July 2025 - Medical Training Review Submission

As part of our ongoing work, the British Orthopaedic Trainees Association (BOTA), submitted evidence to the Medical Training Review, focusing on the ongoing challenges for trainees within T&O training. Our submission was long and detailed, and covered a variety of areas of concern including possible solutions. Most of these are well-known issues, and have considerable overlap with BOTA’s top 5 priorities, published in May 2024, which continue to guide much of our work. 

We canvassed opinion from our network of regional representatives from each deanery across the UK, to relay opinions from their deanery on current issues in T+O training, along with discussions at our Regional Reps day held in Leeds in May. We also took opinions and input from a variety of meetings across training and workforce areas (SAC, JCST, IEST, BOTA and BOA committee meetings, Royal College meetings and others).

We’ve summarised some of the key points from our submission to the review below:

Access to training, particularly in elective subspecialties

Many trainees are having ongoing difficulty meeting logbook numbers, especially in arthroplasty. There has been a loss of elective exposure post-COVID, a shift of low complexity, high volume cases out in to the independent sector, and waiting list pressures impacting training on routine lists. Outcome 3s from ARCPs are rising, primarily due to insufficient operative numbers (especially in arthroplasty).

Mismatch Between Training & Workforce Needs  

Trainees are still expected to undertake post CCT fellowships in order to be prepared to be a day 1 consultant, which has a multitude of financial and family implications. This suggests that training is not being delivered in a manner that allows trainees to become subspecialty ready day 1 consultants at the end of CCT.

High Cost of Training  

Costs for courses and conferences are borne by trainees with significantly delayed reimbursement. There is inequity across regions and nations with regards to study budget access. Some fees (e.g. ISCP) are borne by trainees when they are mandatory for training. We need to invest in the learning and development of our future T&O workforce to ensure we become the best surgeons we can be.

Training vs Service Conflict  

The ongoing issue between access to training and service provision has a significant impact on trainee numbers and ARCP outcomes. There is no penalty to trusts for underfilled rotas, which can leave resident doctors overworked and at risk of burnout. Locum rates have been capped or held static for a number of years, in some case across regions, disincentivising resident doctors from backfilling rota gaps.

Under-Recognition of Trainers / Professionalising Training for Trainers

High-quality training cannot occur without professionalised, supported trainers. Trainers often lack time or recognition for training roles and are unsupported in CPD as educators, face workload pressures that deprioritise training, and are unable to claim back simple expenses such as travel. We need to invest in trainers to ensure trainees get the best training experience possible.

Fragmented Employment / HR Burden  

Hyper-rotational training increases both workforce and training inefficiencies; fragmented employment models (only some regions have single lead employers) lead to regular problems with payroll issues/HR/payroll, stability, mandatory training, and access to things like mortgages, lease car schemes etc; lack of knowledge of upcoming rotations across training years leads to difficulties with family and personal life.

Lack of Accountability for Training Outcomes / Reforming the Payment Model for Training

Currently, training tariffs are paid to Trusts without adequate linkage to delivery. Training is often side-lined for service needs; poor performing trusts and departments persist, and there is no incentive for excellence or penalty for underperformance. There is an opportunity to reframe training levies as investments in defined and modernised outputs, rather than passive subsidies, along with transparency in use of training levies.

Core Surgical Training

GMC NTS data consistently shows CSTs to be unhappy, for which there are a number of purported causes – geographic uncertainty, bottlenecks for competitive ST3 selection, and being the group most at-risk of training loss from expansion of the extended surgical team. Reform of CST is a BOTA Top 5 Priority for these reasons.

BOTA’s submission reflects many of the issues we have heard from you all about key areas for training reform, and as an organisation and committee we continue to advocate for T&O trainees.

We’d encourage all trainees with an interest in making T&O training better to consider standing for the BOTA national committee - nominations and voting opens later this year and the new 2025-2026 committee will be announced at BOTA congress in November 2025 - stay tuned for updates!

Adam Pilarski

Sustainability & Workforce Rep