Trainee Representatives report to BAPS exec Sep'08.

Trainee minutes BAPS EXEC Sep'08.

Trainee report SAC meeting Sep'08.

Surgical neonates need your help please!
Prospective survey of all surgical neonates 1st November 2008 – 31 January 2009
Download details from the files section after logging into the Yahoo group.

Leeds, 23-24 October 2008. Download form and details

Dear All

I am writing to invite you to the BAPS National Training Day which will be held in Leeds on the above dates. On the Thursday, the venue will be the Leeds General Infirmary and Hirschsprung’s disease will be discussed. This will cover clinical management ranging from initial diagnosis, definitive management and outcome. The ISCP curriculum will be addressed and speakers will be from a number of disciplines.

As part of the meeting we will also cover topics that are both common and important in clinical practice and the exam; on the Thursday afternoon we will discuss Inguinal Hernias. This will cover standard management, the evidence surrounding this, and what to do in uncommon situations. On Friday the venue moves to St James’ University Hospital for a joint session with Adult Urology trainees. Here orchidopexy will be covered in detail with a video link for live operating followed by an interactive session.

As well as clinical teaching, there will be a Registrar Meeting and an informal dinner on the Thursday evening. A copy of the programme is attached below.

Unfortunately, the timing of the meeting will clash with the RITAs for the Leeds, Sheffield, Nottingham, Leicester consortium who will be in Sheffield for at least some of the Friday. It has not been possible to move the date or the venue of the RITA or the training meeting. We are very sorry for the impact that this will have on local trainees; we will provide a summary of the discussion on the Friday, have made an adjustment to the cost of the meeting for those effected and hope they will still find it possible to attend at least part of the meeting.

All trainees with an interest in Paediatric Surgery are welcome. The cost will be £40 to include food on the Thursday evening. There will be a reduction to £30 for those who have RITAs on the Friday. To book, please complete the form below making cheques payable to Leeds COPU as soon as possible. The form and cheque should be returned to:

Mr Jonathan Sutcliffe
Department of Paediatric Surgery
Clarendon Wing
Leeds General Infirmary
Gt George Street
Leeds LS1 3EX

This year’s BAPS congress was the second time the congress included a trainee session. This was held on the Wednesday morning and started with a free papers session with nine trainees presenting. The subjects were varied and the talks all well presented and judged for the award of the Trainee Prize.

These were followed by a brief trainee meeting at which the main topic was the current number of trainees and future consultant employment prospects. Unfortunately the recent large expansion in trainee numbers has led to greater uncertainty about long term job prospects post-CCT. The trainee representatives continue to raise these concerns at BAPS executive and SAC level.

The second half of the session was a seminar presented by Ed Holyoake of Covidien on the use of electrosurgery. This was an excellent and interesting session and we are grateful to Azad Najmaldin for his help in the organisation of the session.

That evening consisted of the trainee dinner sponsored by BAPS at which David Keene of Manchester was presented with Spitz and Coran’s Operative Paediatric Surgery as the winner of the trainee prize for his talk on the effectiveness of Broviac line dressings. We are grateful to Rick Turnock for his support of the session, including chairing the judging panel and his after-dinner speech, and to the other judges Tomas Westin of Stockholm and Paul Johnson of Oxford.

We are continuing to consider how we can continue to raise the profile of both the trainee session and the trainee dinner as part of the congress. This has received a significant boost in Paul Johnson negotiating on our behalf that the Trainee Prize winner be invited to submit a manuscript to the Congress edition of the JPS. Other suggestions have been to make the dinner open to all trainees but have an invitation only arrangement for consultants so they can be recognised for their contribution to training in the preceding year. Any other suggestions would be gratefully received.

Iain Yardley & Clare Rees.

Download the recent Elogbook report.

Download the Trainee Rep's report

The National Training Day for SpRs and StRs will be held at Chelsea and Westminster Hospital on the 26th and 27th June 2008. Download the agenda for the programme.

1. Trainee Report - Download

2. Commisioning safe & sustainable paediatric services - Download

3. BAPS Exec report - Download

4. ASiT report - Download

There has been much confusion about this issue recently with the changes to immigration regulations and the court cases that have followed. Our understanding is that those from within the UK and EEA and those from outside these areas who do not need a work permit to work in the UK can apply freely for training posts. Those who do need a work permit to work here can apply but will only be considered if no suitable UK or EEA candidates apply, this is extremely unlikely to apply to any paediatric surgery posts. The matter is currently still in the appeal stages and may change so we strongly recommend that all those who may be affected consider this as advice only and check carefully on the MMC and other websites before making any final decisions.

SAC Meeting in Paediatric Surgery 7th February 2008
Trainee Report

There was a meeting of the SAC at the Royal College of Surgeons on 7th February which Iain and I attended on your behalf. In the afternoon was a further meeting of the SAC with programme directors. Key issues from both meetings are summarised below.

1. ISCP – the JCST is responsible for the ISCP. It was noted that many trainees are signed up to the site, but not enough trainers are signed up. There was discussion about how the ISCP is funded – it has been funded by the DoH but it is likely that trainees will have to fund it in the future. A cost of £125 per trainee per year was suggested. Whether this would apply to SpRs as well as StRs was not known.

2. Subspecialty training posts in Scotland – there are plans for 2 Laparoscopic fellow jobs and one urology job. These would not need further PMETB approval and would be open to applicants from England and Wales as well as Scotland. Trainees would have to have the first part of their exam before applying for these jobs, and would need to be eligible for CCT by the time they finished them. Concerns were expressed about the lack of manpower planning in the NHS – the target of 4 paediatric surgeons per 1,000,000 has already been met in Scotland, but not in England.

