Health care delivery systems: effects on surgical education in the United Kingdom

Surgical education in the United Kingdom has evolved to meet the need of the National Health Service (NHS) for a relatively small body of consultants practicing autonomously and carrying ultimate clinical responsibility for their patients. This form of specialist practice is markedly different from that found in most other countries and has necessitated a longer, more comprehensive training program than is usual where hospital specialists work more in teams and under the supervision of a head of department. Because the ratio of specialists to population is low, case loads are high. Trainees obtain excellent experience and rapidly assume clinical responsibility. Service commitments have increasingly conflicted with the need for more formal educational activity, and the financial problems of the NHS have latterly reduced opportunities for clinical training as well. Scientific advances in surgery have removed a range of cases from the operative repertoire of younger trainees. As a result, it is becoming increasingly difficult to provide trainees with opportunities to develop their surgical skills. The duration of surgical training in the United Kingdom is largely dictated by the availability of consultant posts. It could be shortened substantially with no loss of quality, but only if considerable additional funding were made available to the NHS. There seems little prospect of this boost at present and the impoverishment of the NHS is having an increasingly detrimental effect on standards of surgical education.