The demise of the ‘firm’ – explore the evolution of surgical and orthopaedic training in the UK. Does the current structure need a shake up?

By Conor Jones
ST1 NIHR Academic clinical fellow in Trauma and Orthopaedics

This is the winning essay from the 2023 BOTA Junior Essay Competition

 The demise of the ‘firm’ - explore the evolution of surgical and orthopaedic training in the UK. Does the current structure need a shake up?


“You’re on Team D. You’ll work for consultants XYZ and look after their patients”. My first foundation rotation was orthopaedic trauma at a major trauma centre. Together with two senior house officers (SHO) and a registrar, we worked for four consultants. The workload was variable — dependent on when our consultants were on call. I saw the same patients each day and became familiar with their issues, concerns and management plans. Despite the workload, I felt supported. I became close friends with the SHO and registrar, and I knew who to escalate my concerns to when stuck. Importantly, I felt that my hard work was recognised by the consultant team. This rotation was the closest thing that I have experienced to the traditional 'firm' structure so far in my training. I returned to the same unit two years later. But the firms had gone. Work shifted to the more common ward-based structure, with each junior responsible for a section of the ward. Whilst the workload was more predictable, the patients I saw could change each day and the team spirit was diminished.

The problem

Surgery has historically followed an apprenticeship model1. Trainees would work long hours under the supervision of a small team of consultants. However, Modernising Medical Careers and the European Working Time Directive ushered the transition to more shift-based work2. These systemic factors are extenuated by societal shifts in trainee expectations and priorities. Modern trainees increasingly recognise the value of work-life balance, and are no longer willing to follow the 'knife before life' mentality3. The resultant erosion of the firm system has been cited as a contributing factor for declining morale amongst trainees, rising rates of burnout and the mass exodus from training in the National Health Service (NHS)4.

This workforce crisis has come at a time of immense challenges to the NHS. Currently, 7.57 million people are waiting for consultant-led elective treatment5. Clearing this backlog will require innovative ways of working and huge efficiency drives. However, any changes implemented must keep the needs of surgical trainees in mind. How can we ensure that surgical trainees complete their training as the best possible version of themselves, whilst also meeting the needs of the evolving healthcare system more widely?

Mentoring and supervision

The team-based approach of the firm allowed trainees to work closely with a small number of consultant supervisors4. Trainees would attend the operating lists and clinics of their consultants. Ideally, the consultant would understand the capabilities and learning goals of the trainee, and was positioned to monitor their progress. Trainees could complete projects within their team and gather careers advice from their seniors.

In today’s shift-based work, it is common for trainees to go weeks or months without working with the same consultant — resulting in the need to constantly 'start over'. In the 2023 GMC survey, 55% of trainees felt that they had no support from a mentor6. This was particularly an issue for foundation doctors and core trainees where shift work is especially disruptive.

Formal mentoring schemes for registrars have proven successful and are endorsed by the British Orthopaedic Association7. However there remains a need to extend these to more junior members of the team. To maximise continuity of training and foster stronger trainee-trainer relationships, rota coordinators should aim to schedule dedicated training lists, preferably with the same consultants. This could be taken further by matching on calls with supervisors. Finally the departments should invest in simulation, and other means of minimising the surgical learning curve, so that trainees gather the most from every learning opportunity8,9.

Role of non-medically trained practitioners

Attempts to solve the growing workforce pressures, have inadvertently shepherded a new challenge to surgical training — that is, the expansion of non-medically trained practitioner (NMTP) roles10,11. Roles such as physician associates, extended scope practitioners and surgical practitioners were introduced with the promise of relieving pressure on doctors and feature heavily in the recently announced NHS Workforce Plan12. When utilised effectively, their permanent fixture within a department provides valuable continuity and familiarity with local systems. As a result, they can foster strong working relationships with consultants over many years, learn their preferences and consequently become extremely efficient. However such relationships also have the potential to result in preferential treatment, and stories of surgical trainees competing with NMTP for cases are common13. This is particularly challenging for more junior trainees, who are often left managing the wards at the expense of developing operative skills or outpatient clinic experience.

It is often said that no training today, means no surgeons tomorrow14. It is essential that policy makers, regulatory bodies and trainers remember this, to ensure that the needs of trainees are not compromised for the sake of short-term efficiency. We must also ask the fundamental question of why we are choosing to invest in NMTP roles, when (at least for now) orthopaedic training in the UK remains competitive with significant bottlenecks at both core and registrar level entry15. Is it really efficient or sustainable for core trainees to spend their time scribing on a ward round, whilst a NMTP assists with the sliding hip screw (required for registrar applications) or fracture clinic?


Surgical training in the UK is in crisis. Failure to evolve with changing working patterns, prioritisation of service provision over training and the devaluation of traditional medical roles have resulted in a workforce that feels unprepared and undervalued. If the NHS is to have any hope of preparing a competent surgical workforce of tomorrow, we must radically reconsider how training is delivered. However, hope is not lost. As the NHS itself looks to reform itself in the face of unprecedented challenges, we can concomitantly reform how we train surgeons. Whilst reintroduction of a traditional firm structure may no longer be feasible, we must endeavour to replicate the sense of teamwork and mentorship that they offered. We must also ensure that as non-traditional roles emerge, they are utilised in the most efficient manner and do not compromise the training of surgeons.

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