3. Tooke Report – an official government response is not expected before the end of February. It is likely that FY1 will be uncoupled from ‘Core training’ which will last 3 years and end with competitive entry into specialist raining. Post CCT training is likely to be required in Paediatric Surgery. Recent news from the Home Office blocks entry to training jobs by non-EU trainees.

4. ST3 expansion – there was a delay in advertising London ST3 jobs (have now been advertised)

5. Post CCT fellowships – advantages are that they are forward looking and will be very attractive for trainees. The disadvantage is that training may be diluted. Specific fellowships were not discussed.

6. Urology – there was a long discussion about the plans for Urology to apply for subspecialty recognition. The process involves support from a Royal College (RCS(Eng)), application via the SAC to the JCST which would then put the proposal to college council. If approved, the council would apply to PMETB, and approval in principle would be granted. PMETB would then check specific training programmes. The SAC in Urology has agreed to this in principle. However, after discussion about the practicalities of this plan, Mr Malone decided that BAPU would have to have further discussions about whether they wished to proceed with the process.

7. SAC Liaison members – training programme directors are not necessarily on the SAC, but there is a proposal that they should become members to provide external quality assurance for consortia. The concept of a Penultimate Year review – at the RITA 1yr before CCT to check all paperwork is in order – was supported. This would be undertaken by the external training programme director on the RITA/ARCP panel.

8. Chairman’s report – the chairman reported that there were currently 90 trainees, 40% female, with 12 expecting to achieve CCT in the coming year. It is not known how many people who are currently ST1s will be ST3s in 2009. The challenge is to develop a coordinated strategy with deaneries and the NHS workforce review team to ensure that the right numbers of trainees are trained.

9. National selection for training – has been chosen as a model by Plastic Surgery, Neurosurgery and Cardiac Surgery already. Currently Paediatric surgery in England has not gone down this route, but may consider it in 2009. There is already national selection in Scotland.

10. JCST/PMETB – various issues were discussed including the definitions of
a. OOPT – out of programme training (PMETB involved)
b. OOPR - out of programme research (PMETB may be involved)
c. OOPE - out of programme experience (PMETB not involved, will not count towards CCT)
d. OOPC - out of programme career break (PMETB not involved)
For OOPT/R the deanery seeks prospective approval and must have the support of the SAC. Posts in the EU/EAA are excluded if the posts are approved by the relevant competent authority (but PMETB does not have a list of who these are!). The SAC checks afterwards that educational objectives were met. OOPT counts towards CCT. Jobs done outside of this do NOT count towards CCT and may require that the trainee gets a CESR (Article 14) not a CCT. We will seek clarification on whether this applies to old style SHOs who did jobs that were not prospectively approved by PMETB because it didn’t exist at the time. (Since the meeting PMETB have replied and indicated that SHO jobs which had educational approval will count, see message on mailing list). OOPR can only be recognised towards CCT if the curriculum includes research as an optional element of training – in practice it is unlikely to be recognised for trainees who are not on an approved academic track already. Further information may be available at www.pmetb.org.uk/trainees .

11. Academic surgery – the importance of academic surgery was recognised, but the perceived conflict with service delivery was acknowledged. It is not clear how the Tooke report will influence the path of academic surgery. We presented the results of the trainees’ survey into research, and trainees were thanked for their participation in this important study. The survey had a good response with 60 trainees replying in time for the report. Of these, about half had undertaken a period outside of clinical practice and many thought that they might undertake research in the future, Most trainees who had done research commented on what a valuable experience it had been and we encouraged the SAC to continue to support research. The report will be published on the website in the future.

12. Exam – the next exam will be held in Oxford in March 2008. The current pass rate is 2/3 for the written and 75% for the second part (60% overall). The group of question writers has been increased and there is now a bank of >1500 questions to which 200 are added each year.


Clare Rees
Paediatric Surgery Trainee Representative

Trainee Rep Report
4th February 2008

1. Curriculum update - the BAPS E&T committee will be sending a member to the ISCP curriculum meeting next week. Specific points to be raised include the list of DOPs and PBAs for Paediatric surgery which do not reflect the expected competencies of ST3 trainees who will need to use them. It is not clear who wrote them, and the committee does not propose to offer to write new ones, but will suggest appropriate procedures to be assessed including pyloromyotomy, appendicectomy, inguinal herniotomy, orchidopexy and circumcision (not infant). It was also noted that blank PBA forms would be useful so that trainees can adapt them to any operation.

2. RITA/ARCP process – the ARCPs this year will be very similar to RITAs and trainees should complete the green and yellow forms still.

3. E logbook – the logbook continues to be updated and Miss Cusick is happy to register all new trainees. There will be a logbook committee to be convened soon, with Sarah Wood to represent trainees on this committee.

4. Training meetings – the following meetings are all planned for the near future (dates on Trips diary @ www.trainee.baps.org.uk )
• Oncology course – just completed, no official feedback yet
• Trauma course
• EUPSA
• BAPS training day at Chelsea & Westminster – date confirmed as 26-27th June
• BAPS congress Salamanca
• APA meeting
• Simpson Smith Symposium 21st May – programme reviewed, to include sessions on GORD and Management of Complications, Simpson Smith Lecture to be given by Prof Alan Flake (Philadelphia Children’s Hospital).
• General Paediatric Surgery course – a new course which aims to cover gaps in the syllabus not covered on other courses (eg Trauma, Oncology, Neonatology). It was noted that the title does not necessarily make it clear that this course is for Paediatric Surgeons, and a suggestion was made to remove the word ‘general’ from the title to make this clearer. The cost was discussed, and noted to include accommodation. The course is supported and coordinated by the Raven Department of Education at RCS(Eng).
• Oxford Neonatal Course – 14-18th July
• Basic Sciences course - this was run on a 2-yearly basis but not in 2006 during MMC. Mr Jesudason at Liverpool is planning to run the course this year. No dates available but probably winter.
It was agreed that all courses run by BAPS should have a discount for BAPS trainee members. This will not include externally run courses.
Training days will be centred around a theme, as requested by trainees after the Nottingham training day. Centres which have not hosted a training day in the last 5 years will be invited to choose from the list of topics provided by the committee.

