Knee replacement waiting lists are one of the more headline-grabbing challenges for the NHS to address as we exit the pandemic. But a less well publicised problem is contributing to those numbers: the training of orthopaedic surgeons.

Last month, the BBC published an article about trainee orthopaedic surgeons in Northern Ireland. The story described how trainees had written to the NI Health Minister expressing their concern about the reduction in training opportunities driven by the pausing of elective procedures during the pandemic.

The thing is, it’s not just Northern Ireland. It’s UK-wide.

The problem is as obvious as it is huge. Covid demands – on staff and capacity – forced the NHS to halt elective (that is, non-emergency) procedures. At that point, no registrars (trainee surgeons) could operate. Their practical training was effectively put on hold.

As pressures have lifted a little, and with waiting lists at stratospheric levels, you might have assumed the registrars could swiftly catch up on the patient numbers they had missed. But with many trusts not easily able to separate patients into Covid and non-Covid groups (because, for example, they operate from a single hospital), NHS patients were moved to Covid-secure private facilities for their surgery. Generally speaking, while registrars can assist in private hospitals, they can’t operate there because they aren’t covered by NHS liability insurance.

It’s an enormously frustrating situation, with training opportunities squeezed at a time when we’ve never needed fully trained surgeons more.

Addressing the training challenge

Qualifying as a consultant used to involve six years as a registrar followed by a year or two on a national or international fellowship.

But with opportunities reduced, trainees are now likely to spend seven or eight years as registrars, with time to full qualification extended to nine or ten years. In the meantime, many of our most experienced consultants will retire, leaving us with a shortfall of surgeons to tackle a record waiting list.

There’s no simple solution, but moves are afoot to maximise training opportunities for registrars.

A growing number of private hospitals are now allowing trainees to operate on NHS patients treated on their premises on the basis that NHS liability insurance is extended accordingly.

Then there are the deaneries, the regional bodies responsible for the management and delivery of post-grad medical education to the standards set by the General Medical Council. The GMC sets the surgeon volumes trainees are required to achieve (for knee replacements, for example, that figure is 40) and those numbers are important to protect patient safety and ensure surgeon capability. The deaneries are working with health providers to maximise opportunities for trainees to hit those volumes.

It’s a problem that will take time to overcome, but we are at least seeing some signs that the problem is being treated seriously.

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