January 2019

British Orthopaedic Trainees Association 35-43 Lincoln’s Inn Fields
London WC2A 3PE

0207 405 6507 www.bota.org.uk @bota_UK

About BOTA

The British Orthopaedic Trainees Association (BOTA) was established in 1987. BOTA represents the professional needs of over 1000 trauma and orthopaedic surgeons in training throughout the United Kingdom. BOTA is a democratically elected committee that is affiliated with the British Orthopaedic Association (BOA). It is independent of the National Health Service and the Surgical Royal Colleges. BOTA It is run by trainees, for trainees, for the benefit of patients.

Introduction

The General Medical Council (GMC) has launched a consultation on its draft framework for the introduction of credentialing in postgraduate medical practice in the United Kingdom. This follows an earlier consultation in 2015 when the British Orthopaedic Trainees Association (BOTA) and the Association of Surgeons in Training (ASiT) issued a joint position statement in response to their early plans.1 At the time, the GMC defined credentialing as ‘a process, which provides formal accreditation of competences (which include knowledge, skills and performance) in a defined area of practice, at a level that provides confidence that the individual is fit to practise in that area.’ The GMC outlined that credentials would be recorded on their List of Registered Medical Practitioners. Our 2015 position statement made five recommendations, including that credentialing should not overlap with any skill or competency accredited in the existing curricula for the award of a Certificate of Completion of Training (CCT). Our original recommendations remain relevant to the current consultation.

The current draft framework for establishing credentials states that a credential ‘will provide recognition and training opportunities in particular areas of practice. These will be optional components within specialty training or substantial areas existing outside training. Like postgraduate curricula, they will describe the expected outcomes and capabilities doctors must demonstrate as they become experts in the field.’

The GMC consultation requested a response to each of the six areas highlighted in bold below. We submitted the responses via an online form on the 25th January 2019. We repeat some subject areas as it is not known if answers are to be reviewed separately or as a whole.

Why credentials are needed

BOTA fully supports all activity that promotes excellence in, and improvements to, patient care. The GMC, as the regulator for all medically qualified clinicians, presents the need to regulate areas of clinical practice that are not adequately regulated at present. It is apparent that some areas of practice, for example cosmetic procedures performed by non-clinical providers, would benefit from additional regulation to better protect patients. However, the GMC has not defined how the credentialing framework presented will result in appreciable differences to the vast majority of surgical practice. All doctors are expected to practice according to the professional codes detailed in Good Medical Practice and we believe that in the overwhelming majority of patient episodes surgical care is provided by surgeons who practice within the ‘limits of their competence’.2

At present, the GMC regulates doctors alone, and it is not clear what areas of surgical practice would require additional credentialing. Surgeons throughout the UK are currently supported by a high- quality training structure, world-leading workplace assessments and rigorous professional regulation. It is our primary concern that credentialing represents a process that could, in future, remove areas of clinical practice from postgraduate surgical curricula, with the effect of reducing surgical training opportunities and diluting the breadth and depth of surgical capability at the point of Certificate of Completion of Training (CCT). These concerns were highlighted by those who contributed to the GMC’s original 2015 consultation on credentialing, with ‘many’ respondents concerned that ‘credentialing might seek to duplicate or unpick existing specialty training.’3

In line with Good Medical Practice, surgeons, not least those practicing orthopaedic surgery, establish experience in their subspecialist area of interest during their formal specialist training and during optional post-CCT fellowships. Subspecialist expertise is achieved, and delivered alongside, a generalist practice that permits considered and informed decision making for all patient encounters to provide holistic surgical care. The potential for ‘endorsed modules’ to compartmentalise surgical practice and narrow surgical training opportunities through the removal of valuable content from postgraduate surgical curricula would not be supported.

Defining a credential

The definition of what a credential does or should represent is currently inadequate. The three principle areas of clinical practice that could be credentialed are presented as:

  1. Areas of unregulated practice.
  2. Areas of the current postgraduate curriculum that the UK Medical Education Reference Group (UKMERG) and GMC seeks to remove from postgraduate training.
  3. Areas of the current postgraduate curriculum that the UKMERG and GMC seeks to make attractive for doctors in alternative training programs, SAS doctors and other healthcare professionals.