5. National Surgical fellowships - it is possible that Paediatric Surgery will be awarded up to 6 of these next year. It is not known whether the Department of Health has an ongoing commitment to fund these posts.

6. CPD/ Revalidation - BAPS is represented on a college steering group which represents all 9 surgical specialties. With the exception of the cardiac surgeons, most specialties do not have mechanisms in place for revalidation yet. It is envisaged that there will be generic advice from the RCS and that this will be based on the ISCP website. It was noted that it is particularly difficult to compare outcomes in a specialty with small volume operations which are expected to have good long term outcomes. The difficulties remain as to how to set the standards and what to assess.

7. Electronic training resources - no progress to report, but a grant may be available from the Dept of Health to provide funding for this area. The committee will investigate this.

8. Pilot of OSCIs at RITA/ARCPs
A proposed pilot of an OSCI examination to be held as part of the RITA process is expected to take place in the London/SE deanery this year. This is intended to provide an objective assessment of trainees’ competencies and to highlight areas which need further input. If a deficiency is noted because of a lack of training in a particular area (e.g. laparoscopy) this could be used to decide future placements. It is envisaged that there will be 10 stations including X-rays/CT scans/ Laparoscopic skills etc. If the pilot is successful then this could form the basis of the decision to select trainees to progress from ST2 to ST3 and even be part of a national ranking system.

Clare Rees

1. Consortia:

The basic principle of grouping training centres in consortia was strongly supported with a requirement to train in at least 2 centres being felt to be essential. The ideal program would be to spend three years in a centre but definitely no more than four before a move to another centre. No more than one house move during the training period should be anticipated.
It was acknowledged that the current consortia cannot continue as Scotland and Ireland are not under the auspices of PMETB in the same way as English training programmes now are. Those trainees already appointed on the understanding they will be rotating within consortia as they existed previously WILL be trained within those consortia and have a contractual right to expect this to happen (e.g. Scottish trainees rotating to Newcastle), however new appointments will not be made to these consortia.
The future configuration was discussed with particular reference to London, Belfast and Newcastle.

London: This was felt by some to have become over large and unwieldy, especially since the addition of Eastern deanery centres (Cambridge and Norwich). However, no concerns were expressed from within the London consortium and its management to date was felt to be exemplary. Problems with sub-specialty exposure were explained as a problem for division of the consortium. The consensus was that it would remain as it was for the time being.

Belfast: This has become isolated by the recent changes and concerns were felt that “mainland” trainees would not want to rotate to N Ireland. We felt this may be the case but that trainees desire to train in paediatric surgery may be such that they would be prepared to work there for a period of time. Belfast had suggested a non-reciprocal arrangement with a mainland centre for their trainees to rotate to. Another suggestion was to include Dublin on the PMETB list of approved OOPE centres and provide 2 centre training that way. It was noted that PMETB will approve EU based training automatically providing that the relevant “competent authority” provide evidence of training status for that post. These 2 avenues will be explored.

Newcastle: This is most likely to merge with Leeds in some way but the implications of this on the Leeds-Sheffield-Leicester- Nottingham consortium are unclear.

Through all the discussions we emphasised the trainees’ flexibility and willingness to move for their career but also their requests for clarity in advance of changes that have such huge implications on our personal lives. This was acknowledged and attempts will be made to clarify this in advance of advertising posts but there may be a long list of potential sites to rotate to on the job descriptions that will be reduced as the configurations become clearer.

2. Recruitment for 2008:

Existing appointments to run-through training would be honoured, this would mean that all ST3 posts for 2008 are already accounted for. In order to allow trainees to enter training at this level there will be an additional 10 “one-off” posts at ST3 next year. It was stressed that these represent a last chance for trainees at this level.
The exact location of these posts is unclear but the proposal was for 4 in London and 2 in each of the other consortia. Future opportunities in paediatric surgery may have to be significantly reduced depending on work-force planning estimates.
ST 3 and ST 4 posts will be available in Scotland in 2008, the personal specifications are available to view on-line at the MMC Scotland website:
http://www.mmc.scot.nhs.uk/documents/v5ST3PaediatricSurgery2008.pdf
These jobs are open to all to apply for, not just Scottish trainees. Although personal specs for England have not yet been released they are unlikely to be significantly different to Scotland and prospective applicants would be advised to look at these specifications and ensure they fit them.
All appointments will be at a local (Deanery) level. No new run-through appointments will be made at ST1 or 2.
It is not clear what will be happening to FY1/2 – whether they will also be uncoupled as recommended in the Tooke report, or not.

3. Intercollegiate Exam:

The question bank for the first part is now complete with 1500 questions, of which 200 will be drawn each time to compose the exam. These questions will continue to be refined. The pass rate is currently approximately 60% for each part of the exam; this is broadly in line with other surgical specialties.

4. Logbook:

The correct logbook to use for all trainees, as approved by the BAPS Education and Training committee is the one found at www.elogbook.org. Registering on the site is straight forward. The facilities offered by this logbook continue to improve.

5. PMETB Survey:

The repeat survey is now under way, new questions have been formulated to improve the quality of the survey. Trainees were asked to notify PMETB if they had not received an invitation to complete the survey.

