Royal College of Surgeons of England, Lincoln’s Inn Fields, London
Tuesday 2nd October 2018
BOTA representative: Mr Matthew Brown
The Joint Surgical Colleges Meeting (JCSM) of all the surgical Royal College Presidents (RCSEng, RCSEd, RCPSGlas, RCSI) agreed that national, accredited, post-CCT fellowships should be explored by the Joint Committee on Surgical Training (JCST). The Shape of Training review made 19 recommendations and the current exercise seeks to achieve some of these, in addition to the GMC’s stipulation that speciality and subspecialty training should be ‘approved, regulated and quality-assured’. Gareth Griffiths, JCST Chair and Consultant Vascular Surgeon, is leading the current scoping exercise and convened this meeting to seek opinions from a wide variety of surgical community stakeholders from across the UK and Ireland, including surgical SAC Chairs (T&O was represented by Mr Mark Bowditch), educational committee leads, trainees (BOTA and ASiT) and lay persons. The current JCST scoping exercise will run until December 2018 with the potential for 5 pilot fellowships in August 2019 restricted to cardiothoracic, otolaryngology and general surgery. The pilot will not include orthopaedic surgery.
The proposal presented by Gareth Griffiths was to establish a small number of JCST-accredited post-CCT fellowships, which would be curriculum-based, quality-assessed, assessed and with a defined end-point for completion. Training would be delivered by the host department, with quality assessment completed by the JCST and a statutory body such as the GMC. Fellowships could become consistent with planned GMC ‘credentialing’ (see appendix 1, below) but would be less specific in terms of specification and level of detail as details and scope for credentialing remains unclear. The small number of fellowships would be restricted to clinical areas beyond that expected for certification. There was categorical confirmation and reassurance that these fellowships will not become a de facto extension of training and the value of CCT will be maintained.
In relation to orthopaedic practice, the T&O SAC had been invited to propose potential areas of practice that could benefit from this accreditation. They had suggested: peripheral nerve injuries (PNI), sarcoma, spine/scoliosis and infected revision arthroplasty. These are only suggestions and the appetite for T&O engagement is uncertain (see JCST meeting notes, October 2018).
As credentialing details are not confirmed, particularly with reference to surgical practice, the JCST fellowship project is not linked but may form a way for individuals to provide evidence to achieve a credential in a given area of practice. Although the proposals are for fellowships covering niche and/or high-risk subspecialist areas, BOTA and others highlighted that a drift towards more general areas of practice in the future cannot be guaranteed and it was highlighted by BOTA, ASiT and others that this could dilute the value of the current CCT. Again, there was confirmation from the JCST Chair and project lead that these fellowships are in no way intended to become a de facto extension of training and the value of CCT will be maintained. All fellowships in the UK are optional and it was confirmed that there were no plans to make any fellowship mandatory through this process, a point that BOTA strongly supports. The current proposals are designed to complement the current varied selection of fellowships, with no plans to replace current fellowships.
Funding for these accredited fellowships is not established given the infancy of current plans. It is hoped that central funding (i.e. HEE) would be forthcoming if the value of the scheme was accepted. A potential precedent for HEE funding is the existing pre-CCT Training Interface Group (TIG) fellowship scheme, which is funded by HEE to the tune of many millions of pounds (see appendix 2, below). BOTA highlighted that the current JCST fee should not be used to fund this post-CCT venture, which would benefit only a very small number of post-CCT surgeons. Post-CCT training and education is not currently the remit of the JCST.
Achieving level 4 competence in niche and/or high-risk areas of practice is an early objective of both these proposed fellowships. It was highlighted that Higher Surgical trainees are not expected to achieve level 4 competence in all areas of practice. For example, the T&O curriculum requires level 4 competence at CCT for total hip arthroplasty but not total ankle arthroplasty.
Centralised application through national selection was proposed as the preferred interview process, being modelled on the existing TIG fellowship scheme. The pros and cons of national selection were discussed. The costs of national selection were highlighted as an issue. In support of national selection, it was highlighted that higher surgical trainees on some training programmes would be unable to access training in some niche surgical areas due to geography and regional or national centralisation of services (e.g. sarcoma surgery). These individuals may benefit from national selection, with the best candidates securing a fellowship regardless of pre-existing relationships or training region. BOTA highlighted that many departments, particularly those with established fellowships, would likely be very reluctant to relinquish control of their local recruitment system. BOTA and ASiT highlighted that geography is important to all, not least post-CCT surgeons who will be in their mid-late 30s, often with families and other commitments, and allocation by national selection does not always respect geographic preferences.
There is merit in providing a network of high-quality training fellowships in surgical areas that are recognised to be high-risk for patients and/or technically more challenging for the surgeon. Linking the number of fellowships to workforce planning will prevent too many surgeons being trained in niche areas where few consultant posts exist. However, there is concern that post-CCT fellowships could spread beyond niche areas to more general surgical areas and hence dilute the value of the CCT. If this were to occur, BOTA would expect for higher specialist training to be redesigned to better prepare trainees for consultant practice and maintain the value of CCT.
BOTA and ASiT requested that post-CCT surgeons should not be referred to as trainees in any future communication relating to this pilot.
Appendix 1: GMC Credentialing
The GMC delivered their draft framework for credentials/credentialing. Two types were presented, firstly, looking at the components of training (e.g. taking place in the NHS), and secondly recognised areas of practice. The GMC frequently asks itself ‘does this area need GMC oversight?’. Areas of practice with increased complexity (surgical technique or clinical context) are ripe for inclusion, but another 8 factors are being considered by the GMC. Credentialing will accompany individual clinician details on the List of Medical Practitioners. Framework will be published in spring 2019. The plan is not for all doctors to achieve a credential, and it will not become a legal obligation. For example, those performing cosmetic surgery may practice without a credential (if a cosmetic surgery credential is indeed established!) as long as the clinician is practicing according to Good Medical Practice and therefore practicing within their area of competence and maintaining their professional development. The GMC highlighted that insurance companies have indicated that higher premiums were likely for those practicing without a credential if one existed in that area of practice in future.
Appendix 2: Existing pre-/peri-CCT fellowships
Fellowships are noted to be either regulated (by the GMC) or unregulated, with all except one being unregulated. The GMC recognises 10 surgical specialities and only one sub-specialty (related to paediatric surgery). The only regulated fellowship programme in the UK is the Training Interface Group (TIG) fellowships, that are centrally funded, limited in number, linked to national workforce requirements and awarded according to a national competitive application process. TIG fellowships are regulated by the GMC.
The RCS England currently runs a peri-CCT fellowship scheme, known as the RCS Senior Clinical Fellowship scheme. Established in 2012, there are currently 57 different programmes offered, lasting 6 months to 2 years, in areas of surgery generally considered outside CCT curricula (e.g. bariatric surgery) in 8 of the 10 specialty areas. Fellowships are awarded following competitive application with a TPD report sought that should highlight the potential impact on local trainees (i.e. loss of training opportunities). Registered with ISCP, with monitoring completed at 3 months and 12 months. Reviews and feedback from the fellow and the trainer are sought, in addition to qualitative and quantitative logbook data. There is no specific curriculum and the RCS admit that these fellowships require heavy administration. They are not formally linked to workforce planning. No money is provided to accompany the fellowships and personal financial costs are recognised. Fellowships are awarded at the RCS Diplomates Days.