Census: your thoughts, our actions

In July 2023, we surveyed the UK surgical workforce to identify the key challenges facing surgical teams and to inform workforce planning. Respondents included consultants, surgeons in training, Specialist, Associate Specialist and Specialty (SAS) surgeons, Locally Employed Doctors in surgery (LEDs) and members of the extended surgical team (EST).

The survey findings revealed important insights, and our report, Advancing the Surgical Workforce, published in January 2024, painted a picture of a surgical workforce working long hours, in stressful environments and at risk of burnout. The data also reinforced anecdotal feedback we have received regarding access to operating theatres, overall productivity, and the implications for surgical trainees. Surgical teams are dealing with increasing demand, inadequate infrastructure and a working environment that often feels unsupportive. 

Addressing some of the concerns raised in our census will require a long-term approach, but there are also improvements that be achieved on a shorter timescale. Since you told us the challenges impacting the surgical workforce, we have begun a programme of work to improve surgeons' and patients' lives. Our campaign has three main objectives: 

• Improving access to operating theatres to reduce waiting times
• Addressing the challenges facing surgical trainees
• Ensuring a strong and sustainable surgical workforce

Improving access to operating theatres to reduce waiting times

You told us that access to operating theatres continues to be a major challenge with widespread consequences for patient care, productivity and surgical trainee experience. The waiting list in England alone stands at over 7.5 million. If surgical teams cannot get into operating theatres, patients will continue to endure unacceptably long waits for surgery.

How we are taking action:

We have campaigned for improved facilities and capacity in surgery, including surgical hubs, explicitly calling for £6.4bn annual capital funding increase so that the NHS estates are fit for purpose.

• Our £6.4bn capital funding ask was carried by The Telegraph in the run up to the election.
• We have supported NHS England with its reform of outpatients, recognising a large proportion of the waiting list is outpatient appointments.
• We have highlighted how surgical hubs can help tackle waiting lists and create less stressful working environments for the surgical workforce. 
• Surgical Hubs have been evaluated for their effectiveness by The Health Foundation

We continue to build on the success of our surgical hubs campaign starting with a New Deal for Surgery and then, the Case for Surgical Hubs. The previous UK government invested approximately £1.5 billion in high-volume, low-complexity (HVLC) surgical hubs. Through our ongoing media work we have repeatedly highlighted the benefits of surgical hubs, for patients and staff, and urging the new government to continue to invest in their roll-out. We also continue to highlight how staff vacancies and bed availability impact access to theatres.

In June 2024, we renewed our efforts on surgical hubs, making the case for a £6.4 billion annual capital funding increase to upgrade NHS facilities and expand surgical capacity, including surgical hubs, to help bring down waiting times. These calls formed part of our election manifesto, and we will continue to lobby the new government. 

We have also worked with NHS England and the Getting It Right First Time (GIRFT) team as they have developed new improvement guides on theatres surgery and perioperative care and outpatient services. If you have any views or feedback on these guides, you would like RCS England to share with NHS England, please send details to publicaffairs@rcseng.ac.uk.

We are engaging with the Health Foundation and the University of York to better understand the full effectiveness of surgical hubs and the benefits they bring for both surgical staff and patients. The collected data will help to inform the further development of surgical hubs.

The Health Foundation is working with NHS England and Getting It Right First Time (GIRFT) on an evaluation of elective surgical hubs, something we called for in our manifesto. The first findings from this series of work show surgical hubs could help speed up tackling waiting lists. The University of York is running a longer-term evaluation of HVLC surgical hubs. We also continue to support GIRFT’s surgical hub accreditation scheme.

We will use all the evidence gathered to continue to make the case to government that it must invest in the surgical workforce, NHS infrastructure and surgical hubs.

Back to objectives

Addressing the challenges facing surgical trainees

You told us the knock-on effect of poor theatre access has been a serious problem for trainee surgeons. Insufficient theatre access acts as a barrier to training opportunities. Trainees also raised issues about job and rota planning, the costs of training and pressure put on them to work above their contracted hours due to staff vacancies and service demand. A high number are considering leaving the NHS and going abroad to work.

How we are taking action: 

• We have asked our consultant surgeon members to ensure trainees are prioritised for access to theatres.
• We are working with ASiT to identify and promote good examples of trainee-led rota planning.
• We will respond to the Department of Health and Social Care’s planned review of training rotations.
• We will identify essential training courses for surgical trainees, and work with NHS England to secure funding to reduce the cost impact on trainees.

We have used our member communications to strongly encourage consultant surgeons, and NHS Trust organisations and Health Boards, to ensure trainees are prioritised for access to theatre.

