The Confederation of British Surgery warns that the decision to withdraw funding for specialist surgical training, without national oversight and standard setting, will make "a recurrence of the recent Great Ormond Street Hospital scandal, which affected just under 100 children, more likely than ever."
Training Interface Group (TIG) Fellowships, the only nationally quality‑assured, GMC‑regulated supra‑specialist fellowships have effectively been axed by NHS England. They have been removed as quality assured training opportunities for surgeons leading the Confederation of British Surgery (CBS -www.cbsgb.co.uk) to raise the alarm that the cuts are dangerous and will threaten patient safety.
Specialty Surgical Trainee Raiyyan Aftab is a CBS board member as well as President of the Association of Surgeons in Training (ASiT – www.asit.org).
He warns, “The decision to make the cuts by the Postgraduate Medicine and Dental Education Oversight group in NHS England (NHSE) effectively dismantles a regulated pipeline into complex sub‑specialist surgery at the same time as high‑profile failures in paediatric orthopaedics are exposing the dangers of poorly governed, siloed complex practice. The withdrawal of funding will have inevitable consequences for future patient safety.”
Prior to defunding, TIG Fellowships were curriculum‑based in complex sub-specialist surgical practice which require additional training such as cleft lip and palate, hand surgery, head & neck oncology, spinal, oncoplastic breast surgery and major trauma. Their aim, as described by the Joint Committee on Surgical Training (JCST) is to ensure “excellence in a selected group of talented trainees” over a minimum of 12 months reaching defined competencies for formal certificates of completion.
Raiyyan continues, “In practice the cuts mean, the loss of the single, regulated, UK‑wide pathway for specialist competence in these fields, to be replaced by a patchwork of ad‑hoc, locally employed posts of variable oversight and quality.
“Removing TIG’s creates a patient safety issue in that without quality assurance, patients and commissioners cannot reliably know, what training a surgeon has actually received in supra‑specialist procedures or whether their unit has met any nationally agreed threshold for case‑mix, supervision, and governance.”
The recent internal investigation at Great Ormond Street Hospital (GOSH) into paediatric limb‑lengthening and reconstruction found that 94 of 789 children treated by one surgeon between 2017 and 2022 were harmed, more than one in eight patients.
35–36 children suffered severe harm, with documented issues including: Operations without clear clinical rationale, incorrect bone cuts and implant placement, premature removal of fixation devices, and poor management of complications. A toxic working culture, inadequate challenge, were also serious concerns raised by a Royal College of Surgeons review about how complex cases were overseen.
Raiyyan explains: “This is precisely the kind of complex, high‑risk sub‑specialist work that depends on robust training, multidisciplinary team‑based decision‑making, and strong external governance standards. At a moment when national reviews are calling for stronger oversight and standardisation in complex paediatric surgery, dismantling a proven, quality‑assured national training pathway for comparable supra‑specialist fields is counter‑intuitive from both a safety and regulatory perspective.”
There is plenty of evidence on siloed and poorly coordinated care, for example, a UK perioperative care review describes how multidisciplinary working can improve outcomes but also warns that “less well‑organised” multidisciplinary models are associated with worse survival than conventional care, highlighting how fragmented, poorly structured practice can be.1
Other examples of the value of coordinated training with close national oversight include cleft palate surgery, which historically was a fragmented service being delivered in some places as an ad hoc service with the worst speech, growth and appearance outcomes in Europe. This scandal led to a central government push to centralise services as well as setting clear measurable and quality assured standards for training and practice which has transformed Cleft Lip and Palate Surgery in the UK to world class status.2
Also the Bristol Paediatric Heart Surgery scandal where highly complex paediatric cardiac surgery was performed in a small number of centres with big outcome differences; Bristol’s problems were amplified by insularity, poor external benchmarking and lack of robust national standards and training oversight.
Raiyyan adds:“The lesson is clear: Subspecialisation improves outcomes when it is formally trained, integrated and governed. Removing regulated training pathways risks drifting towards isolated, siloed practice with variable standards – exactly the pattern exposed at GOSH and other examples highlighted above. We do not want history to repeat itself.”
The Plastic Surgery Trainees Association (PLASTA – www.plasta.org) have added their voice to the concerns. President Richard Clough says; “Patients with complex conditions often need specialised care from surgeons with cross-specialty expertise. TIG (Trainee Interface Group) fellowships provide this structured training. Their removal raises real concerns for future training quality and patient care.”
Consultant plastic surgeon Mark Henley, President of CBS, concludes: “While CBS understands the financial challenges facing NHS England, the decision to delegate funding to Trust level and devolve responsibilities to regional and local structures without clear oversight by the UK National Surgical Training organisation (JCST) is inexplicable especially at this time when patient safety and trust has been eroded by maverick behaviour and poor oversight by individual institutions. In addition the loss of formalised interspecialty relationships and working is detrimental to surgical excellence and cost-effective future practice and is an avoidable error.”
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