6. Quality Assurance:

A QA report was presented to the meeting. This was based on information from the JCST website and completed by ST1 trainees in all surgical specialties. Specific Paediatric Surgery info was not available due to small numbers. The gist of the presentation was that trainees have very high expectations of their training programmes which are not always met, and may not be realistic. ST1 trainees felt that they were well supervised but did not get to theatre as often as they hoped. Data from ST2 and ST3 are now being collated.
The SAC felt that trainees should be involved in quality assurance to ensure that we get the best possible training.

E-logbook
This is accessible via elogbook.org and is the logbook we should all be using. There are Palm and Pocket PC versions that can be downloaded. The operation list has been updated and improved and now includes the codes used by HES data to code operations. Presentations showing how to use the logbook will be uploaded to the BAPS website and will be available for all BAPS members (including trainee associate members). All users of the logbook were encouraged to pay the £20/year registration fee which covers running costs and development.

BAPS-CASS Survey
This will commence data collection on oesophageal atresia beginning May 2008.

Revalidation and Recertification
These are going to affect us greatly in our consultant careers and are separate processes. They will run on a 5year cycle and are expected to start in January 2009.
- Revalidation: It is anticipated that this will be a relatively straight forward procedure and ongoing registration with the GMC can be anticipated providing regular appraisal is in place and there have been no serious concerns raised about the doctor in question..
- Recertification: This will be a more involved process led by the College and the Specialty Associations (BAPS in our instance) that will have to be completed in order to remain on the specialist register. The details are not yet clear but are likely to entail the provision of a logbook including CPD activity and evidence of satisfactory practice eg. complication rates and outcomes as well as an examined element that will have to be at the same standard as that required to obtain the CCT. The process will be on a 5 year cycle and the intention is to pilot it in the West Midlands and the South West in the first instance.

General Paediatric Surgery (GPS) Provision
The ongoing debate about the provision of general paediatric surgery continues; it remains unclear if general surgeons will be prepared to take it on or if it will become exclusively our remit. It is worth noting that the president of RCSEng and at least one vice president are of the opinion that it should be undertaken by paediatric surgeons. Whilst we did not voice an opinion as to who should be doing this work we did point out the significant uncertainty this left us in with regard to our future job prospects and appealed for clarity as soon as possible.

Training and the Tooke report

The Tooke report was broadly welcomed, particularly the notion of uncoupling ST1 and 2. This would have some implications for the implementation of the ISCP curriculum for paediatric surgery as it stands but would give the opportunity to create rotations giving a basic grounding in the generality of surgery from which trainees could apply to a variety of specialties. In considering the ideal posts to include in this time, the importance of adult general surgical experience was emphasised.
Run-through jobs offered at ST1 and 2 in paediatric surgery will be honoured. There will however be an additional ten (10) posts at ST3 level next August. It is not clear where these posts will be in the country but will be “one-off” appointments and will not recur in later years. We again expressed our opposition to training number expansion without workforce planning demonstrating a likelihood of consultant posts for the trainees once they held a CCT. Our concerns regarding training opportunity and particularly case numbers were partly allayed by the fact that these posts will not be “new” jobs, rather they will be a re-badging of existing posts (such as FTSTAs).

In the future (possibly 2009) a national selection process for paediatric surgery may be introduced, the SAC however feel they are not yet ready for this and appointments in 2008 will be made locally.

Consortia

The existing training consortia were conceived when Calman training was introduced to enable trainees to work in more than one centre without the need to reapply mid-way through training and potentially move excessive distances. However, there are now significant problems with the way they are set up. Newcastle cannot be linked to Glasgow and Edinburgh any longer as the latter are now part of Scotland, the same applies to Belfast and Dublin as Dublin now lies outwith the remit of PMETB. It is anticipated that trainees could go to Dublin as an OOPE and PMETB have indicated that ‘established links’ between centres (such as Belfast and Dublin) would not require so much paperwork as other OOPEs.
How the consortia would work with a new system is unclear and how centres continue to be grouped is currently under discussion including the need to train in more than one centre. We would welcome your opinions on this via the email group so we can present them to the SAC next time they meet.

Endoscopy
This has become something of a problematic area. Traditionally surgeons had performed both upper and lower GI endoscopy routinely. Now the gastroenterologists perform the vast majority of elective endoscopy, leaving problems for the paediatric surgical trainee who wants training in endoscopy, despite this the surgical service is still expected to provide out-of-hours upper GI endoscopy, for example for bleeding or foreign bodies. It was felt by the council that lower GI endoscopy would be unlikely to remain within the general paediatric surgeons’ skills set (with the possible exception of surgeons carrying out significant amounts of IBD surgery) but UGI endoscopy remained a key skill. The provision of courses was identified as a particular problem area and the possibility of providing these for surgical trainees will be explored.

USB memory sticks
These are in general use but, following an incident at the Edinburgh Congress, we are asked to ensure they are encrypted in case they are mislaid.

Congress 2008
This will be Wednesday July 2nd to Saturday July 5th 2008 in Salamanca, Spain. A trainee session will be held at this congress, likely to be on the Wednesday afternoon. Abstract submission details for this will be circulated soon. This session will be combined with a mini-symposium on “Energy in Surgery” organised by Mr Najmaldin. We also hope to hold a trainee dinner as we did in Edinburgh.

Congress in 2009 will be a joint meeting with EUPSA in Graz, Austria, earlier than usual from 17th – 20th June, 2010 will be in Aberdeen in July.

BAPES
BAPES (British Association of Paediatric Endoscopic Surgeons) are currently seeking a new trainee representative. If you are interested please let us know and we will pass your details on.