BOTA supports the GMC’s intention to ensure all patient care is regulated.

Unspecified areas of surgical training could be removed from current postgraduate curricula and training according to the draft framework. We believe that this will dilute the quality and breadth of the current Certificate of Completion of Training (CCT) and present a risk to patients in the long term. The value of broad and holistic surgical care would be undermined. The absence of specific examples of practice that could be considered appropriate for removal from postgraduate curricula prevents a comprehensive critique and examples and clarifications to this effect would be welcomed. It is not clear which areas of orthopaedic surgical practice, if any, would be considered appropriate for a credential.

The process and cost of training clinicians in a particular credential is not presented clearly. Further clarifications would permit a more specific response. The framework should define the following: example credentials, entry requirements, financial costs, delivery of training in credentials, methods of assessment, and defined outcomes for pilot evaluation. Surgical pilots should be developed with the involvement of trainers, surgeons in training and patients, and should be subject to transparent and independent evaluation. Surgical training is associated with mandatory professional and educational costs, which range between £20,000 and £70,000, depending on the specialty.4,5 Credentialing must not add to this expense and no fees should be required to prove one’s clinical capabilities. Linking credentialing to one’s ability to pay will do nothing to convince the surgical profession of the value of credentialing and will not address the current crisis in specialty recruitment. Talented individuals from all backgrounds should be encouraged to pursue medicine as a career and increasing the costs of training further will do nothing to address long-standing imbalances within the medical profession.

Future proposals to alter current surgical training curricula and structures should be guided by peer- reviewed research and consultation with the relevant surgical professional bodies, namely the Joint Committee on Surgical Training (JCST), Specialist Advisory Committees (SACs) for each surgical subspecialty, surgical Royal Colleges, surgical trainee associations (including BOTA and the Association of Surgeons in Training), and subspecialist societies (for example, the British Orthopaedic Association).

BOTA is concerned that healthcare professionals that lack postgraduate surgical training to the level of CCT will be afforded opportunities to train in narrow areas of practice without the broad experience necessary to provide holistic and safe patient care. Although areas of niche or highly specialised (advanced) practice are expected to be recognised as a credential initially, we are concerned that broader and less advanced areas of practice will become credentialed in the future. The role the GMC will play in the future regulation of physician’s assistants is to be determined.

Criteria and threshold for credentials

If credentialing is adopted by the GMC, it is the opinion of BOTA that it should be restricted to those areas of niche or highly specialised (advanced) clinical and surgical practice not currently expected by the Certificate of Completion of Training (CCT). Establishing credentials for pre-CCT practice risks creating a tiered CCT with a variable ‘product’ that would be to the detriment of holistic patient care and might generate confusion and concern among patients. The limited information provided by the draft framework in relation to particular criteria and thresholds prevents a comprehensive critique and worked examples and clarifications to this effect would be welcomed. It is not clear which areas of orthopaedic surgical practice, if any, would be considered appropriate for a credential in the short or long term.

The regulatory process

The GMC’s aims and processes for the regulation of credentialing remain unclear. Further clarification regarding how individual credentials are to be awarded, regulated and appraised is essential. As previously stated, no fees should be required to prove one’s clinical capabilities. Surgical training is associated with mandatory professional and educational costs, which range between £20,000 and £70,000, depending on the specialty.4,5 Linking credentialing to one’s ability to pay will do nothing to convince the surgical profession of the value of credentialing and will not address the current crisis in specialty recruitment. Talented individuals from all backgrounds should be encouraged to pursue medicine as a career and increasing the costs of training further will do nothing to address long-standing imbalances within the medical profession. Alternative avenues of funding should be explored.

As previously stated, it is the opinion of BOTA that credentialing should be restricted to those areas of niche or highly specialised (advanced) clinical practice not currently expected by the Certificate of Completion of Training (CCT). Establishing credentials for pre-CCT practice risks creating a tiered CCT with a variable ‘product’ that would be to the detriment of holistic patient care and might generate confusion and concern among patients. Unspecified areas of surgical training could be removed from current postgraduate curricula and training according to the draft framework. We believe that this will dilute the quality and breadth of the current Certificate of Completion of Training (CCT) and present a risk to patients in the long term. The value of broad and holistic surgical care would be undermined.

