Introduction

Cataract surgical skill is a core competency in ophthalmology training in many countries. UK ophthalmology trainees are expected to complete a minimum of 350 phacoemulsification cataract procedures by the end of 7-year specialist training. Recent guidance from the Royal College of Ophthalmologists (RCOphth) and Get It Right First Time (GIRFT) committee now further expects experienced trainees to complete at least 10 cases/list on a high volume basis to prepare for their future consultant role [1].

Ophthalmology trainees have expressed concerns on reduced training in cataract surgery during COVID pandemic [2, 3]. Recent studies have also highlighted the lack of confidence among senior trainees in managing cataract surgery complications, particularly posterior capsular rupture (PCR) [4, 5]. In addition, there has been a considerable shift of cataract surgery being performed in the independent sector (IS) in England (increased from 11% in 2016/17 to 46% in 2020/21), raising concerns on the potential impact on surgical training [6].

In 2021, RCOphth published a position statement and training guidance setting out the college’s commitment to rapidly increase access to surgical training in the IS [6]. Nonetheless, there are limited studies evaluating the current cataract training situation in the NHS and IS. In addition, no study has specifically evaluated ophthalmology trainees’ perceptions and experience in IS.

Methods

To evaluate the above issues, we conducted a cross-sectional, questionnaire-based survey study between December 2021 and April 2022, involving all members of the North East Trainee Research in Ophthalmology Network (NETRION) [7, 8], working in five tertiary hospitals across the North East of England, UK. The questionnaire was sent to all NETRiON trainees in December 2021, followed up by another reminder in April 2022 (see Supplementary Table 1). Relevant data on trainee’s grade, number of cataract cases performed, current cataract training opportunities, and perception and training experience in IS were collected. Ethical approval was not required and the study was conducted in accordance with the tenets of Declaration of Helsinki.

Results

A high response rate of 87.5% (28/32) was received, with 14 (50%) respondents being senior trainees (ST5-ST7; Fig. 1A). Only 6 (21.4%) trainees had performed ≥400 cataract surgeries, and 9 (32.1%) trainees agreed that they had received adequate cataract surgery training (Fig. 1B, C).

Fig. 1: Survey responses.
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a What is your current stage of ophthalmology training; (b) Current number of full cases of cataract surgery performed; (c) Do you think you have exposure to adequate cataract surgery training opportunities in your training so far? d Have you had any training in managing a high volume cataract list? e Perceived benefits of training on an IS high volume list (most important 1 – least important 5); f perceived barriers of training on an IS high volume list (most important 1 – least important 5).

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The mean percentage of list offered to trainees to operate on was 48 ± 20% (43% for junior trainees vs. 54% for senior trainees; p < 0.001). Overall, 14/25 (56.0%) trainees observed a decrease in cataract training over the past two years. Eleven (39.2%) trainees strongly disagreed/disagreed that the extent of current training is sufficient to reach CCT level, defined as an independent cataract surgeon who is competent in performing the surgery and managing intraocular complications, including PCR. Only 2/14 (14.3%) senior trainees felt very confident/confident in managing high volume cataract lists (≥8 cases/list), and 22 (78.6%) felt they would benefit from such training. Sixteen (57.1%) had received human factor training in surgery, and 25 (89.3%) agreed with the importance of this aspect.

Nearly all (25/27, 92.6%) trainees reported that IS providers have impacted on cataract training in the NHS (Table 1). Only two (7.2%) trainees had observed/operated on IS theatre lists. Many (19, 67.9%) trainees would take on the training opportunity in IS, and 17 (60.7%) trainees felt that IS training should be incorporated into the training programme. High case number and limited time for teaching/training were the most common perceived benefit and barrier of training in IS, respectively (Fig. 1E, F and Table 1).

Table 1 Survey questions with free text comments.
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To ensure effective and safe training in IS, most trainees had expressed the importance of adequate cover of indemnity/legal issues, high-quality supervision, set allocation of training time with clear guidance and monitoring from RCOphth and GMC.

Discussion

To our best knowledge, this represents the first study that evaluates trainees’ perception and experience in cataract surgery training in IS. Our survey result demonstrated a reduction in cataract training and many trainees did not feel confident in reaching the CCT level of competencies. Despite the push from RCOphth and GIRFT [9], most trainees did not receive any training on managing high volume cataract lists and had inadequate training on human factors and ergonomics, which are crucial to running a safe and highly efficient surgical list.

In addition, many trainees have perceived significant impacts of IS on cataract surgery training in the NHS. Whilst the benefit of reducing waiting list is recognised, trainees expressed concerns regarding the reduction in cataract surgeries in the NHS. With nearly 50% of the cataract surgeries are being performed in IS, incorporating training in the IS during the ophthalmic specialist training appears to be the way forward in the current climate. To date, there are a few studies evaluating the experience of surgical training in IS in the UK, including orthopaedic and general surgery, with 75–80% of the trainees reporting a positive experience [10, 11]. However, some of our trainees were unsure about the transition of training in IS, highlighting the need for systematic guidance and implementation of such training, particularly with high volume lists, without compromising patient safety. Concerns regarding lack of training regulations at the IS were frequently mentioned, and suggestions for support included ensuring adequate training of trainers and regulation of training as in the NHS with oversight by GMC/college and regular monitoring.

We recognise that the results of this study were restrained to only one of the 15 deaneries in England, however all trainees in the UK are required to undergo the same national training programme approved and accredited by the RCOphth and GMC. Furthermore, the shift in cataract surgery providers has been consistently observed across England. Therefore, we believe our results are likely to be representative of the training throughout the country. Future studies conducted at the national level would help to further validate our findings.

In view of our results, we therefore urge the GMC, Health Education England and RCOphth to address the concerns raised by trainees by changing regulations of training and setup an established framework for the delivery of cataract training within IS, to ensure the surgeons of tomorrow are receiving the necessary training to meet the growing demands of healthcare services.