BAPS Membership
All trainees with an interest in becoming paediatric surgeons are invited to join BAPS as associate members. This is relatively inexpensive (£100 a year) and easy to apply for via the BAPS website. The benefits include a reduced fee for the congress and the trainees’ dinner. In order to benefit from this reduced fee, applications will need to be received before the Spring council meeting for approval. Associate members are also welcome to attend council meetings.

Iain Yardley and Clare Rees.

Dear All,
At the recent BAPS educating and training committee meeting the following points were raised that you might want to know about:

1. e logbook – this is now live and we are all recommended to use it. You can find it at http://www.elogbook.org/ . ST trainees are required to use it as their logbook. Your trainers also need to sign up to the logbook as cases are only added when the trainer approves them. One of the incentives to participate in this process for trainers is that any case that they were the trainer for will be added to their own logbook, so the data will then be easily available for M&M, Audit etc. If you have any questions about the logbook, or there are operations you can't find, please email Miss Cusick directly at Eleri.Cusick@ubht.nhs.uk . If anyone has emailed via the logbook she has dealt with these queries but can't get back to you directly because she doesn't get the address of the sender!

2. Training opportunities in South Africa: an offer has been made by the South African centres at BAPS International forum in Edinburgh for their unit (RedCross Tygerburg Durban and Johannesburg) to provide training posts for SpR's from the UK. Unfortunately, these posts are not funded but there is the possibility of applying for travelling fellowships (e.g. from Ethicon). Prospective PMETB approval would also be required.

3. Nottingham training meeting – excellent feedback, we all seemed to enjoy this meeting and there was a very strong indication that themed training days were most useful to trainees. This will be taken into account for future meetings.

4. Next training day – will be held at Chelsea on 6th March 2008.
If there are any training issues that you would like me to raise at the next meeting, please email me.

Thanks.
Clare Rees.

It has been proposed that all appointments to surgical training schemes at ST level 1 or 2 be time limited, meaning that there would be no guaranteed progression to higher levels of training and that an additional competitive selection process would occur prior to ST 3. This would be broadly similar to the previous situation with SHO grades seeking progression to SpR training and has been referred to as “uncoupling”. In the MTAS process, however, there were appointments made at ST2 level in paediatric surgery that were not FTSTAs, with the understanding of the trainee that they had been appointed to “run-through” training. This has left the situation unclear as to how ST3 posts will be appointed next year and may mean that those who were unsuccessful in applying to ST3 level in 2007 are unable to compete for ST3 posts in 2008.

The following is an attempt to present the views of paediatric surgical trainees following an open discussion at our National Training Day on 2nd October. This meeting was attended by a variety of trainees including foundation level doctors, FTSTAs, trainees at ST 1, 2 and 3 level (some of whom had been appointed to “run-through” posts), SpRs and those seeking entry into training posts in MMC.

It should be noted that whilst on some issues opinions were unanimous, on others opinion was divided, reflecting the fact that in order to progress it is not possible to act fairly to all groups of trainees.

Current Situation

Trainees have been appointed to ST2 posts in paediatric surgery with the expectation that this will be a “run-through” appointment and, assuming satisfactory progress and assessments, they will arrive at a CCT without further selection.
There remain trainees committed to the specialty who are seeking ST3 level appointments having failed to secure posts in the MTAS round 1 or 2. It is unclear how many ST3 level posts will be available in future years.

Firstly the situation as exists currently needs to be addressed and then a consideration of how things may be arranged in the future can be undertaken.

Current Selection of ST3 Run-Through posts

We feel that two separate groups of trainees need to be considered and that it is important to try to act fairly to both those seeking ST3 posts and those already appointed to ST2 posts. Regrettably seems it will not be possible to produce a solution that will be satisfactory to all.

Three possible options were considered as a way forward:

The first option was to introduce uncoupling with immediate effect. This would mean that any trainee appointed at ST2 level as a “run-through” would have this appointment retracted and would have to enter an open, competitive selection process in order to obtain an ST3 post in paediatric surgery. This proposition had significant support from those present for several reasons including the manner in which the selection process was carried out and the lack of opportunity for other, more experienced candidates to apply to ST3 posts. Conversely many felt this was unfair to the trainees from whom an offer would be withdrawn who would face further uncertainty and who may have made firm plans for their futures based on the appointment to “run-through” training. Doubts were also expressed as to the legality of withdrawing job offers once made.
A second option was to honour the appointments made to ST2 trainees and allow them to run-through. This met with some support as it was felt to be dishonourable to withdrawn previously made offers and, providing that the competency assessments were robust enough, only good trainees would progress. Opponents to this felt that to allow these trainees to run-through would prevent many high calibre, committed trainees from ever being able to enter higher surgical training in paediatric surgery.
The third option would be to further increase the numbers of training posts at ST3 level in order to accommodate the extra numbers. This was unanimously rejected, even by those seeking ST3 appointments as it was felt that this would lead to problems with training in our numbers sensitive specialty and the prospect of post-CCT unemployment.

It was clear from the lack of consensus at the meeting that there is no possible way forward that will satisfy all groups of trainees. In determining the fairest and most acceptable way forward further information is requires including the actual number of ST3 posts that would be available were all ST2 run-through training offers honoured based on a robust and accountable assessment of capacity. Also the legality of each option needs to be considered, both for those who have received a contract with run-through training, and those who may have been let down by the significantly flawed appointment system over recent months. And It seems inevitable that some high quality candidates will not be able to continue in paediatric surgery, although it was pointed out that this was always the case with the previous system as “Calman numbers” were always limited. A system whereby these trainees could be supported and counselled as to their career options would be valued.

Additional concerns were expressed by trainees in ST3 posts that they had only been given one year contracts and that it was unclear with whom their contract was, either the deanery or the employing trust.

