Training in the independent sector

Ran Wei, Rob Gregory, George Holland and Josh Burke

Ran Wei is an ST8 in South West London with an interest in Knee Surgery. He is the current President of BOTA, having previously served as Vice President and SAC Rep. He represents T&O trainees within a number of important forums including RCSEng Council, RCSEng L&A Committee, BOA Council, BOA EdCar Committee, IST Assurance Board, T&O SDG and ATDG.

Rob Gregory is a Consultant and Lead Clinician in Trauma and Orthopaedics at County Durham and the Darlington NHS Trust. Robert has an interest in surgical education and is currently chair of the specialist training committee for T&O. He is quality management lead in the School of Surgery in the Northern Deanery, an examiner at MRCS level and also a Regional Specialty College Adviser in T&O.

George Holland is the current Vice President for the BOTA Committee, following on from the Secretary position in 201920 and Education rep in 2018-19. He is an ST6 in the South East Scotland deanery, currently working in Edinburgh. As BOTA Vice President George attends meetings as the trainee rep on the JCST Quality assurance panel. He also sits on the BOA Trauma Committee and ICBSE Committee as a trainee rep.

Josh Burke is an ST3 in General Surgery based in Yorkshire and currently completing a RCSEng and Bowel Cancer UK PhD fellowship investigating gastrointestinal anastomotic leak at the University of Leeds. He current President of The Association of Surgeons in Training (ASiT), postgraduate lead for the NIHR MedTech Foundation and Trainee Editor for the RCSEng Bulletin. Working closely with BOTA, he represents ASiT on the RCSEng Council, JCST, ATDG, BMA and the GMC.

Events over the past twelve months have resulted in the greatest challenge to surgical training that we are likely to experience within our lifetime. Cessation of elective operating coupled with workforce redeployment has resulted in an effective pause in T&O training for most trainees across the UK.

In the wake of the first national lockdown, concerns over the increased morbidity and mortality of patients who contract COVID-19 around the time of surgery led to the guidance provided by both the BOA and NICE to help ensure a safe return to elective operating. The requirement for the establishment of ‘Green’ sites, intended to minimise the risk of patients contracting COVID-19 during the perioperative period, meant that many NHS hospitals utilised independent sector (IS) hospitals for their ever-growing elective workload. Initial contracts between the NHS and the participating IS providers did not include any formal obligation to facilitate surgical training. This led to considerable regional variation in elective surgical training across the UK. Despite further contracts being negotiated between the NHS and the IS providers which included obligations relating to surgical training, and despite the subsequent release of position statements jointly agreed by IHPN, NHSEI and HEE, and despite guidance set out by HEE, trainees continue to encounter problems when attempting to access training in IS hospitals.

Survey data

In November 2020, BOTA began surveying trainees across the country in an attempt to understand and voice the issues encountered by trainees when trying to access training in the IS. The survey was conducted over a three-month period from 16th November 2020. Through the Regional Representative network, BOTA was able to achieve 150 responses from trainees of all grades (Figure 1) in all 29 training regions across the UK (Figure 2).

Figure 1: Survey responses by grade.

Figure 2: Survey responses by training region.

The survey identified that 27.3% of respondents did not have access to any elective operative training at their NHS hospital(s). 56% of respondents worked in an NHS hospital that utilised IS hospitals for their patients. 26 of the 29 training regions surveyed utilised IS hospitals for NHS funded operating lists. BOTA was concerned about the wide range and extent of the difficulties identified (Table 1).

Discussion

Utilisation of IS hospitals for delivery of surgical training pre-dates the COVID-19 pandemic. Trainees in regions where this care setting is not commonly used may find the emerging dependence on IS hospitals for training a daunting prospect. Failure of IS hospitals to comply with their contractual training obligations in addition to NHS hospitals failing to support their trainees further exacerbate the unrelenting disruption to surgical training caused by COVID-19.

BOTA’s national survey of training in the independent sector has revealed significant deficiencies relating to access to elective operative training within the UK associated with the COVID-19 pandemic. The survey suggests that 90% of training regions are currently utilising IS hospitals for NHS funded operating lists. BOTA understands that reliance on delivery of training within the IS setting is not a long-term solution to the deficit in training caused by COVID-19. Initial efforts to minimise the Frequency (%) consequences of disruption to surgical training resulting from COVID-19 are becoming largely ineffective. It is therefore vital that every training opportunity is utilised within the NHS and that further efforts are made to engage the IS providers with training of the next generation of T&O surgeons.

