Minutes of the meeting of the Surgical Specialties Training Board held at 10.30 am on Thursday 18 April 2013 in Meeting room 3, Westport, Edinburgh

Present: Mr Dominique Byrne (DB) Chair; Mr John Anderson (JA), Ms Helen Biggins (HB), Mr Richard Buckley (RB), Professor James Garden (JG), Mr Gareth Griffiths (GG), Ms Alison Howd (AH), Mr Brian Howieson (BH), Mr Alan Kirk (AK), Professor Anthea Lints (AL), Mr Graham Mackay (GM), Ms Jen MacKenzie (JM) part meeting, Mr Anas Naasan (AN), Professor Rowan Parks (RP), Professor William Reid (WR); Mr Andrew Renwick (ARen), Ms Angela Riddell (AR) part meeting, Professor Hamish Simpson (HS),

By videoconference: Aberdeen – Ms Aileen McKinley (AM), Glasgow (1) – Ms Ruth McKee (RMcK) Mr Douglas Orr (DO), Mr Michael Palmer (MP); Glasgow (2) – Mr Ian Holland (IH).

Apologies: Mr Angus Cain (AC), Ms Anne Dickson (AD), Mr Laurence Dunn (LD), Mr Nick George (NG), Dr Alison Graham (AG), Mr Graham Haddock (GH), Mr Ewen Kemp (EK), Ms Lorna Marson (LM), Mr Sai Prasad (SP), Mr Ian Ritchie (IR), Ms Rachel Thomas (RT), Mr Kenneth Walker (KW).

In attendance: Ms Helen McIntosh (HM).

1. Welcome and apologies

Mr Byrne welcomed all to the meeting and in particular Mr Michael Palmer, to his first meeting of the STB replacing Mr Bob Meddings as Urology representative. Mr Meddings valuable input to the STB was noted and the Board’s thanks recorded.

2. Minutes of meeting held on 16 January 2013

The minutes were accepted as a correct record of the meeting and will be posted on the website.

3. Matters arising 3.1 North and East General Surgery programmes

AM reported she and GG discussed amalgamating programmes and after canvassing opinions from trainers and trainees agreed this was acceptable. However lead Dean arrangements have proved difficult to resolve and so momentum has halted and while some training has been combined (notably involving the teaching programme), full amalgamation was not being actively pursued at the moment.

RP was undertaking a global piece of work on national programmes and noted this programme has been proactive in considering amalgamation. Although there were still 26 ST3 trainees in the North programme and 18 in the East there are many other smaller programmes elsewhere, and curriculum delivery had to be main consideration. In response to the suggestion (RB) that the STB could set a minimum programme size, RP reminded the meeting that, while this remained core business for the STB as part of the quality remit, the STB’s role was advisory. MDET has approved in principle the proposal for the East/North programmes to amalgamate and would have to give its specific approval to any other proposals.

WR confirmed NES has been working to establish host boards for some time; this was currently being addressed by the work on shared services. It was agreed specialty leads would consult with colleagues on any proposed programme amalgamation and feedback outcome to DB.

Action:  Specialty leads to consider programme amalgamation with colleagues; to feedback specialty view to DB.

3.2 Spinal Surgery AMTF

Central funding has not yet been identified for this post. HS will discuss this further with LD, giving consideration to the combination of 6-month slots in Neurosurgery and T&O.

3.3 Paediatric Surgery/Urology

Communication from the Chair of the SCCCSS (Scottish Consultants’ Committee on Children’s Surgical Services) had been shared at the last meeting of the STB outlining the volume of Surgery for Children undertaken by Adult General Surgeons “with an interest”, and of Paediatric Surgery lists undertaken by Paediatric Surgeons outwith their own central hospitals. Consultant Paediatric Surgeons undertaking lists at these other hospitals did not take trainees with them, and these lists therefore represent a training opportunity for General Surgery trainees (possibly most appropriately at ST3/4 level). DB suggested that LEPs might allocate trainees to these lists in order to take advantage of these opportunities. However it was felt that this could prove impractical where trainees’ timetables were already full.

GG said the General Surgery curriculum required knowledge of General Surgery of Childhood but little technical skill unless individuals wanted to develop an interest. The issue was therefore not of providing opportunity but of interesting trainees in this area of surgery as they generally did not see this as a significant part of the portfolio or as a means of increasing their competitiveness. DB stressed the need for trainees to gain experience in dealing with childhood surgical emergencies in order to prevent delays in treatment as well as to reduce the volume of potentially unnecessary referrals to the main Paediatric centres. AM noted that all ST3/4s in NoS were given experience in Paediatric Surgery in the local Paediatric hospitals and that trainees were keen to do this.

