Shaping the future of surgical training: our response to NHS England’s Medical Education Review

The NHS faces a dual challenge of meeting rising patient demand, particularly in ageing and underserved populations, while also training a future healthcare workforce that is resilient, diverse, and equipped for modern practice.

The Royal College of Surgeons of England has submitted a comprehensive response to NHS England’s Medical Training Review which makes specific recommendations for the Department of Health and Social Care (DHSC), NHS England, and sets out actions we will take.

Our submission reflects the voices of our members - particularly resident doctors - and sets out a vision for a modern, inclusive, and sustainable surgical training system. We have drawn on feedback from our workforce census.

We have also written to the co-chairs of NHS England’s review, ahead of meeting them, to further emphasise the key themes and recommendations from our submission.

Our main recommendations

Expand postgraduate surgical training places

An ageing population is creating significant challenges for the NHS. As the number of older patients with complex, long-term conditions grows, so does demand for healthcare. At the same time, more NHS staff are approaching retirement. Without swift action to expand training places, the health service risks staff shortages and reduced capacity to meet future needs. To address this:

• NHS England/DHSC should expand core and higher surgical training posts immediately to meet rising patient demand and increased undergraduate numbers.
• They must address bottlenecks impacting resident doctors’ career progression.
• They should create posts in under-doctored areas with appropriate transition funding to ensure roles are not lost elsewhere in the system.
• They should publish the data being used to model future workforce numbers across specialities and geographies to enable challenge.
• They should ask an independent agency to provide a bi-annual report which transparently sets out the assumptions around future workforce needs – equivalent to the way the Office for Budget Responsibility (OBR) sets out economic and fiscal forecasts.

Integrate training into service delivery

The culture within NHS trusts needs to change to one that prioritises training the next generation of surgeons. Training often takes a back seat to service delivery, but quality training demands dedicated time and resources, not just 'on the job' practice. Resident doctors must have protected time for training, access to theatres, and high-quality mentorship to thrive in their roles and develop into confident consultants. To achieve this:

• NHS trusts must better balance training and service delivery by ensuring resident doctors have sufficient time for training in the breadth of their specialty, and particularly in operating theatres to practice their technical skills.
• NHS England/DHSC must guarantee resident doctors are also able to access training opportunities when NHS treatment is delivered in surgical hubs and the independent sector.
• NHS trusts should protect and fund trainer time, recognising that high quality training requires resourcing.
• NHS England/DHSC should review how funding allocated to trusts for education is transparently reflected in job plans. Alternatively, if this is not feasible, they should investigate changing the way the tariff is applied, centralising contracting for training time in a similar way to primary care.
• They should ensure consistent standards and support for SAS and LED doctors, with equitable access to training and career development.
• The abolition of NHS England could lead to a gap in governance. DHSC should confirm that the oversight and standardisation of training for resident doctors, SAS doctors, and LEDs will continue to be provided nationally to ensure consistency and quality, as there is a risk of fragmentation if devolved to local levels.

RCS England and ASiT have previously written to the co-chairs of the NHS England Medical Training Review - Professor Sir Stephen Powis, NHS England National Medical Director, and Professor Sir Chris Whitty, Chief Medical Officer - to raise concerns about access to operating theatres for surgical training. We are due to meet them in July to discuss our concerns.

Training should support wellbeing

Modern training programmes must deliver greater flexibility, geographical stability, and strong support for work-life balance, portfolio careers, and mental health. Providing flexibility and boosting morale are essential for retaining a diverse and resilient workforce. To achieve this:

• NHSE England/DHSC must introduce a wellbeing package to improve flexible working options and ensure both the physical and cultural aspects of workplace environments are conducive to high quality training.
• The equality impact assessment for the review should detail the positive impacts of proposals on resident doctors by protected characteristics.
• NHS trusts must move to a model based on whole-time equivalents, rather than number of doctors, to ensure resident doctors can work flexibly, while maintaining appropriate cover for rotas.
• RCS England will continue to develop mentoring with the aim of preparing and supporting resident doctors for their transition into consultant practice. This will assist with retention and succession planning, especially in highly specialised fields.This will assist with retention and succession planning, especially in highly specialised fields.

Reform surgical curricula

Curricula must be agile and prepare doctors for digital innovation, AI, robotics and an increase in community-based care, while maintaining focus on essential surgical competencies. To achieve this:

• RCS England will collaborate with other surgical royal colleges to reform curricula, promoting surgical generalism, ensuring competence across the generality of a specialty, and reducing reliance on specialist centre rotations.
• DHSC/NHS England should provide funding for new technologies that support training so that practical training experiences can be enhanced through the integration of simulation, virtual reality, and extended reality.
• There needs to be increased support for Out of Programme (OOP) activities to develop expertise in areas such as leadership, quality improvement and service development, while supporting portfolio careers.
• DHSC/NHS England should address the cost of surgical training through an increased study leave budget to widen access and support retention.

What’s next: how will we keep up the pressure?

This submission is just the beginning. We will continue to engage with NHS England, the Department of Health and Social Care (DHSC), and other key stakeholders to ensure our recommendations are adopted.

We will advocate for a national approach to workforce planning, including transparent data and independent forecasting. We will also push for a cultural shift within trusts - where training is prioritised alongside service delivery, and where every surgical episode is seen as a learning opportunity.

We will also highlight how any changes to medical education, may later impact dental training, and our Faculty of Dental Surgery members. We will raise this in our regular meetings with NHS England’s Chief Dental Officer.

Above all, we will keep championing the voices of our members because the future of surgery depends on them.