Current Newsletter

Mr John Black, President

Exciting times

Many thanks to all 980 of you who completed the recent survey on the effects of the European Working Time Regulations (EWTR) on safe surgical practice and training. The message was stark. After a year of supposed 48-hour working in the NHS, things are worse than they were a year ago. More consultants and trainees than in 2009 thought that patient care and training had deteriorated.

Any idea that the EWTR could be accommodated by the professionalism of surgeons and others working in the NHS is wrong. The stark truth is that the NHS, like every other healthcare system in the world, just cannot work with these artificial hours restrictions, designed for a totally different group of workers. The results of the survey and the comparisons with a year ago are appended below. The EWTR is bad for patient safety, training of surgeons and ironically for the lifestyle of those it is meant to protect.

The good news of course is that we now have a sympathetic government, which I trust will have the political will to solve the legal problems by one of the several methods available to them. We will continue to impress on them that this is an urgent matter, with patient safety compromised and the training and experience gap of future consultants increasing by the day.

The Royal College of Physicians, with their new President, Sir Richard Thompson, is also expressing strong concerns about the effects of the EWTR. For those doing acute medical emergency takes, with the staggering volume of emergency admissions these days, it is a major problem. Some of the medical specialties such as cardiology and gastroenterology are very similar to surgery, with a significant out-of-hours emergency commitment and a lot of daytime procedure-based elective skills to be learned. The solution is the same: sensible working hours and a contract based on training and not hours worked.

One of the ironies of the EWTR is that it is not health department legislation and takes not a fig of notice of the difficulties and dangers inflicted on the consumer, in our case patients. It is part of the social chapter and comes under the remit of the Department for Business, Innovation and Skills. ‘Limiting the application’ of the EWTR is in their work programme for the coming year and we will impress upon them the urgent and critical nature of the problems for patient care and training in the NHS.

It is now three-and-a-half years since the Modernising Medical Careers (MMC) programme collapsed and the subsequent Tooke inquiry recommended a restoration of traditional basic (core) training followed by competitive entry into one of the nine specialties. In surgery, as always, there is a large excess of core trainees for the number of opportunities to enter specialty training. The ratio of applicants to posts for ST3 entry to the surgical specialties, the old SHO/registrar hurdle, varies from 4.4-to-one to 14.9-to-one. Many have experience way beyond that stipulated in job specifications and a substantial proportion has been qualified for more than ten years.

We are back to where we were in 2002, when the Chief Medical Officer (CMO) tried to address the problems of the large ‘lost tribe’ of SHOs unable to get a specialist registrar post. The solution put forward at the time was run-though training from the foundation years, which was imposed from above and led to the catastrophes of MMC and the Medical Training Application Service (MTAS). Some of those displaced at that time are still working in surgical or research posts and continue to aspire to a surgical career.

So what are we going to do about it? What would we have done in 2002 if the CMO had asked us for advice and not set up MMC? We have to grasp the nettle of defining a career structure that allows fair competition to select the best while being fair to those who lose out in the inevitable fierce competition. I think one way would be to have some sort of limit on the number of attempts made for entry into specialty training and there needs to be debate on what the competition ratio should be. How much oversupply should there be at the core/specialty career hurdle? We need to give firm advice to the government on this critical issue.

To this end the College is carrying out an online survey of its fellows and members. I hope we can finally draw a line under MMC/MTAS and move on with a fair career structure. To achieve this I need to know the views of surgeons at the grass roots. I apologise for asking you to take part in another survey so soon after the EWTR consultation. However, this is important and the more of you that give us your opinion, the more likely we can get what surgeons want.

The fee charged to trainee users of the Intercollegiate Surgical Curriculum Programme (ISCP) is not a topic to warm the heart. It came about because the last government withdrew funding from the colleges for administration and quality assurance of training posts and gave it to the Postgraduate Medical Education and Training Board, which after its failure in the MMC/MTAS disaster has from April 2010 been subsumed into the General Medical Council. You may well ask why the government does not now restore the funding to the colleges, which continue to do most of the work, and I will be making this point to them.

The fee helps to meet the costs of the Joint Committee on Surgical Training (JCST), of which the ISCP is part. This is an intercollegiate body, responsible to all four surgical colleges. As well as administering the online system, its work includes writing and updating the surgical curricula, keeping trainee records and running the specialty advisory committees that provide external advice to regional training committees. The total cost is around £1.5 million; there are 17 staff in the JCST secretariat and approximately 10 other staff also working on an intercollegiate basis. The fee was set at £125 in a three-year agreement two years ago. However, if the full cost were to be paid by each trainee using the JCST/ISCP it would be around £350 per annum.

Council debated the future level of the fee on 8 July and decided to support members of this College to keep the fee they pay at the current rate of £125 from July 2011. This recognises the fact that our members already pay a subscription to the College. There will also be a review of the function of the JCST.

The MRCS examination is intercollegiate but is not fully integrated into a single organisation as for the FRCS. Each college retains its own court of examiners but the examination itself is standard with a multiple-choice first part and an objective structured clinical examination second part. Although at one time the pass rate varied depending on where the exam was taken, this is no longer the case. The chance of passing for an individual candidate is the same, regardless of which college is applied to and the centre where the examination is held. Examiners are appointed and trained to the same standards and there is significant exchange between colleges.

Some forthcoming changes should make life easier for candidates. From 2012 there will be five sittings each year instead of three. Candidates, depending on demand, may be asked to attend at a session run by a different college. Be reassured, however, that those applying for membership of this College will on passing the exam become members of The Royal College of Surgeons of England.

I spoke at an enjoyable session at the end of June at the staff and associate specialist grade (SAS) doctors’ conference held in the Manchester United football stadium. I was delighted to compliment them on the invaluable service provided to the NHS by those who are neither consultants nor trainees. We have a very active SAS committee in the College, which sends representatives to very many areas of College activity and whose chair is an invited member of Council. SAS doctors may become examiners in basic sciences and there is a wide range of specific courses and training sessions.

Revalidation for SAS surgeons will be to the same standards as for all surgeons. To this end they should contribute to national and regional audits, keep a logbook of personal activity and outcomes (using the single portfolio when it becomes available shortly) and conduct personal audits where required.