To conclude the discussion, DB summarised that while trainees could be encouraged to seek experience in the General Surgery of Childhood, the potential rota implications in the different hospitals meant that this could not be made a requirement. General Surgery trainees should also be made aware that Paediatric Hospitals had the capacity to accommodate trainees who wished to develop this as an interest on OOPT placements.

In response to the request for STB representation on the SCCCSS, it was agreed this was not necessary in view of the active representation of Paediatric Surgery on the STB but that minutes would be exchanged between the two groups.

2 3.4 HAI programme

To note: information was received and response completed.

3.5 Recruitment 2013: Cardiothoracic Surgery

To note: Scotland was participating in the pilot for UK runthrough and one post each was being recruited at ST1and ST3.

3.6 QM – Scottish QM reporting template

The last STB meeting discussed using the JCST trainee survey to drive the QM remit. Although both surveys cover broadly similar areas, the JCST survey has a more binary approach to questions than the GMC’s NTS, and surveys against Quality Indicators and Smart Indicators produced by the surgical SACs resulting in more direct relevance to Surgery. The question remained as to whether the JCST survey could add to the existing QM process. DB proposed running a limited trial using both Deanery QA and JCST information for Paediatric Surgery. WR and RP both supported the proposal as a means of providing triangulation and externality which linked with the work of the Francis Report. DB cautioned that survey responses may differ as the GMC survey was anonymised whereas the same level of protection was not given to respondents to the JCST survey.

DB will discuss the proposal with the WoS QIM and GH and feedback at the next STB meeting. RP noted that QIM capacity was currently an issue and that this could delay progress.

Action:  DB to discuss running pilot in Paediatric Surgery with WoS QIM and GH and to report on outcome at next STB meeting.

3.7 Simulation

The initial JCST submission had been rejected by GMC; JCST was now preparing to submit a revised proposal.

3.8 ISCP training day

HB provided a report of the training day on 7 March. Training was not as ‘hands on’ as anticipated and there were some technical computer issues. A particular issue emerged on the day which provoked much discussion; ISCP’s expectation was that Deanery administrative staff would validate information on enrolment forms including the listed previous training posts which help to determine the allocation of trainees to the CCT or CESR(CP) route to the specialist register. DB and RP discussed this on the day with the ISCP representative who conceded that the term ‘validate’ in this context was incorrect; it was the responsibility of trainees to submit and JCST to validate the information in question and the role of Deanery staff should be to confirm factual information in agreement with Deanery records. ISCP has agreed to amend the form to reflect this.

The group discussed at what stage trainees should be informed of their CCT or CESR status and whose responsibility this should be. It was felt trainees

3 should be informed of this as close as possible to the time of their appointment. However this information was not usually available in the current national recruitment process. Currently there was not a consistent process across all 4 Deaneries, and information was often sent to Deanery Administrative staff rather than TPDs. RP confirmed the appropriate route must be agreed at NTN allocation, and so it was essential for communication between TPDs and Deanery staff at this stage. Trainees should be aware of their route to specialist registration by the time of their first ARCP.

GG noted that the only route to CCT was through the completion of a formal Core Surgery programme or a recognised Basic Surgical Training programme and that all others would have to be allocated to the CESR/CP route.

4. Recruitment 4.1 T&O: Round 1 SMT

All 11 ST posts and one LAT post had been filled; only one candidate had declined a post.

4.2 Core Surgery

Sixty six posts remained to be filled in the UK after Round 1 including 10 Scottish posts. Round 2 will be held at a single centre in London 14-16 May. Scottish consultants were needed to assist with the interviewing process which would be conducted using the same process and criteria as in Round 1.

Fill rates in UK were generally down from last year; AH felt that candidates were choosy about what posts they would accept in Round 1 but less so by Round 2. Nevertheless, it was thought unlikely that all vacancies would fill in Round 2 and so LAT posts should be available. Selection standards would not be set lower for these. In the event that applicants for LAT positions did not meet the required standard for appointment to these posts, LAS appointments could be made.

RB felt that trainees might be deterred from applying to Core training in Scotland due to the lack of a T&O element and that this should be addressed by using disestablished posts. AH pointed out that two posts had been identified for next year in the West and DB also noted that a small number of T&O posts were already available in the West programme (confirmed : two).

AK considered that the recruitment process was based on candidates achieving a “score” rather than a standard and that there was therefore a risk that candidates were inappropriately rejected as unappointable.

