Tristram Lesser Brian Bingham ENT.UK British Association of Otorhinolarymgology Head and Neck Surgery And British Academic Conferences in Otolaryngology SAC in ORL JCST ISCP

Presentation to UEMS-ORL Section Numbers of ENT doctors Career of ENT doctors Selection of ENT doctors Training of ENT doctors

SAC/ENT.UK Training Workforce Numbers for training are national Numbers for workforce are local

ENT Workforce in England 2014 Robert Hone & Jeremy Davis With thanks to Lyndy Pullan and the ENT UK Office

Previous Surveys / Other Sources of Information The results of this survey have been compared to the 2010 workforce survey undertaken by Tristram Lesser and Jeremy Davis which just looked at Consultant and SpR numbers. The results have been ‘sense checked’ against the Workforce Plan for England (2014/15) published by HEE which is based on employment records HEE underestimates Locum Consultants as it does not always pick up agency employees HEE more accurately reflects StR’s as it includes many of those on OOP

ENT services in England 153 Trusts surveyed 34 do not employ ENT surgeons 119 trusts provide ENT services 703 consultant posts including 6 Vacant Posts and 59 Locums

Total Number of Clinicians – Q1 & Q2 Permanent Posts Male 537 (84.2%) 638 (91.5%) 697 Female 101 (15.8%) FT PT Locums Consultants 56 (95%) 59 (8.5%) 3 (5%) 45 (76.3%) 14 (23.7%)

Middle Grades & Juniors Junior Clinicians – Q4 Total of 892 of which 470 are “middle grade” Middle Grades & Juniors   FT Vacant Total Fellows & HST’s 263 3 266 Staff Grades 189 15 204 Core Trainees 60 2 62 GPVTS 82 F2 116 4 120 Other SHO's 143 6 149 F1 42 Clinical Assistants

Number of Higher Surgical Trainees 2010 vs 2014 vs HEE data

LETB’s

Ratio of HSTs to Consultants per LETB Averages: 0.46 in 2010 to 0.31 in 2014

Previously Underestimated Projections Higher population growth Current England Population 54 million Projected England Population 2030 61 million

Previous Underestimated Projections Underestimated Emigration Anecdotal reports of between 5-7 CCT holders in ENT emigrating per year Is this set to increase?

Doctors working in NHS

PMQ country No. of doctors % United Kingdom 179,527 63.9% India 25,503 8.9% Pakistan 10,503 3.7% South Africa 5,127 1.8% Nigeria 4,513 1.6% Ireland 4,227 1.5% Greece 3,757 1.3% Italy 3,740 1.3% Egypt     3,587 1.3% Germany 3,166 1.1% Romania 2,504 0.9% Sri Lanka  2,479 0.9% Iraq 2,408 0.9% Poland 2,206 0.8% Australia 1,985 0.7% Sudan 1,792 0.6% Spain 1,724 0.6% Hungary 1,521 0.5% Czech Republic 1,308 0.5% Bulgaria 1,006 0.4% Total 262,583 93.2%

Doctors added to the LRMP by World Region of PMQ for 2006 - 2015

Doctors by gender from 2006 - 2015   

Future Projections for ENT training numbers Increase in workforce HEE forecast a 20% increase in ENT consultants by 2020 Between 2000 and 2012 all staff groups in the NHS grew over 50% more consultants 13% more nurses (32,000) ~140 new posts - ~28 per year to meet increased demands Workforce requirements equate to approximately 60 posts per annum (28 replacement, 10 associate specialist replacements plus 28 new (growth) posts = 66)

Future Projections

National Selection for Higher Surgical Training Once a year 1 venue Fixed number of places for England Scotland and Wales Northern Ireland separate. 6 stations Portfolio Assessment Clinical Scenario Communication Skills Managerial Scenario Skills Assessment Structured Interview

The Training in ENT Governed by the General Medical Council (GMC) Paid for by the Medical Programs Board (MPB) Commissioned by Local Education Training Boards (LETB) Delivered by Hospital Departments and Deans (including courses) Over seen and recorded by ISCP Syllabus, Competencies, Assessments and Recording training (log book etc) requirements (Intercollegiate Surgical Curriculum Programme. (ISCP) Part of JCST/SAC Exams iMRCS-ENT (European Board equivalent) iFRCS ORL-HNS (HST completed)

Can include some Pre CCT Specialist Fellowships in UK or Abroad 1-2 years post CCT Fellowship Sub- specialist ENT consultant SAC CCT check list Specialist Register GMC ENT Consultant in Independent Practice year 6 years of Higher Specialist Training Can include some Pre CCT Specialist Fellowships in UK or Abroad 87 6 5 4 3 FRCS(ENT) Part 1 and Part 2 Apply for HST at National Selection MRCS-ENT EU-Diploma EU-Board Speciality ENT Doctor in supervised practice 2 years Core Surgical Training Take MRCS(ENT) 12 months of ENT 12 months of related Specialities. 2 1 2 years foundation in medicine and surgery Take MRCS part A Undergraduate Medical School MBBS 5-6 years.

