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Presidential Address to Annual General Meeting of Fellows, Members and Licentiates

11 June 2008

Fellows, Members and Licentiates

It is a privilege and a pleasure once again to give the presidential address to the College’s Annual General Meeting. I am doing so for the third and final time as I enter the last month of my presidency. This is an opportunity to review a number of professional and political developments over the last 12 months, to refer to some highlights in the College’s year and to mention various plans for the future. As I said one year ago, at a time of unprecedented change in the National Health Service and formidable challenges for the profession on a range of fronts, I have no shortage of material.

It is good to see so many of you here today, reflecting I believe continuing interest in, and commitment to, the work of the College, supporting surgeons at all levels as we seek to provide the safest and highest quality surgical care for our patients.

I opened my address last year with reference to Modernising Medical Careers and the Medical Training Application Service and I make no apology for doing so once more. In the wake of the shambolic introduction of MTAS, as a cornerstone of the MMC initiative, everyone – the profession, the public, politicians and the media – waited fearfully for last August. In the event, while we continued to see personal injustices, distress and disillusionment, this passed without quite the catastrophe many predicted. Clinicians across the country had feared for the worst, but had made preparations to ensure that their patients’ care would not be affected. That said, the adverse impact of this scandalously flawed recruitment process on the careers of a generation of talented and committed trainees has been devastating and professional morale, not high in recent years, has been severely and, perhaps for some, irreversibly damaged.

My continuing priorities on this issue over the last year have been to secure a significant temporary expansion of ST3 surgical training posts and to ensure that selection into run-through surgical training programmes will in future generally be at ST3 level. Our best efforts have achieved additional posts, but the numbers have been disappointingly low – 49 extra national training numbers in 2007 and 37 in 2008. Also, there is a regrettable division between the surgical specialties with regard to the preferred level for selection into run-through training and the debate continues. The post-CCT clinical fellowships initiative is intended primarily to provide opportunities for individuals to obtain specialist skills and experience not readily available within training programmes and then offer specialised regional services for managing rare and complex conditions. This also has the potential to enable earlier release of some training numbers to help a few more of our beleaguered trainees caught in the transition bulge. I was particularly pleased that we have managed to obtain 70 fellowships for surgery.

It was a measure of the ineptitude and unfairness of this disastrous exercise, and its profound implications on so many fronts, that not one but two independent inquiries were launched. Sir John Tooke and his team undertook a forensic analysis of the huge body of evidence submitted to them and produced a comprehensive report with 47 recommendations that received near-universal approval from the profession. I welcomed this report and emphasised that it must not be allowed to linger on Whitehall desks. It would be entirely unacceptable for its recommendations to be delayed or lost by being subsumed into wider-ranging reform proposals for the NHS. However, the Department of Health’s response, while prompt and substantial, gave only a qualified commitment to many of the Tooke recommendations and there was a lack of any commitment to others. It was also disappointing that no timetable was given for implementing those recommendations it did support. The Health Select Committee of the House of Commons undertook an equally comprehensive inquiry and its measured report was no less critical of those directly associated with this ill-conceived and incompetently managed project. The Government’s response to this report is awaited. I have to say, with personal experience of submitting written and giving oral evidence to a number of Health Committee inquiries, that there has been a depressingly familiar cycle of crisis, major inquiry, damning report and defensive reaction. I do fear that the impact of both reports, and their potential to effect essential changes to the arrangements for specialist training, will be lessened if they are subsumed within the wider context of the review and future plans for the NHS to be published in a few weeks time.

Despite our concerns about the appointment process, the College has remained committed to the original underlying principles of MMC in unfinished business and the structured training programmes in the various specialties are underpinned by a surgical curriculum. The intercollegiate surgical curriculum, defining the standards for progression, incorporating assessments of competence and supported by a web-based e-portfolio or data management system to facilitate the annual review process and ultimately the award of the CCT, was successfully implemented last August. Take-up since then has been remarkable with the number of trainees registered and validated now approaching 3,500. The curriculum requires constant review and updating. Many of you were involved in its development and I hope we can count on your continuing and essential support as this evolves.