Whilst surgical trainees and trainers need to adapt to the ever-changing healthcare delivery landscape, additional support must be provided in order to minimise the inevitable reduction in the rate of trainees achieving CCT. After all, the next generation of surgeons will be providing care in both the NHS and the IS hospitals.

FAQs on Training in the independent sector

Am I only allowed to assist in the independent sector?

Answer: No. Trainees and trainers need to be given the opportunity to utilise NHS patients relocated to IS hospitals for training. There are formal training obligations detailed within the contracts agreed between NHSEI and IS providers.

Guidance: Joint position agreed by IHPN, NHSEI and HEE and HEE guidance: “Trainees must be given the opportunity to gain a wide range of competencies. This will mean in specialties like surgery, taking part in theatre sessions.”

Suggestion for trainer: Support your trainee by identifying the training cases at the team brief prior to the start of the NHS funded IS list.

Suggestion for trainee: If you are only allowed to assist, then you should bring this to the attention of your Educational Supervisor who, through your TPD, will escalate the problem to the postgraduate dean.

Who should be making me aware of the NHS funded IS lists?

Answer: Your trainer(s) (i.e. Clinical Supervisor) should be making you aware of any NHS funded IS lists that are due to take place.

Guidance: HEE guidance: “Trainees should be included in the planning for the resumption of diagnostic and surgical services in order to ensure that training opportunities are identified and exploited wherever possible.”

Suggestion for trainer: Inform your trainee of any NHS funded IS lists as soon as they are confirmed. Facilitate arrangements to temporarily alter pre- COVID work timetables if required to allow trainees to attend these lists.

Suggestion for trainee: Engage with NHS service managers to ascertain updates about upcoming NHS funded IS lists. Utilise local trainee networks on secure social media platforms (e.g. WhatsApp) to inform other trainees if you identify an NHS funded IS list that you cannot attend.

What paperwork do I need to supply before attending IS operating lists?

Answer: Most recent ARCP form and Form R. Your NHS employer will be able to supply any additional documents/forms requested by the IS provider as part of their pre-employment checks, but you will have to give consent for this.

Guidance: HEE guidance: “The receipt of the most recent ARCP form as well as form R which can only be issued if the prerequisite employment and other checks have occurred. This should negate the need for any other additional pre-employment checks although to fulfil requirements of the CQC Schedule 3 the independent healthcare provider will need to obtain this evidence from the NHS employer of the DiT with their consent to do so.

The DiT must give permission for release of the forms or provide the forms personally. If this is not possible then the DiT cannot work/train at the independent sector site.”

Suggestion for trainee: Inform your departmental service manager of your intentions to attend any IS lists so that the appropriate documents/forms are provided to the IS providers in good time.

Will I be Indemnified by my NHS employer when operating in the IS sector?

Answer: Yes, but only for NHS patients. Indemnity for trainees treating NHS patients who have been relocated to the IS for treatment will be provided by the trainee’s NHS employer. However, HEE advises trainees to have additional indemnity in place. If additional indemnity is in place, then trainees should inform their indemnity provider of their work at the additional site(s).

Will I be Indemnified by my NHS employer when operating in the IS sector?

Answer: Yes, but only for NHS patients. Indemnity for trainees treating NHS patients who have been relocated to the IS for treatment will be provided by the trainee’s NHS employer. However, HEE advises trainees to have additional indemnity in place. If additional indemnity is in place, then trainees should inform their indemnity provider of their work at the additional site(s).

Guidance: HEE guidance: “NHS staff in the training grades who work in independent hospitals as part of their NHS training, are covered by NHS Indemnity (the Clinical Negligence Scheme for Trusts membership of the employing Trust), provided that such work is covered by an NHS contract of employment (as per Annex A of the NHS Indemnity Arrangements for Clinical Negligence Claims in the NHS) and the trainee is under the supervision of an NHS consultant.

DiT are always strongly advised to have additional personal indemnity. If this is in place already, then the DiT should advise the indemnity provider of the additional site of working.”

Suggestion for trainee: If you have additional indemnity in place then you should inform your indemnity provider of your additional site of work.

References

References can be found online at www.boa.ac.uk/publications/JTO.