Flexible and Out-of-Programme Training: Differential Attainment in ARCP Outcomes for LTFT and OOP Surgical Trainees in the UK

• National ARCP data show that less-than-full-time (LTFT) training is not associated with higher odds of developmental outcomes overall in UK surgical training. • Specialty-specific differences exist with higher odds of developmental outcomes for LTFT trainees in trauma and orthopaedics and vascular surgery. • Surgical trainees returning from out-of-programme (OOP) training have significantly higher odds of a developmental ARCP outcome at their first postreturn review. • Elevated odds of developmental outcomes for OOP returners persist at the second postreturn ARCP suggesting challenges extend beyond initial re-entry. • Findings support the overall equity of flexible training pathways, while highlighting the need for targeted re-entry and specialty-specific support. To assess whether Less-Than-Full-Time (LTFT) training or return from Out of Programme (OOP) is associated with developmental Annual Review of Competence Progression (ARCP) outcomes among UK surgical trainees, and to describe demographic and specialty-level variation in these associations. Retrospective cross-sectional analysis National ARCP outcome data across all UK surgical specialties A total of 5911 surgical trainees (54,016 ARCP outcomes) for the LTFT analysis and 761 returners from OOP (761 ARCP outcomes on return to training) receipt of a developmental ARCP outcome, defined as outcome 2 (targeted additional training required without extra time) or outcome 3 (inadequate progress requiring extension of training). These outcomes indicate development of competencies are occurring at a slower rate than expected. LTFT status was not associated with increased odds of developmental outcomes in the overall cohort (adjusted OR: 0.98; 95% CI: 0.87–1.10, p = 0.697), although higher odds were seen in trauma and orthopaedics (OR: 1.28; 95% CI: 1.04–1.58) and vascular surgery (OR: 1.97; 95% CI: 1.13–3.44). OOP returners had higher odds of a developmental outcome at their first ARCP after returning to training (adjusted OR: 1.88; 95% CI: 1.32–2.69, p = 0.001). Among OOP returners with at least 2 postreturn ARCPs, repeating the analysis using the second postreturn ARCP as the outcome showed that they continued to have higher odds of a developmental outcome compared with trainees who had not taken OOP (aOR: 1.80, 95% CI: 1.29–2.52, p = 0.001). All models were adjusted for age, gender, ethnicity, and sexual orientation. Flexible and out-of-programme pathways are not associated with higher odds of developmental ARCP outcomes overall, but targeted support may be needed in specific specialties to ensure equitable progression.