Undergraduate Medical School 5-6 years MBBS Foundation 2 years medicine and surgery Part A MRCS Core Surgical Training 2 years Part B MRCS (MRCS(ENT)) DOHNS Part 1 and 2 or EU Diploma Post CCT Fellowships 1-2 years General ENT Consultant Or Super Specialist ENT Consultant CCT Higher Surgical Training 6 years Part I and Part 2 FRCS ENT May include some fellowships CESR After FRCS and Article 14 application Working as Specialty Doctor in ENT (not independent practice) General Practice Medicine With a Specialist interest

Uncoupled/Themed Programmes Training to Consultant/CCT Working as Speciality Doctor and possible CESR CT1 CT2 Run through to ST3 in future Early Years Uncoupled/Themed Programmes 12 months ENT early in CT (6 months minimum 18 months maximum) Additionally 2 or 3 placements over 12 months in a range of related specialties: Plastic Surgery Oral and Maxillofacial Surgery General Upper GI Surgery Neurosurgery Paediatric Surgery Paediatrics Cardiothoracic Surgery Ophthalmology need to check this one Accident and Emergency Medicine ITU General Practice The common surgical components are covered in Otolaryngology placements and complementary placements. The ENT components are covered in ENT. A CT2 extension in ENT may be available for trainees who have chosen to change to ENT from generic CST. CT2 extension in generic surgery may also be available for themed ENT trainees who chose to change to another surgical speciality or for trainees who require additional time to pass exams or need a second attempt applying through National Selection. The minimum ENT experience for ST3 application is 6 months and the maximum is 18 months. MRCS(ENT) required for National Selection ST3 ST4 ST5 ST6 ST7 ST8 Final Stage (Special Interest) (Fellowships/Interface) National Selection The trainee will undergo a period of specialty training of 6 indicative years in the broad specialty as defined by the final stage (including special interest) syllabus General ENT and Emergency Safe Training with or without subspecilaist training/fellowships. iFRCS ORL-HNS Trust grade LAT Fellowship SD Undertake LATs and Trust Grades or straight into Speciality Otolaryngologist grade The decision to become a Speciality doctor; DO-HNS exam required Working in General ENT and some sub specialisation as required by the service needs. FRCS or other qualifications will only be required if applying for CESR.

MRCS(ENT)or Equivalent e.g. European Board Exams Part A MRCS is normally taken in Foundation Year 2. Otolaryngology trainees will be required to complete the MRCS(ENT) examination or the MRCS and the DO- HNS examinations and should do so as early as possible in the initial stage. Those not progressing through national selection at the first attempt should either decide to become SDs and can then move into the LAT/Trust Fellowship grades. Or re-submit the next year for national selection but do non-ENT jobs in the meantime. This will enhance the chances of a career change to another specialty if unsuccessful again.

STANDARDS FOR HST in ENT  Ten Standards separated into three groups Experience standards: Experience over the last 6 years of training Exposure standards: Training and the standards and exposure for each job. Programme standards: Support for subspecialist, generic and academic exposure.

Experience Standards Undertaking a minimum of 2000 operations during the last 6 years of training as principal surgeon or main assistant. Undertaking, as principal surgeon, a broad spectrum of operations that are allied to emergency work, these being 10 mastoid operations, 40 tympanoplasties, 10 major head and neck operations, 10 tracheostomies, 10 paediatric endoscopies (including flexible), 5 vocal cord palsy procedures, 10 septorhinoplasties, 30 FESS, 10 removal of foreign bodies from airway including nasal and fish-bones. Exposure to the management of emergencies as manifested by 300 nights on call and/or having managed 1000 emergencies in higher surgical training.

Exposure Standards Clinics: 3 or more a week, including emergencies Conform to ENT guidelines (Numbers, Facilities) ST3 to include weekly special interest clinics (paediatric, vertigo, audiological, otology, tinnitus, head and neck, voice, rhinological and others) Operating Lists: 3 a week in CT/ST1 and 2, 4 a week in ST3 to ST8 Hospital Throughput: 500 ENT operations per annum per higher surgical trainee in that unit  

Programme Standards Rotate through sub-specialities otology, neuro-otology, paediatrics, benign head and neck, head and neck oncology, rhinology, sinus surgery, facial plastics, voice and balance. Generic skills training in management skills, teaching, education, leadership and team working. Support provided for extra curricular activities; for example to the level that would support for 3 papers per year, 2 audits per year and 1 presentation per year, or a higher degree )eg MS, Mphil, MBA, Educational or other diploma) or leadership skills training or similar. Facilities for sub special interest training within the programme.

“Training The Trainers” TRACE Course Education Theory Practical Skills Equality and Diversity Structure of Training Assessments Work Based Assessments GMC requirement

Web Sites e-log 2016 The updated Otolaryngology curriculum came into effect in August 2016. https://www.iscp.ac.uk/curriculum http://www.e-lefent.org.uk