Future Selection of ST3 Run-Through posts

It was felt to be unrealistic to expect that future consultant surgeons could be identified and selected only 2 years post-graduation. Doubts were also expressed as to the robustness of workplace based assessments and it was felt that mediocre trainees would be able to progress leading to a lowering of standards. An additional selection process may help ensure standards remain high. It would also have the additional benefit of introducing more flexibility to the early part of a surgical career with potential to move between specialties. Consequently the meeting unanimously favoured uncoupling of surgical training for all future appointments and introducing competitive selection at ST3 level.

Summary

These are difficult and challenging times for the profession and for trainees in particular. It is unclear who is responsible for the situation we find ourselves in and it seems to trainees that there has been a lack of planning and accountability. There is a widespread lack of confidence in those overseeing these changes. Whatever plans and changes are to be introduced we feel strongly that trainees should be consulted and involved in order to produce a solution that is acceptable to those people who will be most affected..

We particularly despair of the apparent lack of central planning and control of trainee numbers and the absence of any transparent workforce planning. We feel this is essential to ensure adequate employment prospects in the future.


What all trainees would value most highly is clarity and the ability to make long term plans for their future careers.

Iain Yardley, Jonathan Sutcliffe and Clare Rees

“Grid” training for HPB surgery.
This has been agreed in principle by BAPS and passed to the SAC for further agreement and for the practicalities to be addressed. This will mean a system, similar to urology training, where sub-specialty posts are nationally controlled and advertised.

College statement on General Paediatric Surgery provision in DGHs.
Seems likely our specialty will end up as monopoly General Paediatric Surgery providers as general surgeons who had previously done this work retire and no trainees come through to replace them. This could be viewed as a threat to our specialty in that it would dilute our “specialist” practices but could also be seen a major opportunity to claim a good deal more work, raise the profile of our specialty and increase our influence. Whether to resist or embrace this is unclear but would have major implications for consultant jobs and training in the future.

BAPS Congress 2008, Salamanca. - The symposium topic will be AVMs.

BAPS Winter meeting. Joint Feto-maternal meeting, RCSEng 16th Nov 2007.
It was emphasized that this is not just a consultants meeting and trainees are very welcome, ideally at least one trainee and one consultant from each centre would attend.

Syllabus for Surgical Care Practitioners in General Neonatal and Paediatric Surgery.
The authors of this document will be invited to the Winter meeting to provide some clarity as to what role these practitioners may be envisaged taking in the future.

USB keys.
Trainees have been asked to ensure that all USB keys with presentations or other work documents are encrypted or password protected in some way. This follows an incident at the BAPS Congress in Edinburgh regarding a trainee’s USB key containing a Powerpoint presentation going missing.

Trainee representative.
Jonathon Sutcliffe is standing down. Nominations for his successor are invited.

MRCS and evaluation of progress

The role and future structure of the MRCS and its integration with “work-place assessment” is currently being discussed. It seems possible that it will take some time for the new types of assessment to bed in, so again further change is likely.

ST2 Progression

The number of ST3 posts available next year will depend very much on whether ST2 trainees go on to run through training. It seems the ability of non-ST2 trainees to apply for ST3 posts will vary with deanery. The views of Paediatric Surgical trainees were again canvassed (“Appointments to ST1/2”-below)

PMETB Survey

There will be a national survey of trainees in all specialties in December. Due to the size of our specialty, it is particularly important there is a complete response and some consortia have made it a requirement of the RITA process. Accurate responses will produce information that is likely to improve our training. So it is intrinsically worth doing.

Intercollegiate Exam

The year in which the exam can be taken is no longer defined. The standard is said to be high and there was a recommendation from some of the examiners that sitting in year 5 of SpR training is appropriate.
The syllabus has recently been updated in printed form. There is also a URL

General Surgery of Childhood
This document summarises the management of “surgery of childhood”. Click on the image opposite to download the document. It might be useful for interviews…




Jonathan Sutcliffe
Iain Yardley

Appointments to ST1/2 in Surgery
Paediatric Surgical Trainees Perspective

It has been proposed by the RCSEng that all appointments to surgical training schemes at ST level 1 or 2 be FTSTAs, meaning that there would be no guaranteed progression to higher levels of training and that an additional competitive selection process would occur prior to ST 3. This would be broadly similar to the previous situation with SHO grades seeking progression to SpR training. In the MTAS process, however, there were appointments made at ST2 level in paediatric surgery that were not FTSTAs, with the understanding of the trainee that they had been appointed to “run-through” training.

It is not clear to us how this situation has arisen, and this must be addressed. Nevertheless, in considering how to take things forward, we have been asked to give comments on the views of Paediatric Surgical SpRs. We have drafted this response and would be grateful for your comments. We would also welcome the comments of non-SpRs. Please could you could state your current grade with your comments and e-mail them to us or post them on the forum. Additionally, there will be time to discuss this at the SpR Training Day in Oct in Nottingham.

Current Situation

* Trainees have been appointed to ST2 posts in paediatric surgery with the expectation that this will be a “run-through” appointment and, assuming satisfactory progress and assessments, they will arrive at a CCT without further selection.
* There remain trainees committed to the specialty who are seeking ST3 level appointments having failed to secure posts in the MTAS round 1 or 2. It is unclear how many ST3 level posts will be available in future years.

Firstly the situation as exists currently needs to be addressed and then a consideration of how things may be arranged in the future can be undertaken.

Currently

We feel that two separate groups of trainees need to be considered and that it is important to try to act fairly to both those seeking ST3 posts and those already appointed to ST2 posts, regrettably this may not be possible.

Offers of “run-through” training should be honoured as these trainees will have made personal plans such as housing around these offers and to move the goal-posts once more at this stage would be grossly unfair. There should however be a proper assessment of these trainees prior to moving into an ST3 post. It is possible some may not be able to progress to later years of training. Any ST3 posts coming available due to non-progression of trainees should be then made available to open competition.

