As the GMC consultation on revalidation draws to a close, many doctors and surgeons in particular are expressing serious concerns about the complexity of the process, especially surrounding data collection for the craft specialties. A process which, for 99% of doctors should be simple, achievable and routine is perceived as too complex, resulting in a mixture of emotions from anxiety about whether individual data collection is possible on the scale prescribed by the Standards Frameworks of the AoMRC to outright rebellion in some cases.
 Thus, an event which should be straightforward for the vast majority of us, is about to become entangled in a bureaucratic web which, given the views of the Revalidation Support Team (RST) in England (a Department of Healthfunded body), many are beginning to fear is an opportunity to introduce rigorous performance management through an enhanced appraisal process. The recession and the Coalition Government’s new agenda will see major service changes in the NHS and result in an increased focus on the efficiency of service provision. With this comes the production of more comparative activity, cost and outcomes data at an individual level. There is a danger, inherent in the process, that revalidation becomes a management tool to drive up levels of efficiency.
I expressed the view at the launch of the GMC consultation in March that the process of revalidation must be simpler and affordable, and introduced incrementally. I also took the opportunity, when I met Professor Sir Peter Rubin recently, to stress that the standards framework should now be regarded as aspirational at this stage on the grounds that there is considerable variation around the UK about the completeness and reliability of the data collection needed to establish those standards for an individual doctor. He was sympathetic to this view and indicated that a degree of pragmatism was now required by the GMC.
I welcome the sensible and pragmatic decision taken by the Secretary of State for Health, Andrew Lansley, to instruct the GMC to slow down the introduction of the revalidation process until after the pathfinder pilots have been completed. It is clear from the many discussions which have taken place throughout the UK that there are significant practical difficulties which, at present, would inhibit the introduction of a fair and consistent process. This will also allow the AoMRC through its constituent Colleges and Faculties to revisit the standards framework which, in its present form, should be regarded as aspirational Following the successful roll out of a series of meetings in the spring in Scotland, the North and South West of England, our Regional Surgical Advisor (RSA) programme is proceeding apace and by the autumn we shall have established a network of some 40 RSAs throughout the UK whose primary task is to act as a conduit between the Fellowship and Council. The programme, is being led by Messrs Ian Ritchie (Vice President for External Affairs), Roger Currie and Alistair Murray (RSA Leads) and if you would like to help the College in this way or to find out more please email. RSAs will have the opportunity to interact with the Surgical Specialty Groups (which have replaced the SABs) at what I intend will become a regular meeting with Council in the autumn, just prior to the Annual General Meeting. In addition, I shall visit (with the RSAs and Office Bearers) a number of centres around the UK in a series of evening meetings throughout the next year.
May I also take this opportunity to thank those of you who responded to our online survey of the adverse effects that the Working Time Regulation is having on patient safety and morale. The results add to the mounting evidence that patients’ wellbeing and surgical standards are being seriously undermined by rotas and shift working required by the joint constraints of WTR and the New Deal. Although the new Government has signaled its intention ‘to limit the application of the Working Time Directive in the United Kingdom’, there is as yet no firm indication of the priority which will be given to this initiative or what the final outcome will be. Although this interest is welcome news, in the context of the present difficulties facing the country, our priority as a College is to ensure that professional standards are maintained and that we find ways of supporting trainers and trainees to deliver surgical training by working within the 48-hour envelope which exists at present.
We believe that we can move a considerable way towards achieving the goal of training within a 48-hour week, provided that training and service elements of the trainees’ contract can be separated. This was first mooted by Ian Ritchie during our meeting with the Specialty Association Presidents and Council last autumn: the principle is encompassed in the diagram pictured. What is required is a radical step towards a new training contract for trainees, where the focus is on training and not on service provision. Clearly, some service delivery is required in order to gain experience but the JCST has already indicated that a trainee’s working week should include a minimum number of attendances at theatre lists. This is the first step towards developing a session-based contract which should be flexible enough to take account of varying needs at different stages of trainee development. In short, what is now urgently required is empowerment of the Educational Contract and Learning Agreement.
In the meantime, a Short Life Working Group convened by Mr Rowan Parks has suggested a number of initiatives, all of which have been supported by Council, which can be delivered now. These are contained in a document which has been sent to all Fellows and Members. I would welcome your comments on the contents which include separation of elective and emergency training with exposure to emergency surgery concentrated in high volume settings. This will inevitably require some service redesign and utilisation of non-medically qualified but trained support from, for example, surgical care practitioners. Simulation must play an increasing role in training, particularly in the early years of a training programme. Simulation training could be delivered outside the 48 hours. Surgical simulation is second best to true clinical exposure but would allow development of operative skills, non-operative technical and communication skills, and team working which would enhance the training experience.
Clinical exposure has undoubtedly been diluted since the introduction of EWTR, and the challenge is to ensure that by the time of CCT, trainees are truly competent. However, we must also recognise that education and professional development continues beyond CCT and throughout a consultant career: thus the concept of post-CCT training and mentorship should be encouraged and developed. Subspecialisation could be delivered in the post-CCT period, following appropriate selection through fellowships, combining advanced training with some service delivery. Last, but by no means least, raising the profile and status of surgical educators and trainers is imperative. We need to encourage and retain participation from excellent existing trainers, but also to engage new dynamic trainers. Dedicated time dependent on roles and responsibilities must be clearly stated and reviewed within job plans, both in timetables and in objectives and supported by medical directors. Trainers should be recognised and rewarded, and given appropriate time and remuneration for undertaking training responsibilities Finally, almost 5000 of you responded to the Membership Survey. As I write, the results are being analysed and an action plan being taken forward by a SLWG chaired by Council Member, Cate Scally, to enable us to best respond to your needs by the autumn.
David Tolley
President, RCSEd
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