The Royal College of Surgeons of England (RCS England) and the Association of Surgeons in Training (ASiT) have issued a stark warning to the government and NHS England’s top medics that access to operating theatres for surgical training has not recovered since the COVID-19 pandemic and planned government reforms, if not carefully implemented, risk creating further barriers.
New evidence suggests resident doctors have missed out on over three million training opportunities since March 2020.
Writing to Professor Sir Stephen Powis, NHS England National Medical Director, and Professor Sir Chris Whitty, Chief Medical Officer, Mr Tim Mitchell, President of RCS England and Miss Roberta Garau, President of ASiT, said: “If we do not act now to protect and expand surgical training, the NHS will struggle to maintain a sustainable surgical workforce for future patients”.
Data from RCS England’s most recent surgical workforce census revealed that 61% of resident doctors in surgery identified limited theatre access as a major challenge, while 52% report inadequate time for training. Similar challenges are cited by SAS and locally employed doctors.
In the letter, Mr Mitchell and Miss Garau, urged the co-chairs of NHS England’s postgraduate medical training review to “send a clear, unequivocal message to all NHS leaders: training must be prioritised alongside service delivery.”
RCS England and ASiT said that to prevent government reforms from exacerbating the challenges around training resident doctors in surgery face, three urgent actions are needed:
• Better balancing the needs of training and the focus on service delivery
• Requiring the private sector to support training opportunities
• Ensuring surgical hubs deliver on training opportunities
The letter states that it is “absolutely right” tackling unacceptably long waits for patients remains the top priority, but “there is a real risk that training opportunities will be sacrificed at the altar of productivity” in the drive to meet ambitions waiting time targets.
The surgical leaders say that resident doctors in surgery must be actively involved in the evening, weekend, and high-intensity theatre (HIT) lists introduced to reduce waiting times. The letter also asks NHS England to set out how financial reforms to incentivise waiting list activity will also facilitate high quality training.
They also address the increasing proportion of NHS care delivered by private and not-for-profit providers and their involvement in training. The letter said, “Many of these providers are actively engaged in high-quality training. Nevertheless, we continue to hear of NHS Trusts unwilling to release resident doctors for training opportunities outside their organisation, as well as independent sector providers reluctant to meaningfully support opportunities for resident doctors.
"The expansion of independent sector provision must not come at the cost of our future workforce and patient care.”
RCS England and ASiT are calling on NHS Trusts to establish flexible job plans for resident doctors in surgery that include timetabled time working in the independent sector.
The two surgical organisations have welcomed the recognition of concerns about training in the independent sector in a partnership agreement between the government and the Independent Healthcare Providers Network (IHPN), published alongside the elective reform plan, but add that to maximise its impact, this commitment now needs clearer implementation details and tangible outcomes.
Surgeons have advocated for the establishment of surgical hubs, which Mitchell and Garau describe as a crucial reform to increase elective activity, giving patients quicker access to procedures, and providing a ringfenced environment for resident doctors to develop their skills. However, emerging data from the Joint Committee on Surgical Training (JCST) suggests these opportunities are not being fully realised, with fewer than 10% of surgical training episodes currently occurring in hub centres.
RCS England and ASiT will continue to work with Getting it Right First Time (GiRFT) to strengthen its hub accreditation scheme and set even higher expectations for training. The letter calls on NHS England, as it rolls out the next wave of hubs, to ask Trust leaders to explicitly outline how they will support surgical training within these centres.
Finally, the letter also raises other frustrations that will be contributing to the challenges facing resident doctors in surgery including costs, lack of flexible working opportunities, and workplace culture. Mitchell and Garau say it is vital the review of postgraduate medical training listens first and foremost to the voices of those in training.
Commenting on the letter and concerns about surgical training, Mr Tim Mitchell, President of RCS England, said: “Nearly five years on from the start of the Covid-19 pandemic and the suspension of all non-urgent elective surgery, surgical training still hasn’t fully recovered. Data from the Joint Committee on Surgical Training (JCST) suggest over three million operations which could have provided training opportunities have been lost since March 2020.
“Resident doctors in surgery just aren’t getting enough time in operating theatres and their training has consequently taken a major hit. If we don’t do something now to improve their access to theatres and allow them to develop their surgical skills, we risk losing a generation of surgeons. This is essential to ensure the future of surgical services to NHS patients."
The Association of Surgeons in Training (ASiT) added: "Surgical trainees are being pushed to the sidelines, struggling to get the hands-on experience they need to become the consultants of tomorrow. Years after the pandemic, theatre access is still limited, and system pressures continue to put training second to service delivery. If we don’t act now, we risk losing a generation of surgeons – and with them, the future of patient care. Training isn’t an afterthought; it’s the foundation of a safe and sustainable surgical workforce. The time to invest in trainees is now."