Additional ST3 posts should only be created where there is a reasonable expectation that consultant jobs will be available at the end of their training. Extra posts without this expectation will only delay a problem emerging and seriously dilute training experience in the meantime.

Advice and support should be given to those trainees who are unlikely to be able to obtain training posts in paediatric surgery.

Future

In the long-term many trainees have doubts that future consultant surgeons can be identified and selected only 2 years post-graduation and consequently would favour a competitive selection at ST3 level.

What all trainees would value most highly is clarity and the ability to make long term plans for their future careers.

Iain Yardley and Jonathan Sutcliffe

General Paediatric Surgery
There has been a decline in the number of Adult General Surgeons intending to take on general Paediatric Surgery as part of their practice and the way to address this shortfall has been contentious for some years. A document due to be released this week suggests that service provision stays predominantly with adult surgeons with the option to bring them to tertiary Paediatric Surgical centres for 6/12 to train.
An alternative is for the work to be undertaken by Paediatric Surgeons. This may involve working in a “hub and spoke” post (ie based at a tertiary referral centre but with a formal appointment and therefore, commitment to, a recognised DGH). It was suggested that children may receive optimal care if looked after by Paediatric Surgeons. Formal links between the DGH and Teaching hospitals would benefit the DGH (not shipping out as much work) and the teaching hospital (better handle on the management and audit of surgical practice within a larger area). A hub and spoke configuration would prevent trained Paediatric Surgeons working in isolation in DGHs.
It seems that 86% of adult surgical trainees don’t want to pursue a paediatric surgical post. From the information you provided for Richard Lindley’s survey last year, approximately 2/3 of people felt that ideally we should provide both elective and emergency cover in DGHs. Furthermore, 75% of respondents in that survey would consider working in a DGH for at least part of their career. The view put forward as your representatives was that we would support the second approach – the provision of paediatric surgery by paediatric surgeons as far as possible, and within a hub and spoke configuration. We felt that this system would be optimal for patient care and would also potentially facilitate an expansion in consultant numbers if this were needed to accommodate the expansion in numbers of CCT-qualified surgeons in the next few years.
On that note, Professor Thomas, Chair of the SAC said there had been an increase in consultant posts over the last 3 years and felt that this is likely to continue, making a significant mismatch in numbers unlikely. Mr Drake suggests that other potential sources of expansion include
i) increased consultant time devoted to training and teaching (MMC).
ii) the stated aim to reduce all consultants to 10 PA Job Plans
iii) the potential to expand numbers of paediatric surgeons performing the general surgery of childhood

Nevertheless, we feel that keeping a close eye to see that these jobs actually materialise seems sensible.

Run Through Training
The position for ST1 and ST2 trainees in terms of whether their appointments will lead to run through training to CCT needs to be clarified. We will appraise you of further developments in Paediatric Surgery as we hear about them.

-Trainee Representatives

SAC June 2007

The main points of interest to trainees were as follows:

CCT
As you know, our recent trainees’ survey showed there are 59 NTN trainees due to obtain CCT in the next 4 years with additional numbers eligible to apply for consultant posts from Article 14 and the EU. The survey can be downloaded from here .This information was sent to the chair of the SAC in April and has now been presented to their meeting. The number of consultant posts becoming available during this time is unknown although at present it seems unlikely that there will be an equivalent number of consultant posts. If this survey is accurate, the SAC feel this is likely to be a significant problem in the future. They will talk urgently to BAPS about what can and should be done.

Addressing this issue now is important. We should aim to reduce the likelihood or number of people becoming unemployed post CCT. Such unemployment would clearly be a disaster for individuals, and result in people having to take sub-consultant jobs here or overseas. This in turn is likely to fragment us professionally, reduce our professional independence and therefore directly affect patients.

We need to make constructive suggestions. Some thoughts:

*We should think about future working patterns (as per Richard Lindley’s survey). Perhaps we should make active efforts to take on “General Surgery of Childhood” as the General Surgeons and Urologists who previously undertook this retire.

*We need to grasp thorny issue of future numbers of NTNs/ST posts. This is particularly difficult following the way MMC has been introduced. I guess that even those trainees who do get run through posts don’t want to be faced with the same difficulties 6 years down the line.

*We need to have a mechanism to keep track of the number of people in training. This will perhaps mean an annual survey of numbers. There may be training organisations that could and arguably should do this, but until this is in place we as trainees should perhaps take it on.

*I think it would be good to have an idea of the number of consultants planning to retire in the next 5 years. Although this does not necessarily equate to the numbers trust agree to replace, it will give us an idea.

*I think it would be ideal to have a neutral body identify exactly what should be the correct number of Paediatric Surgeons to provide the current service to the population, so we can have a target to aim for. At present, there are “aspirational” numbers provided I think by the SAC, but there is no requirement for individual trusts to make the suggested number of appointments. If a neutral body said X was the number required to provide a service, one could say, “if you want a full service, you support it”. Who would be the “neutral body”?

*We should support the consultants if they ask for proper recognition of time spent training us etc. Consultant numbers should accurately reflect clinical and non-clinical duties.

*If this does end up becoming a problem, we should think about what can be done to support colleagues who don’t get jobs. What have other specialties (Obs and Gynae, ENT etc) come up with in the past? What can we do to prevent people being stuck working for PCTs or ISTCs with the need to show high throughput at the expense of quality and training (or even operations that aren’t strictly indicated - circs for mild phimosis, UDTs for retractile foreskin, Umbilical Hernias at 2, Hydrocoeles at 6/12, contralateral explorations for herniae etc). This will put pressure on tertiary centres to show they can match throughput and will end up affecting all of us.

