The President of the Royal College of Surgeons of England (RCS England) has said that problems accessing operating theatres are contributing to long waiting times for hospital treatment across the UK.
A census conducted by RCS England found more than half (56%) of the UK surgical workforce find that operating theatre access is a major challenge. Worryingly, that figure rises to 61% for all surgical trainees – meaning they are missing valuable training time.
Advancing the Surgical Workforce: 2023 UK Surgical Workforce Census Report, published on 18 January, paints a stark picture of a surgical workforce working long hours and in stressful environments. Too many staff are trying to navigate a system that often frustrates the delivery of surgical care, rather than enabling all members of the team to deliver services to patients in the most timely and efficient way. Surgical trainees are increasingly being affected by these pressures. The census findings become even more concerning when set against the backdrop of a waiting list of 7.6 million1 in England and similar relative high levels of demand in Scotland, Wales and Northern Ireland2.
RCS England surveyed the whole surgical workforce to identify the key challenges facing surgical teams and to inform workforce planning. This includes consultants, surgeons in training, specialty and associate specialist (SAS), locally employed doctors in surgery (LEDs) and members of the extended surgical team (EST). The main findings showed that:
- 56% of respondents cited that access to theatres was a major challenge and this was specifically cited by 61% of all surgical trainees.
- 50% of respondents across all career grades indicated that they have considered leaving the workforce in the past year.
- 61% of respondents cited that burnout and stress is the main challenge in surgery – due to excessive workloads.
- 64% of the 55-64 age group of consultant surgeons plan to retire in the next four years.
- Surgery remains a popular career choice, however, 52% of all surgical trainees reported a lack of adequate time for training.
- 47% of respondents said they believed that ‘system challenges’ had an impact on their ability to deliver their work – such as balancing clinical work with managerial responsibilities.
- 67% of consultants always or frequently work beyond their contracted hours.
- 42% of respondents did not take their annual leave entitlements in the past year.
Responding to the findings of the census, and current pressures facing health services, Mr Tim Mitchell, President of the Royal College of Surgeons of England, said: “At a time when record waiting lists persist across the UK, it is deeply concerning that NHS productivity has decreased. The reasons for this are multifactorial, but access to operating theatres and staff wellbeing certainly play a major part. If surgical teams cannot get into operating theatres, patients will continue to endure unacceptably long waits for surgery.
“Our census findings tell us nearly two thirds (64%) of consultant surgeons aged 55-64 are looking to retire in the next few years. This will create a significant loss of experienced surgeons who are key to helping bring NHS waiting times down and training our future surgeons.
“Tackling the challenges health services face hinges on having a happy and fulfilled workforce. We should not be losing any talented surgeons or surgeons in training because they do not feel valued, or they are denied the flexibility in their careers they require.
“There is an urgent need to increase theatre capacity and ensure existing theatre spaces are used to maximum capacity. There is also a lot of work to be done to retain staff at all levels by reducing burnout and improving morale. RCS England stands ready to work with NHS trust organisations and health boards to develop policies and guidance that improve staff wellbeing.”
RCS England has made several recommendations reflecting the current state of surgery in the UK. The census data will provide a basis for future comparative work to support the working lives of surgeons and the wider surgical team. Recommendations include:
- Increasing productivity to reduce waiting lists – there is an urgent need for theatre capacity to be increased by ensuring existing theatre spaces are used to their maximum capacity. This needs to include increasing the number of surgical hubs and ring-fencing beds for elective surgery. The consultant surgeon workforce needs to increase year-on-year and work differently to enable more efficient working. There must also be a significant increase in theatre staff numbers, including anaesthetists.
- Ensuring a sustainable surgical workforce – RCS England will work with NHS trust organisations and health boards to develop a national focus on policies and guidance that will beneficially impact the wellbeing of surgeons. This includes tackling bullying and harassment, sexual misconduct, and enabling flexibility and Less Than Full Time (LTFT) working. There must also be improvements in the working environment, such as providing places to rest, availability of hot meals and dedicated places for personal study. RCS England recommends increasing training numbers across all surgical specialties and prioritising training opportunities for those in designated training programmes.
- Changing the way the whole surgical team works – RCS England will work with NHS trust organisations and health boards to develop and implement national job planning appropriate to career stage. RCS England will further promote the integration of SAS surgeons and LEDs within the surgical team, ensuring their inclusion in service planning, education and leadership opportunities.
The census exposes particular challenges for surgical trainees, with the pressures of service provision preventing them from attending training sessions both in the clinical environment and in educational settings. Many are considering their career options – a sizeable number (45% of core trainees and 28% of higher surgical trainees) have considered leaving the profession in the past year.
RCS England strongly believes there should be dedicated time for training in the job plans of Educational and Clinical Supervisors.
Mr Srinivas Cheruvu, President of the Association of Surgeons in Training (ASIT), said: “Access to theatres is fundamental for surgical trainees, and despite some improvements following the pandemic, this continues to be a major barrier to their progress. There is still a shortfall of elective operating for trainees as compared to pre-pandemic. They need dedicated time for training across all areas where training opportunities exist including the independent sector.
“The surgical workforce is committed and attends to service needs at every call. The census shows that despite 62% of trainees not taking their full annual leave entitlement and 97% working above contracted hours, they have not seen a recovery to training opportunities. The census provides insight into a range of issues that need to be addressed urgently to support a sustainable surgical workforce; one that is highly trained and will deliver safe patient care for both the short and long-term.
“The linear career path need not be the norm. Opportunities should be available to surgical trainees to work flexibly, including learning, education, and research alongside clinical commitments. Trainees are the consultants of the future, and we need to listen to their needs and do all that we can to attract and retain them in what is a hugely rewarding career.”
Reflecting on keeping members of the surgical team working in the health service, Mr William Allum, lead report author and Royal College of Surgeons of England Council Lead for Workforce and Training, said: “We need targeted action to increase retention at all career levels in surgery. This will go a long way to address waiting lists, meet the expectations of patients increasingly presenting with more complex problems and create the capacity to train and mentor a sustainable surgical workforce for the future.
“We must ensure SAS surgeons and LEDs are recognised for the high-quality services they provide both in planned surgery and the emergency setting. They often feel undervalued and marginalised by their employers and their colleagues. By embracing them within clinical teams and providing training, education, and leadership opportunities, we will unlock the full potential of this significant and growing section of the workforce.”
1. An estimated 6.4 million patients were waiting to start treatment at the end of November 2023 – https://www.england.nhs.uk/2024/01/waiting-list-falls-again-as-nhs-staff-treat-more-patients-than-ever-before-in-one-month/
2. The following links provide the latest data on waiting times for elective care published by the devolved administrations in Scotland, Wales and Northern Ireland:
· Scotland: https://www.nhsinform.scot/waiting-times/