We recognise rotational training, and rotas have a negative impact on trainees’ quality of life, as identified in ASiT’s report Cost of Surgical Training (CoST) – Non-Financial.  There are still too many examples when poor rota planning has intervened with key life events such as weddings, holidays and family life or has been geographically challenging.  We are engaging with ASiT to identify good examples of trainee-led rota planning, and we will promote this to our members, NHS Trust organisations and Health Boards. The Joint Committee on Surgical Training (JCST) has also developed a series of Quality Indicators (QIs) to enable the quality of training placements within each surgical specialty and at core level to be assessed.

As part of pay negotiations with the BMA, the Department of Health and Social Care has announced that it will lead a review of the current system of rotations, with the intention of reforming the number and frequency of rotations. RCS England will respond to this review. We will seek input from the surgical trainee associations when developing our response.

In addition, we are working closely with ASiT and BOTA to understand the financial cost of training, and particularly the need to recognise and fund essential courses, as well as continuing to argue for protected time for teaching and training.

We meet regularly with NHS England’s Workforce, Training and Education Directorate, and we have advised that training in secondary care should be contracted, as it is in primary care. We have also highlighted the need for increased training numbers and will influence NHS England’s plans for postgraduate surgical training places.

Back to objectives

Ensuring a strong and sustainable surgical workforce

You told us burnout and stress are major issues, with 61% of surgeons citing them as main challenges, and poor working conditions and workplace culture also affecting staff. At least 50% of you said you had considered leaving the profession in the last year. There are huge demands on the surgical workforce’s time, and system challenges such as broken IT, an increased administrative burden, vacancies within teams, and a lack of resources like beds and operating theatres, often make the work more frustrating and stressful. If we want to have happy, healthy patients, we need happy, healthy staff.

How we are taking action:

• We have lobbied government for increased investment in the surgical workforce, NHS infrastructure and surgical hubs to take pressure off the existing workforce.
• We have supported the Working Party on Sexual Misconduct in Surgery, enforcing a zero-tolerance approach to sexual misconduct in healthcare and taken action to improve our own policies and working practices.
• We were successful in getting 20 additional trusts to sign the NHS England Sexual Safety in Healthcare Charter and since then NHS England has asked all NHS organisations to implement the actions set out in the charter.
• We have published a new Code of Conduct which sets out the expected behaviour of members, non-members in appointed or elected roles, and our staff. This includes tackling sexual misconduct.
• We have hosted a roundtable with government officials, NHS England and trainee organisations to influence the implementation of the government plans to use waiting list initiatives to tackle waiting lists.
• We will develop updated job planning guidance for the surgical workforce.
• We will commission research to determine the day-to-day pattern of a surgeon’s time so we can demonstrate to NHS employers how surgeons can spend more of their time treating patients.

We are calling on the new government to make the NHS a more attractive place to work by introducing a wellbeing package to support the morale of our workforce. This includes putting pressure on NHS employers to ensure they are providing adequate welfare facilities for staff, including 24-hour access to nutritious food and drink; places to rest, study and eat meals; changing facilities and lockers; facilities for parents returning to work. At the same time, we have been lobbying the new government for the significant investment the NHS requires to expand surgical capacity, update infrastructure, and grow the workforce.

We have also called on the government to require NHS England to ensure policies on flexible and LTFT working are in place at each NHS trust and that each NHS trust is proactively enforcing these policies through effective delivery and support of staff. 

Earlier this year we wrote to 49 NHS trusts who had not signed the NHS England Sexual Safety in Healthcare Charter, and we were successful in getting more than 20 additional trusts to sign. Since then, NHS England has announced it is asking every NHS organisation, not just existing signatories, to implement the actions set out in the charter. In July, we published our new Code of Conduct. No matter how technically competent or senior you are, if you abuse your position as a surgeon, you will have no place in our College. In October, we will host a meeting with the Working Party on Sexual Misconduct in Surgery to discuss what further action needs to be taken to reform reporting and disciplinary processes across NHS Trust organisations, health boards and regulators.

We have invited the new government to attend a roundtable with senior colleagues from Council, NHS England and trainee organisations to discuss their pledge to deliver an extra two million NHS operations and appointments every year through more evening and weekend work. Key to discussion will be how the NHS can make the policy work at its best for patients and staff, without contributing further to burnout.

We are revising job planning guidance, seeking to further understand the barriers in current job plans and ensuring guidance is inclusive of SAS doctors. We are also undertaking a piece of work to compare wellbeing scores from our census to published data, to develop a better idea of what specifically contributes to the wellbeing of the surgical workforce, and how we can help improve wellbeing. 

Lastly, we are looking to partner with a think tank or research group to analyse the day-to-day pattern of a surgeon’s time. This will help determine how we can influence NHS Trust organisations and health boards further, so you can spend more time doing what you joined surgery to do: look after patients in clinics, on ward rounds and in the operating theatre.

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