Richard and I are due to hand over the posts of trainee reps this year. Please could someone offer to take over? It would be a shame if there was a gap between reps.
There is likely to be more to be said about this subject by the SAC but I would be grateful for suggestions. In the meantime, thankyou once again to the consortium reps and individuals who helped collect this data.

CESR
CESR, the equivalent of CCT for trainees going through the article 14 route, is recognised in the UK but not in Europe.
Regulations
The new guide to training, the “Gold Guide”, will be published in the next few weeks. It will contain all the regulations for training and replaces the “Orange Guide”.

Registration with JCHST
Apparently all NTNs should register with JCHST when first appointed otherwise they may not be eligible for CCT. If you aren’t sure if you did this, it would be worth contacting the JCHST to check.

A survey of trainees was conducted from December 2006 to March 2007 to ascertain
the number of trainees, their likely year of CCT and current main interests.
Jonathan Sutcliffe
Download/View file in PDF format

BAPS are keen to increase trainee involvement at the annual congress. They suggested a specific Trainee Session on the Tuesday afternoon (17/7) to give trainees a further opportunity to present work. Richard Lindley and I have been involved with the development of this session and hope the session will be one in which clinically important work is discussed. BAPS have offered to provide a prize and will also fund a Trainees' Dinner on the Thursday night for BAPS associate members going to the congress.
Abstract submission form
Download flyer

In addition to the OOPE issue, these topics were also discussed at the Surgical Accreditation Committee meeting
RITA
The name is going to change and there will be only one chance to get a fail; the trainee will leave the training scheme on the second fail.
External Assessor
Each RITA panel should comprise an external SAC assessor. There was a discussion about how anonymous comments from trainees could be passed to the SAC Assessor before the RITA.
If you have suggestions regarding the desirability of this, or the mechanism, please let me 
know.
Workforce Planning
There has been no expansion in numbers in most specialties because of concern re post CCT unemployment. Mr Ribero (PRCS Eng) says that the consultant job in the future is going to be different and therefore encourages expansion.
Unfortunately, the survey we have recently undertaken indicates that Paediatric Surgery trainees may be affected by unemployment post-CCT. Numbers are not available as we do not yet have information from the London trainees, nor do we know how many Article 14 people will go through. If you are a London trainee and the information from your training centre has not yet gone back to Niall Jones, please could you return it.
Consultant Job Eligibility
There are 3 potential routes for eligibility for consultant post application:
1. CCT
2. CEST
3. Article 14
Locum Consultancy cannot be used as a way to go through as Article 14 unless clear 
appraisal using Consultant Appraisal forms as potentially narrowed experience.

MTAS
16 posts are currently being interviewed for ST3, 26 for ST2 and ST1 17 NTN in Urology was intended to act as a way to expand numbers and increase the numbers of trained Urologists. On that basis, the NTN Urology Trainee should be asked to give up NTN to allow someone else to start.

PBAs 
Procedure based assessment (PBAs) will be used for ST1 – 3 from August this year and are available on the ISCP website.

Overseas posts/non-accredited posts

The SAC were told this week that as of 1 January 2007 all posts leading to CCT must be 
approved prospectively by PMETB. Without this prospective approval, the trainee will no 
longer be eligible for a CCT if they wish this time to be counted. Instead the trainee will 
need to apply to be given Certificate of Eligibility to the Specialist Register (CESR). CESR is 
intended to allow the holder to apply for consultant jobs and is the route taken by people 
going through Article 14.

A possible alternative (although I have not been able to confirm this) is if the trainee 
wishes to maintain eligibility for CCT, to apply to the Dean for time out of training and not 
recognise the OOPE.

The application process is likely to take 3/12 from submission of forms.

I have contacted The Head of Approval and Visits at PMETB and obtained clarification for 
the following groups. These are her comments:

1. Trainees with SAC approved posts already on OOPE:
If approval for the OOPE post was granted prior to 1 January 2007, and evidence of this 
approval from the Deanery and SAC can be provided, then approval will be honoured.

2. Trainees with SAC approval about to go (say in the next few months):
These trainees need prospective PMETB approval. These applications for approval will 
need to come directly from deaneries; PMETB is unable to accept applications from 
individual trainees, SACs or Colleges. This is consistent with PMETB policy of holding the 
deaneries responsible for local level quality management of education and training. 
Trainees are therefore advised to liaise with their deaneries to co-ordinate the applications 
for approval. PMETB guidance on prospective approval of overseas posts can be found 
here:
http://www.pmetb.org.uk/fileadmin/user/Policy/Policy_Statements/
Prospective_approval_of_overseas_posts_-_Guidance_2_Oct_06.pdf
and PMETB guidance on general post and programme approval, including research posts, 
can be found under the `latest news' section in the following part of the PMETB website:
http://www.pmetb.org.uk/index.php?id=postandprogrammeapproval

3. Trainees who have begun planning but not yet obtained approval:
Need to apply as above.

4. Point of contact for further questions to PMETB:
quality.assurance@pmetb.org.uk

I have written to PMETB to say that none of us were aware of this change is concerning and 
indeed it is possible that there are other significant policy changes which we don't know 
about. Better communication would also allow us to discuss out professional concerns 
regarding training in the way we have done and continue to do with the SAC.

Read all about it in as a downloadable pdf file from the RESOURCES page

Joint Statement on General Paediatric Surgery provision in District General Hospitals on behalf of the Association of Paediatric Anaesthetists, the Association of Surgeons for Great Britain and Ireland, the British Association of Paediatric Surgeons, the Royal College of Paediatrics and Child Health and the Senate of Surgery for Great Britain and Ireland. Download this pdf file.