A phased approach to implementation

A plan for implementation can only be considered when the aims, objectives and specifics of credentialing are better defined.

To maintain patient safety and the trust of the public and the surgical workforce, a considered and phased series of pilots should precede any plans for widespread implementation. Each surgical pilot should be developed in consultation with trainers, surgeons in training and patients. Each pilot should be subject to transparent and independent evaluation at every stage, with clear outcome measures, influenced by key stakeholders, defined from the outset. The pilots should help define example credentials, entry requirements, financial costs, delivery of training in credentials, methods of assessment, regulation and ongoing appraisal. There must be mechanisms to stop the process if patient safety is compromised or if the outcome measures do not demonstrate appreciable or significant advantages to clinical practice and patient care.

The final reports of the three credentialing pilots from 2012 provide an insight into how credentialing could be applied to different areas of clinical practice, not just surgery.6 However, it is not apparent that external professional bodies, for example, the Royal Colleges, were invited to review the findings of these reports. Enhanced engagement with the professional bodies listed throughout this response is recognised as essential if curricula and structures for surgeons in training are to be affected by credentialing. The necessity and process of awarding credentials to those already practicing independently also requires clarification.

Supporting flexibility in training in other ways

BOTA is concerned that the proposed ‘endorsed modules’ may permit areas of postgraduate medical practice to be reallocated or shared with healthcare professionals who lack the depth and breadth of surgical training to provide the highest quality patient care. The draft framework provides limited information in relation to how credentialing could or would support flexibility in training, which prevents a comprehensive critique. Future clarifications to this effect would be welcomed. Any changes to current postgraduate curricula and training structures must support current trainees and avoid exacerbating the current recruitment crises seen across surgical (and non-surgical) specialties. Surgery must continue to attract the most able medical graduates to maintain the highest levels of patient care as part of the multi-disciplinary team.

The completion of post-CCT fellowships of varying duration in advanced areas of orthopaedic surgical practice, perhaps not sufficiently achieved (in terms of access or overall numbers) during postgraduate medical training, remains an important option for those wanting to consolidate their knowledge and surgical skills. The potential for commonality between credentialing and experience gained during such experiences is observed. The GMC’s commitment to competency-based training is supported by BOTA. However, it remains important for both UK and international pre- and post- CCT fellowships to be recognised as beneficial and for them to remain optional (decided upon at a surgeon’s discretion) and for no fellowship to become mandatory to achieve a credential.

Any other comments

The draft framework appears to have been developed with little stakeholder involvement and presents few specifics for organisations, such as BOTA, to make an informed and comprehensive critique. In addition, presentations delivered by the GMC, and witnessed by BOTA, in recent months have presented few details and provided limited answers to questions asked.

References

  1. Credentialing in postgraduate surgical practice: A joint statement from the Association of Surgeons in Training and the British Orthopaedic Trainees Association. Available at: http://www.bota.org.uk/wp- content/uploads/2015/09/ASIT_BOTA_Credentialing_Position_Statement.pdf. Accessed January 2019.
  2. GMC Good Medical Practice. Available here: https://www.gmc-uk.org/- /media/documents/good-medical-practice—english-1215_pdf-51527435.pdf. Accessed January 2019.
  3. GMC credentialing consultation: Results and next steps. Available at: https://www.gmc- uk.org/-/media/documents/06—credentialing-consultation—results-and-next-steps_pdf- 65711404.pdf. Accessed January 2019.
  4. O’Callaghan J, Mohan HM, Sharrock A, et al. Cross-sectional study of the financial cost of training to the surgical trainee in the UK and Ireland. BMJ Open 2017;7(11):e018086.
  5. Davies P, Morrison R, Bucknall V. The cost of training in trauma & orthopaedics: Where do all the pennies go? JTO 2017;6(2):52-3.
  6. GMC final report credentialing pilot studies. Available at: https://www.gmc-uk.org/- /media/documents/final-report-credentialing-pilot-studies_pdf-61540524.pdf. Accessed January 2019.