Should I CCT or CESR?

Last updated on Feb 24, 2025

I've been asked a number of times while working as a locum registrar whether I intend to CESR or pursue the traditional training pathway and CCT.

My short answer is that I have no idea.

So I've scoured the interwebs and put all the useful stuff I found in one place here.

What are the options?

There are essentially three winding routes that one can follow in their quest to end up on the specialist register as an anaesthetist.

Certificate of completion of training (CCT)

The traditional pathway to CCT is to apply to:

core training, be that pure anaesthetics or ACCS - for 3 or 4 years respectively
followed by higher specialty training from ST4-7

You are only able to CCT if you have completed your training in an approved UK post.

This route requires you to successfully apply to both stages of training, each of which is painfully competitive.

Certificate of Eligibility for Specialist Registration (CESR)

Technically this is now called the 'Portfolio pathway' programme, but we'll refer to it as CESR given that's what everyone calls it.

This is the alternative option for those who haven't completed a GMC-approved programme but are clearly capable of everything expected of a UK-trained consultant anaesthetist.

Those who have trained abroad
Those who have built significant experience outside of a training programme

To achieve this you need to build a bulletproof portfolio that maps fairly closely to the standard pathway, to demonstrate your equivalence of experience and training.

Certificate of Eligibility for Specialist Registration Combined Programme (CESR-CP)

This is a bit of both - this pathway is for those who haven't completed the full UK training programme but have a mix of approved and non-approved training or experience.

According to new GMC rules, if you're on the CESR-CP pathway and complete at least three years of training in the UK, then you might be eligible to CCT instead, if you'd prefer.

So what are the differences?

It seems to be a bit like comparing a motorway to taking country A roads when driving to somewhere rather far away.

Both can work just fine, and both have their drawbacks.

The standard pathway (CCT) is the motorway - well established, structured and with substantial proactive guidance from college tutors, your Deanery and a specific, topic-based portfolio to tick off. But like the M25, you know the rotational training to potentially far-away hospitals is going to be a faff even on the best of days.

However in the absence of major incidents - or intentionally going less than full time - you can be fairly sure how long it's going to take (3-4 years for core, 4 years HST) as long as you tick off the right boxes in good time.

CESR is taking the scenic route

It'll probably take longer, and you'll have to pull over once in a while to check you're still on track and maybe ask for directions, but if it takes the motorway hassle away and gives you a sense of freedom and control, it might be the better option.

"Owning a house, having children, being older, alternative careers or looking after sick relatives may make the prospect of entering full-time training daunting. When you consider the relatively inflexible entry points into training at ST/CT1 or ST4 combined with the prospect of moving around different hospitals, subject to biannual ARCPs and exams, the more flexible CESR option might become more attractive. However, because there is no one chasing you, it becomes all the more important that you are sufficiently disciplined, attentive to detail and organised in your approach to collecting evidence." - link

Bias and recognition

I'm a locum registrar who has completed core training in the UK, so I have no personal insight or experience of this myself, but having asked around a substantial number of colleagues, the general census seems to be that consultants who have CCT'd are held in higher regard than those who have CESR'd, despite them being legally completely equivalent.

Often those who have CESR'd have even more years and breadth of experience

I have heard of departments hiring CCT over CESR despite negligible differences in skillset and ability, and a general perception of CCT being superior, regardless of whether this carries any validity whatsoever.

If you're a non-UK trained anaesthetist

If you've trained elsewhere and moved to the UK with the long-term intention of working as a consultant in the NHS, then the general advice seems to be:

Start with a non-training post in a department to get a feel for the system, how things work, and decide whether you like what you
Think about your own experience and level of training, to see how far off satisfying the CESR requirements your portfolio is
Decide whether it is quicker/preferable to CESR or to apply for CT1/ST4 and progress through to CCT
Start collecting as much evidence of experience and competence as possible, and as soon as you can!

Many departments have significant experience with anaesthetists doing this, and so can offer guidance on what may work best for you and your particular situation.

