DOI: 10.

1308/147363514X14042954769915
SHAPE OF TRAININg
I M P L I C A T I O N S O F T H E
S H A P E O F T R A I N I N g
R E V I E W F O R S U R g E R Y
Ann R Coll Surg Engl (Suppl)
2014; 96: 357359
HJM Ferguson, JEF Fitzgerald, AJ Beamish
on behalf of the Council of the Association of Surgeons in Training
Published in 2013, the Shape of
Training review is an independent
review of postgraduate medical
training overseen by Professor
David Greenaway.
1
This review has
set out recommendations for the
structure and delivery of training
for the next 30 years,
1
including
a framework and timescale for
this reconfguration. There is a
wide range of key themes, listed in
Table 1. The changes proposed in
its 19 recommendations are far-
reaching, with implications for both
current and future surgical trainees
in the UK.
The Association of Surgeons in Training
(ASiT) is a professional body and
registered charity working to promote
excellence in surgical training for the
beneft of patients and trainees alike.
With a membership of more than 2,300
surgical trainees from all 10 surgical
specialties, ASiT represents a voice for all
surgical trainees. ASiT submitted written
evidence to the consultation component
of the review, addressing issues relating
specifcally to surgical training.
Report analysis
A summary of the key recommendations
made by the review is provided in Table
2. The broad goal of delivering trained
doctors who match the needs of the local
population is laudable. ASiT supports
the notion that postgraduate surgical
education must be able to respond to
changing demographics and patient
needs. Specifc note and endorsement is
made of the recommendation to improve
the holistic nature of care, reinforcing
key aspects such as cultural awareness,
patients individual circumstances and
communication skills. The support of an
apprenticeship model for ongoing surgical
training is also welcome.
Concerns
The main concerns identifed by the
ASiT are:
1. Run-through training as proposed in
the review has been tried previously
in surgical specialties and was rapidly
withdrawn.
2. The shortening of specialty training
such that a surgical trainee could
be considered a consultant surgeon
and practise independently, perhaps
only six years following graduation
fundamentally misunderstands
the rigours of surgical training and
the demands of being a consultant
in ever evolving craft specialties.
Furthermore, we do not believe the
NHS is fnancially or organisationally
capable of delivering such training in
the time specifed.
3. The proposal for the insertion
of a year for additional career
development within training, as
opposed to an out-of-programme
period outside of training, further
reduces the available specialty
experience or possibility for formal
research and should be abandoned.
4. We feel that the term Certifcate
of Specialty Training (CST) implies
that CST holders will be specialist
generalists. If this is what is intended,
then these new specialist generalists
must be recognised as such in the
future NHS hierarchy as of equivalent
seniority to subspecialists. If a
non-specialist generalist is what is
desired, then we offer no support
to these proposals as it represents a
subconsultant grade by another name.
5. The award of a CST would result
in a generalist who may still require
supervision for all but the most basic
of procedures. This is incongruous
with the current Certifcate of
Completion of Training (CCT) and
there is no support for the endpoint
of surgical training to represent
anything other than a fully trained
consultant surgeon, capable of fully
independent practice. As ASiT
has recently stated, it has never
previously been deemed acceptable or
workable to have a grade whereby the
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
overlap in duties and responsibilities
makes roles diffcult to distinguish or
whereby despite undertaking similar
duties (eg operations), one is deemed
to be of lower responsibility or
requiring less skill.
2
6. The migration of subspecialty
credentialling beyond formal
postgraduate training raises
signifcant fnancial and organisational
questions, which appear not to have
been given consideration. Surgical
trainees should not have to bear any
further costs for their training as a
result of the delivery system.
7. The plugging of service gaps in the
emergency department by broadly
training surgeons fails to address
the root cause of these service
defciencies and risks further
decreasing hands-on surgical training
in the time available.
Although it is outside of the remit
of ASiT, broad concerns have
also been raised regarding other
recommendations, including moving
General Medical Council registration
to the completion of medical school
training rather than after Foundation
Year 1. It is unclear how medical schools
can deliver this and it would also open
up the foundation programme to
considerable competition from newly
qualifed European doctors, who would
then be eligible to compete for posts.
Conclusions
The motivations of this review
are broadly laudable but the
recommendations are generally lacking
in suffcient detail to allow meaningful
abstraction on to future surgical
training. Furthermore, in a document
that seeks to improve the training
of the surgeons of the future, there
is disproportionate reference to the
improvement of service provision.
We accept that these two entities are
interdependent but feel that trainees
should not be the solution to service
gaps, nor should a subconsultant grade.
We have specifc concerns regarding
the potential product of the proposed
training system in surgery. Although
it is commendable that the review
acknowledges that there is no appetite
for a subconsultant grade, this appears to
be the reality of what the reforms would
lead to in all but name. Within the term
subconsultant we include the possibility
of a consultant only in name, with a
different contract, pay and employment
opportunities from the subspecialist.
The CST holder of the future will lack
the in-depth knowledge and operative
experience of current trainees owing
to the shortened and broadened
training structure proposed. While the
review intends these trained surgeons
to provide the majority of generalised
care, it is clear that they will be working
at a lower level to that of the current
CCT consultant. This is not in the best
interests of future patient care in surgery.
Patient expectations for their care
continue to rise. At the same time, the
complexities of surgical care together
with the focus on surgeon outcomes
are driving the profession towards ever
GREATER FLEXIBILITY MUST BE GIVEN
FOR CRAFT SPECIALTIES TO ACHIEVE
THE TECHNICAL, PROFESSIONAL
AND KNOWLEDGE-BASED SKILLS
THAT THEIR FUTURE CONSULTANT
CAREERS WILL NECESSITATE