4.3 National recruitment: all specialties

Information received as follows:

 Cardiothoracic: 2 candidates appointed; one at ST1.  General Surgery: offers will be issued in May.  Vascular Surgery: offers will be issued in May.  OMFS: interviews next week for one post and outcome known by end of week.  Plastic Surgery: National recruitment taking place in London in May with a

4 number of Scottish Consultants participating in the interviews. Difficult to ascertain the likelihood of filling all vacancies at this stage.  Neurology/ENT/Ophthalmology/Paediatric Surgery: no reports. 4.4 Specialty training numbers beyond 2013

DB has circulated an email to the STB Specialty Leads seeking information on expected numbers of CCTs in year the 2013-2014 in order to allow planning of recruitment numbers for 2014.

HS reported T & O would like to add 4 posts to Core Surgery in the West from decoupled posts; however, it was noted that this would result in even more West Core Surgery programmes offering T&O while the Eastward Core Surgery programme did not. If the posts were sited in Forth Valley, this could be helpful for Eastward; however these posts must present real training opportunities.

MP highlighted a need for exposure to preferred specialties during Core training. He feared that trainees completing Core Surgery training in Scotland might be disadvantaged in National recruitment to ST3 in Urology through having spent too little time in the Specialty, even though there is some element of theming of individual Core programmes in both West and Eastward CST programmes. MP felt they should wait to see how competitive Scottish core trainees were compared to those applying from England who will have done more Urology within core training; however AH confirmed that several trainees will have completed 12 months of Urology in Core. In general, it was believed that trainees with experience of themed posts tended to be more successful at recruitment to ST3; however, theming was still a developing workstream.

5. Updates 5.1 Specialties

 Cardiothoracic Surgery Scottish Government wanted the specialty to increase training numbers. AK considered the West would not be able to deliver training if its numbers increased to 7 from 4. This has not previously been raised as a concern by SP; DB will discuss this with SP; DB, AK and WR will discuss salaries outwith the meeting.

 General Surgery JA reported JCST guidelines for CCT were to be used at ARCPs; these were very useful and will be recommended for general use. DB noted that this tied in with the process of Penultimate Year Assessment where a checklist could be applied for each specialty; GG confirmed the SAC was discussing the use of the checklist.

 Vascular Surgery Interviewing for the first 2 trainees scheduled to start in August 2013 was taking place. These will be allocated to East and West Deaneries in line with funding. Trainees will move between Deaneries after the first 2 years of training and RP confirmed that labelling of individual posts would have to change between General and Vascular year on year since funding would not follow trainees.

 OMFS

5 - Recruitment next week to one post this year; 2 next year then 3. - GMC review in June. - Small specialty issues – service/training issues affected attractiveness of posts. - Clear definition of eligibility to sit the Exit exam was being developed by JCST. This had given rise to some confusion over the requirement to have achieved four outcomes 1 at ARCP. GG clarified that this should be taken to mean that the need for an outcome 1 at the time of application to sit the exit exam indicates that the trainee should have no outstanding learning requirements when taking Part 1 of the exam. He has rewritten the guidance accordingly and this should be ratified in due course.

 Plastic Surgery - No issues in delivery of modular structure. - Proposed reduction in training numbers was felt to be too severe. AN met Professor Padfield to discuss and was asked to provide further information for meeting with DB and RP later today.

 T & O - Preference to recruit on Scottish rather than UK basis due to concerns posts could be less attractive and harder to fill. RP said UK national recruitment was being piloted this year and will be reviewed; however, the general experience of specialties taking part in national recruitment so far was that this provided a better pool of candidates and, ultimately, better trainees. Previously there were a number of parallel recruitment processes, often resulting in people initially accepting posts and then dropping out later to take up a post elsewhere.

Actions:  DB to discuss Cardiothoracic training capacity (especially in West) with SP.  DB, AK and WR will discuss Cardiothoracic salaries outwith the meeting.

5.2 MDET

To note: Third Scottish National Postgraduate Education conference will take place on Tuesday 30 April at EICC. Numbers registered were high and a good programme of speakers has been organised.

5.3 Service 5.4 Colleges

No reports received.

5.5 Simulation

The most recent simulation group meeting was held in February when it was agreed to focus and make recommendations on inclusion of simulation in Core Surgery. It was hoped to include the Highland Surgical Boot Camp in the first few months of training as part of induction with costs covered by the Study Leave budget. A basic course at the new Anatomy Skills Centre in Glasgow for 6-10 CT2 trainees will be held in June and this may become a recommended course. The group was now working on assessing/recommending in house. Dr Jean Ker shared information on a QA

6 self-reporting tool which the group was likely to recommend.