The Eagle Project is also complementary to MMC. The first phase of this ambitious £13 million project, the Wolfson Surgical Skills Centre, was opened by Lord and Lady Wolfson on 17th October 2007. Work is well advanced on the second phase, the Clinical Skills Unit, that will include a bench top skills area, a minimally invasive surgery and critical skills area and a virtual operating theatre for human factors training. Completion is anticipated later this summer. The design of the third phase, the Seminar Suite, is now under consideration and the funding required for this will be our next priority.

I have sought over my presidency to engage the College more effectively across the political spectrum as it is only by direct involvement with politicians and policy makers that we can influence developments in healthcare. I have had another full year of meetings with ministers and officials at the Department of Health, representatives of the opposition parties and the leaders of many medical organisations. I should say that access to the highest levels of the Department of Health has been facilitated greatly with the appointment of a surgical colleague, Lord Darzi, as a health minister. I look forward to the publication of his next stage review and I hope that his findings and proposals will reflect my discussions with him in which I have identified what the College considers a number of priority areas for surgery. A new area of engagement for the College in the last year was the annual conferences of the major political parties. The programmes of fringe events give access to many major organisations and key individuals involved in healthcare issues. I attended the Labour Party conference in Bournemouth and was on the panel for a debate on the reconfiguration of services. Professor Tony Mundy and Dermot O’Riordan represented the College respectively at the Liberal Democrats conference in Brighton and the Conservative Party conference in Blackpool. The College’s involvement was warmly welcomed by all three parties. My dealings with politicians generally have demonstrated that there are rarely quick wins, but perseverance can pay. The European Working Time Directive and Independent Sector Treatment Centres have been regular agenda items in my meetings at Richmond House, the House of Commons and elsewhere. With regard to ISTCs, for example, I can reflect with some satisfaction on the Department of Health’s decisions not to sanction a third wave, to remove the additionality clause and to require second wave centres to provide training opportunities for junior doctors. The EWTD continues to be a source of real concern as August 2009 looms, but I was encouraged recently to learn that primary care trusts collectively have been given some £100 million to help trusts achieve compliance in one year’s time.

I have had another busy year of visits to hospitals around the country, learning at first hand of the problems you face on a day-to-day basis and hearing about local innovations that are improving surgical services. I am very grateful indeed to all of you who have helped to organise presidential visits, roadshows and other events locally. As I have said before, it is essential that I am aware, and indeed have evidence, of the issues affecting surgeons and the care of their patients for my meetings with Department of Health ministers and officials and NHS managers.

The various divisions and departments within the College have had another busy year on a wide range of activities. I shall not outline these today, but the 2007-8 annual report is in preparation and you will be able to read a full account of the College’s work when this is published. I will refer now, however, to a few examples of important developments that indicate that the College is active and looking to the future on all fronts.

Council decided last autumn to commission an independent external review of the structure and operation, activities and plans of the Education Department. Similar reviews of other areas of College activity have been undertaken over the years and proved invaluable and it seemed appropriate to review this, our largest department, 15 years after its establishment. The review was particularly timely with the redevelopment of our education and training facilities on the fourth floor, increasing regionalisation of our activities, emerging proposals for continuing professional development and recertification and the impending retirement of the Director of Education. The review panel, led by Sir Peter Simpson, past president of the Royal College of Anaesthetists and an Honorary Fellow of this College, consulted widely and produced a report, with a series of recommendations, that was acclaimed and unanimously supported by Council. The department will be substantially restructured over coming months to be led by a newly-appointed director and managed by another new appointee, an operations manager. The department will be more fully integrated within the College and it will have a focus on the development and piloting of courses with increasing delivery of courses with double badging on a regional basis. I can assure you that the College’s leading role in surgical education will be strengthened, not diminished, by the changes taking place.