Five themes were identifed that the review focused on:
> patient needs
> balance of the medical workforce specialists or generalists
> fexibility of training
> the breadth and scope of training
> tensions between service and training
KEY THEMES OF THE SHAPE OF TRAINING REVIEW
TABLE 1
1. Full GMC registration should move to the point of graduation from medical
school.
2. The FP should continue as a two-year programme, facilitating broad-based
learning in community and secondary care settings.
3. Following the FP, doctors will enter broad-based specialty training in a general
area of practice. (Child health, womens health and mental health are
specifcally mentioned.)
4. This training will proceed for 46 years.
5. There will be the option of a single year to be taken within training to expand
management/educational/clinical experience.
6. The CCT will be replaced by a CST.
7. The future CST holder will be eligible to apply for consultant-level posts in the
generality of their training area.
8. Subspecialty skills will be acquired after obtaining the CST by a process of
credentialling.
9. All changes in training (and therefore the products of the proposed training
system) will be based on the local needs of the population.

GMC = General Medical Council; FP = Foundation Programme; CCT = Certifcate
of Completion of Training; CST = Certifcate of Specialty Training
SUMMARY OF THE REVIEWS KEY RECOMMENDATIONS
TABLE 2
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
increasing specialism. In parallel to this,
factors discussed previously by ASiT
37

are conspiring to substantially reduce the
operative experience of current surgical
trainees. ASiT therefore fnds it diffcult
to see how the generalist model proposed
in this review can be reconciled against
these pressures and be of beneft both to
patients and trainees. Greater fexibility
must be given for craft specialties to
achieve the technical, professional and
knowledge-based skills that their future
consultant careers will necessitate.
With regard to post-CST training,
ASiT does not support the notion
of subspecialty credentialling in the
ten existing surgical specialties. The
migration of subspecialty credentialling
beyond formal postgraduate training
raises signifcant fnancial, organisational
and gatekeeping questions, which appear
not to have been given consideration.
ASiT believes that the one-size-fts-
all approach to postgraduate training
taken in this review is inappropriate for
surgery. Even in the unlikely event that
the NHS were able to commit signifcant
fnancial resources to undertake
a complete reconfguration of the
current model of postgraduate medical
training, it is diffcult to see how these
recommendations could be implemented
in surgery.
The respective royal colleges have
been challenged to deliver their future
plans for surgical training based on the
recommendations of the Shape of
Training review. We look forward to
engaging with the profession, patient
groups and other stakeholders to
ensure the highest standards in the
shape of future surgical training.
Further information
> Shape of Training webpage:
www.shapeoftraining.co.uk
> Full ASiT response to the review:
www.asit.org/resources/articles/
shapeoftraining
References
1. Greenaway D. Securing the Future of Excellent Patient
Care. London: GMC; 2013.
2. Shalhoub J, Giddings CE, Ferguson HJ et al.
Developing future surgical workforce structures:
a review of post-training non-consultant grade
specialist roles and the results of a national
trainee survey from the Association of Surgeons in
Training. Int J Surg 2013; 11: 578583.
3. Association of Surgeons in Training. Aspiring to
Excellence: Findings and Recommendations of the
Independent Inquiry into MMC Response by the
Association of Surgeons in Training. London: ASiT;
2007.
4. Association of Surgeons in Training. Optimising
Working Hours to Provide Quality in Training and
Patient Safety. London: ASiT; 2009.
5. Fitzgerald JE, Marron CD, Giddings CE. The
infuence of specialty, grade, gender and deanery
on the implementation and outcomes of European
working time regulations in surgery. Br J Surg 2011;
98: 21.
6. Fitzgerald JE, Giddings CE, Khera G, Marron
CD. Improving the future of surgical training and
education: consensus recommendations from the
Association of Surgeons in Training. Int J Surg 2012;
10: 389392.
7. Wild JR, Lambert G, Hornby S, Fitzgerald JE.
Emergency cross-cover of surgical specialties:
consensus recommendations by the Association of
Surgeons in Training. Int J Surg 2013; 11: 584588.
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