AH noted the Study Leave budget (£500) would not cover the cost of the Highland Boot Camp (£800); she felt the Boot Camp should be an integral part of training with funding for the course provided and trainees paying their own accommodation costs, but until it becomes a compulsory component of the curriculum it would have to be funded by the Study Leave budget.

5.6 Trainees

No report was received.

5.7 ISCP

RM reported ISCP was now widely used, apart from T & O which has only recently joined, however the quality of information entered could be improved. Many trainees were not on standard start dates for placements/OOP making it difficult to get good statistics and she felt each TPD could access and match ISCP information with what they held. To note some core trainees were still incorrectly entering their parent specialty.

5.8 JCST

DB highlighted from the most recent meeting  ARCP checklist (mentioned at 5.1 General Surgery);  definition of eligibility criteria for Exit exam;  expectation that Supervisors and TPDs would have to be stricter in providing references for application to sit the Exit exam.  MRCS to become an exit requirement for completion of core surgical training; this would be applied to current CT1s (ie those in programme at August 2013) but not to current CT2s.  JCST Strategy Action Plan was circulated for information; this showed a significant focus on patient safety.

5.9 CSTC

DB highlighted:  Discussion on 2nd round interviews and need for interviewers 14-16 May 2013.  Clarification and guidance on possible ARCP outcomes in Core Surgery. This highlighted the fact that outcome 2 is not a possible outcome at the end of CT2. Thus, if a trainee did not achieve an outcome 1 at the end of CT2, the award would have to be an Outcome 3 or 4. Outcome 3 comes with a recommendation that an extension to training should be offered. Failure to complete the MRCS would now be one of the reasons for not issuing an outcome 1. In discussion, the issue was raised of trainees who have not passed all parts of the MRCS exam at the end of CT2 and who opt to go into research rather than extend their Core training. GG confirmed that these trainees would not be able to complete CCT and would therefore later have to go through the CESR/CP route to specialist registration. It was agreed that to follow this course would therefore be unwise as MRCS was now a requirement for CT2 completion.  National recruitment – discussion taking place on eventual move towards single centre recruitment model for 2014/15.

7  Career choice – progression from CT2 programmes. A survey is to be carried out by Karen Daly (London) over the next few months on core trainees’ progression to other programmes using ISCP data in order to gain some measure of the “success” of Core Surgery Training Programmes in preparing trainees for their later careers.

5.10 COPSS

Noted: the group will next meet in May.

6. AOB 6.1 Academic reviews in conjunction with ARCPs

JG will be involved in reviews in Glasgow. All arrangements were in place for all reviews.

6.2 AMTFs

WR said the process was not working as well as had been hoped although there was a strong desire in Scotland to create such posts. This STB has approved in principle a number of posts but these have not progressed due largely to a lack of corresponding disestablished posts. MDET was currently reviewing the situation and will reissue guidance on how to establish posts such as AMTFs. . Regional Workforce has control of funding but the STB needed to highlight the benefits to NHSScotland. RP felt this would be more easily accomplished if funding stayed in the same place, but this did not address the desire to create innovative cross-specialty, -Deanery or -Health Board posts. DB and RP will discuss AMTFs at the meeting with Professor Padfield.

6.3 NES Knowledge Services

Anne Lees, NES Knowledge Services, has requested information from each of the STBs on recommended online core journals and learning resources to which NES should subscribe. DB will contact Specialty Leads from the surgical specialties seeking suggestions of appropriate lists of such resources.

Action:  DB to contact all specialty leads seeking recommendations of online resources for each specialty.

6.4 Award of Personal Chair

The STB extended its congratulations to Mr Kenneth Walker on the award of a personal chair as Honorary Professor of Surgical Training.

7. Date of next meeting

The next meeting will take place at 10.30 am on Tuesday 2 July 2013 in Room 6, Westport, Edinburgh.

Actions arising from the meeting

8 Item no Item name Action Who 3. Matters arising To consider programme Specialty 3.1 North and East General amalgamation with leads/DB Surgery programmes colleagues; to feedback specialty view to DB. 3.6 QM – Scottish QM reporting To discuss running pilot in DB template Paediatric Surgery with WoS QIM and GH and to report on outcome at next STB meeting. 5. Updates 5.1 Specialties: Cardiothoracic To discuss Cardiothoracic DB/SP training capacity in West with SP. To discuss Cardiothoracic DB/AK/WR salaries outwith meeting.

6. AOB 6.3 NES Knowledge Services To contact all specialty leads DB/ seeking recommended core Specialty journals. leads

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