Council also gave its support last autumn to the establishment of a policy unit within the College. A policy manager has now been appointed to head the unit with the intention of expanding the staffing as resources permit. In broad terms the unit will establish a bank of existing policy documents and statements outlining the College’s views across a range of professional issues; keep these under review and update them as necessary; identify new topics for policy development in line with the College’s overall strategy through horizon scanning and liaison with other professional organisations; co-ordinate research and evidence gathering for those policy topics approved for development; and work with the Communications Department on a communications plan for selected policy areas. The Council lead members for strategy and policy will be closely involved in the work of this unit.

While much attention and substantial resources have been given to the Eagle Project, the College is not ignoring the need for other major capital developments. In particular funding was allocated a few months ago for a detailed feasibility study and costed plans for a major redevelopment of the first floor of the College building. It is intended through this project to improve access to modern learning resources and the historical collections of the College, enhance the experience of visitors to the building through the development of a visitors centre, increase income through sales, catering and the corporate hire of facilities, with the added advantage through this self-contained area of improving security within the building. The plans are at an early stage, but I am sure you will be kept informed as this proposal is considered further.

When I was elected President in 2005, I identified four issues that would be personal priorities during my presidency. I have referred today, on many visits around the country and in my presidential newsletters, to the SHO bulge and the need for additional training opportunities during the MMC transition period; to the EWTD and the challenges of 2009 compliance and seeking an opt-out for surgical trainees; and to access for NHS surgeons to work, and junior doctors to train, in ISTCs. The fourth issue was the development of outcome measures in surgery. This will remain a major challenge during my successor’s presidency and beyond, but I believe significant early progress has been made. After a decade or more of a relentless and often misguided target culture in the NHS that has distorted and marginalised the clinical basis for many aspects of patient care, politicians, the profession and the public now seem agreed on the importance of quality and its measurement. Effective measures of quality of care will be essential in the NHS of the future to enable patient choice, ensure effective commissioning and promote best practice. Two weeks ago in the College we held a seminar on Outcome Measurement in Surgery – the case, the tools and the timing, convened by Sir Ian Kennedy, Chairman of the Healthcare Commission, with an invited audience including members of Council, presidents and others from the specialist associations and representatives of a wide range of healthcare organisations. The scene was set by Sir Bruce Keogh, medical director of the NHS, and a succession of excellent speakers addressed different aspects of this issue. A number of important conclusions emerged from this event with a clear outline of the way to take this initiative forward. Progress will be gradual, based initially on a few index procedures and team or unit rather than individual results, but the process is now underway. This is an area in which I intend to retain a personal interest and involvement over the next few years.

In closing this address, can I take this opportunity once again to congratulate John Black on his election as President of the College. He will succeed me at the Council meeting on 10th July. I know he will bring to this office the experience, insight, vision, commitment and enthusiasm it requires. He will be ably supported by the new Vice-Presidents, Bill Thomas and Linda de Cossart, and to them also I offer my warmest congratulations. I shall be leaving Council next month along with elected members Anne Moore and Chris Russell who have so effectively supported me over the last two years as Vice-Presidents. I owe them my sincere thanks. My thanks go also to the other members of Council who have been so supportive during my presidency. We welcome to Council Steve Cannon, Derek Alderson and Chris Milford following the recent election and I know they will make significant contributions to the affairs of the College in years to come. This is an opportunity for me to thank you and many hundreds of other Fellows and Members around the country who act on behalf of the College in a wide range of roles. I and Council are very grateful indeed for your willing and continuing support, often in the most demanding of circumstances. Additionally, I offer my thanks to members of the College staff at all levels who have provided first class service across the full range of our activities, some in high profile posts and others in unsung roles in remote parts of the building. Thank you all for your contributions to the work of the College.

Finally, let me say once again what an immense privilege it has been to serve as President of this Royal College over the last three, shall we say eventful, years. I hope I have been able to repay in some part the debt that I owe my professional colleagues and my College for being with me and supporting me throughout my own career.