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Srinivas Cheruvu
ASiT Immediate Past President,
T&O ST6

Fundamental to the practice of surgery is the experience of operating, a skill developed following many years and numerous professional hurdles, focused training and continued learning. For surgeons, operating remains one of the most stimulating aspects of their professional work and surgical trainees must train to operate. This is surely obvious, but surgical operative training is now in a chronic deficit and we can’t ignore this or allow it to continue. Why are we facing the most significant loss of surgical operative training on record, and what needs to be done?

There are many factors – including a shortage of surgical resources, the non-clinical activity burden for trainers and the increasing role of the inaccessible independent sector (IS), among other issues that have contributed to the current dilemma and how training has fallen to the back of the queue.

Pandemic restrictions may have been lifted, but the practices brought during that period have left handcuffs on the world of surgical training. The shortfall in operative training was devastating, with an immediate loss of nearly one million cases from logbooks. Four years on and we continue to see 20% fewer cases logged, with a disproportionate decline in the cases trainees perform.

Training staff

The NHS Constitution is unequivocal and pledges to “provide all staff with personal development, access to appropriate education and training for their jobs, and line management support to enable them to fulfil their potential”. Access to resources and the training of staff are synonymous with the provision of healthcare.

The figures are stark, with 97% of trainees working above contracted hours and two-thirds not taking all of their annual leave. These trainees are fighting for every chance to progress their surgical careers, covering gaps and potentially leading to burnout. A colleague said: “I wish they’d let surgeons be surgeons and focus some of our time on operating.”

Is being a surgeon the same now as it was when we started medical education? The concept of a linear career path has evolved over recent decades, with greater opportunities for less-than-full-time research, leadership, teaching and education, as well as other career pathways. The diversification of skills provided by the workforce is to be welcomed and celebrated, for we all have many attributes to offer. High-quality training is essential to achieve this and for a sustainable surgical workforce capable of providing safe operative care. We need to understand how the environment has changed and led us to this point.

Surgeons as trainers

We must acknowledge the considerable efforts trainers undertake to shape the future of the surgical workforce – one that receives little reward and is predominantly reliant on altruism.  In its latest survey results, the Joint Committee on Surgical Training has highlighted the constraint on many trainers across the UK for the allocation of training time to their job plans: 60% of trainers receive less than 0.25 PA (programmed activities) in the UK and 21% afforded absolutely nothing. It comes as no surprise that 52% of surgeons struggle to find time to train and mentor. This is despite a training tariff of more than £12,500 per annum additional to in-hours salary being provided to each Trust every year (to date there is no clear accountability or audit of this money once it has reached local Trusts).

“We must acknowledge the considerable efforts trainers undertake to shape the future
of the surgical workforce”

Instead, we see multiple competing demands expanding by the day, increasing the strain placed upon surgeons. In a digital age, emails and instant messaging mean you are accessible at all hours and held accountable for many factors beyond your control: waiting lists, relentless admin, shortage in theatre staffing, complaints, list cancellations, sickness and service provision pressures. It’s easy to see how operating becomes a respite for surgeons and a call regarding clinical work is a welcome change. Trainers need support to train, with financial recognition and protected time. Every operation, every list, every clinic and every time a trainer is with their trainee is an opportunity to train. Competing to attain a surgical job must then extend beyond service provision, with equitable access to operating at all locations where NHS care is being undertaken.

Inadequate resources

Winston Churchill’s wartime radio broadcast to the Americans resonates with us all: “Give us the tools and we’ll finish the job.” Surgery is reliant on resources to deliver care: time, qualified staff, space and specialist equipment. The 2023 UK Surgical Workforce Census Report identified that surgeons are struggling, with 56% identifying theatre capacity shortages, and nearly half highlighting the conflict between clinical and management priorities.

Within the national context, more than 20,000 NHS elective operations were cancelled due to non-clinical reasons in the third quarter of 2023/24. Those reasons included unavailable beds, anaesthetic shortage, shortage of staff and administrative errors. In England the total number of beds has decreased over the past 30 years, from 299,000 in 1987/88 to 141,000 in 2019/20. In Scotland the average number of available staffed beds for acute specialties was 13,323, down 2.4% since 2016/2017. In parallel, we see the highest occupancy rates for hospital beds and a waiting list at an all-time high of 7.8 million.

There is an unprecedented demand for surgical care, one that can be addressed only with investment in the expansion of surgical infrastructure. From the latest announcements of a further £4.5bn cut to NHS budgets, it is unclear if surgical services will receive the much-needed development.

Independent sector

This dilemma of resource shortage was put to the test during the Covid-19 pandemic and alternative options had to be explored. From this the IS came into focus. Elective recovery was a chance to provide patient care and train surgeons. Throughout my time in ASiT the feedback has been clear: no consistent access for training to the IS. We now have the highest ever proportion – 10% – of NHS elective care provided by the IS. This was a 30% increase in IS elective surgery since 2021 and a 50% increase since before the pandemic.

As reflected in surgical logbooks, the expansion of NHS work in the IS has extracted low-complexity and high-volume cases – the foundation of practice for new consultants and trainees to obtain competency. Residual complex cases in NHS hospitals may exacerbate the diminishing opportunities for training. IS organisations have been supportive of training at a number of stakeholder meetings, but contractual commitments are required, such as a review of training tariffs, whereby training is integral to the transfer of NHS work to the IS, remaining true to the NHS Constitutional pledge to train.

Recovery of surgical services means the recovery of surgical training, both for the short and long term, and must be done now. Every surgeon is a trainer and can take positive steps to train today. In the new surgical landscape we must access all our NHS patients, including those in the IS, without hurdles. High-quality training is integral to a sustainable workforce, where surgeons perform the fundamental aspects of their profession: to care for patients, operate and train.