey rota’ is not safe, not sustainable, and no way to train a modern surgeon in the 21st century.
A compromise on working hours is not the complete solution for surgical training, and no-one is suggesting it is. Professor Eraut’s recent report flagged up many problem areas. Other initiatives will be required, such as concentrating training in the hands of dedicated trainers, and concentrating trainers in units accredited and funded for this. However, the pace of change in the NHS is painfully slow and any such modernisation will take many years to approve, fund and implement.
We must take a pragmatic view of the NHS we are currently faced with. An increase in hours is vital to enable adequate training within these current constraints. Only in this way can we prevent creating another lost tribe of surgical trainees without the skill, confidence and experience to give our future patients the care they deserve.