Things to consider

Competition

ST4 posts are highly competitive, with many applicants having to apply multiple times
CESR route is more self-guided and doesn't have the same barriers to entry

Financial

Pay may be lower as an ST trainee than CESR contract
But your many of your CPD expenses are covered
CESR may have to fund own CPD
CESR costs over £1500 to apply while CCT is around £500

Work-life balance

CESR often has more control over your work life balance and geographical stability
Rotational training is well-known for taking its toll on mental health
The stress of having to build your own portfolio may outweigh the benefits of not having to move hospitals

Timeline

CCT is fairly fixed - 7 years plus however much delay is added for LTFT or other unexpected events
CESR is very variable - potentially shorter if you have lots of experience already, but potentially significantly longer

Admin

CESR requires organising one's own training and seeking out posts in specialty departments if these haven't yet been signed off
You have to gather robust evidence without a whole load of external guidance
CCT is a fixed pathway where lots of this is hopefully sorted for you
CCT appears to have more established international recognition

Overall vibe

If your priority is a clear training pathway, with structure and a set time limit, and you may want to work abroad in the future - CCT.

If you want geographical stability, have a wealth of previous experience, don't want to restart your training at a more junior level, and aren't too fussed about how long it takes - CESR.

It seems that the experience you will have, however, will depend significantly on the department in which you find yourself working.

💡

Beware advice from those with no experience of the other side - grass is greener and all that.

What does Reddit say?

While not exactly held to Cochrane standards of robust scientific data handling and statistical interpretation, Reddit does give a useful insight into experiences of others who have travelled the path ahead of us.

Here are some insights we've found:

CESR ain’t easy. You need a supportive department and a ton of motivation. You likely won’t get a job abroad. If possible, push through for a CCT.
The GMC used to say that CESR was ‘equivalent’ to a CCT. They now don’t say this and just the ‘portfolio pathway’ makes you eligible to work in the UK on the specialist register. It’s obvious that they have lowered standards - CESR/ portfolio pathway is worthless when applying outside the UK.
Cesr is difficult to get your competencies (unless you have already got neuro / cardiac / paeds - not just got them but have them recently enough for cesr.
ICM and obs are much easier to get in a DGH but you are always going to be fighting for limited space in cardiac / neuro lists.
Rotational training is hassle, but you'll get all the lists you need.
Similarly you are with a cohort of individuals who are all doing the same things at the same stage.
Trainees will always be prioritised for training opportunities - that thoracic list you've been trying to get onto? Sorry, the trainee is only here for 3 months so they take priority. We'll get you onto it some other time. Except "some other time" could be years later, or never.
Despite the obvious issues with rotating, if you stay in one place, you will only learn how things are done in that place. Your department doesn't like thoracic epidurals? Subclavian central lines? TIVA for obstetrics? You'll never learn them.
You will be expected to take up a consultant job in the place that trained you. (Could be an upside if you're certain you want to work there forever.) It is very unusual to CESR and then work at a different trust.
Paperwork requirements are vast and onerous compared with being a trainee. On top of this, once you're finished you have to pay approx £1000 for the GMC to check your documents - no refunds if they decide you've missed something.
I in no way feel “ restricted” or “inferior” to CCT consultants as I know my training has been brilliant. My CESR was done prospectively, in London teaching hospital along side many HEE trainees in a supported CESR program. The longer placement meant I was well known in the department, gained autonomy, built relationships with other trainees and consultants that would not be possible on 3-6 months placements. I was also given placements based on my career aspirations and life circumstances, never felt like a number and always had engaged and supportive consultants to guide me along.

My take

Having discussed with a variety of consultants, both CCT and CESR, the general advice I have been given is to follow the traditional route and CCT if possible, largely for the convenience, structured training, certainty of time limit and perception of CCT as a consultant.

So if and when I do decide to progress, that's probably the route I'll try to follow.

For now though - I intend to sit here as a reg for just a little longer.

References and Further Reading

Chapter 9 – The portfolio pathway to Specialist registration