CESR - a comprehensive guide for histopathologists

  • May 02, 2022

IMGs from any country in the world can apply for Specialist Registration, provided certain eligibility criteria are met, though there are different routes available based on a doctor’s qualifications and training. 

Here we explore specialist registration in histopathology for overseas consultant pathologists and specialists more closely. We’ll cover the Certificate of Eligibility for Specialist Registration (CESR) specifically, including the application, costs, and eligibility criteria, along with some other topics, summarised in the headings below: 

Skip ahead to the relevant section if you know what you’re looking for. 

Specialist Registration 

Specialist registration in any specialty means that you can be appointed to a substantive (permanent) consultant position in the NHS. All physicians who wish to take permanent consultant roles in the UK must show evidence of skills, knowledge, and experience in order to gain Specialist Registration.  

Specialist Registration is additional to full registration with the GMC and is therefore not required to practice as a histopathologist in the UK. 

Routes to Specialist Registration 

There are three types of certificates issued by the GMC for specialist registration across all specialties, and the type of certificate you receive depends on which training route you followed. 

For pathologists who have completed their full training outside of a GMC-approved training programme, CESR is the route they will usually take towards attaining specialist registration. This route does not require further training, but rather the submission of an application.  

Doctors who have trained outside the UK or Switzerland, but within an EEA country, will be awarded CCT (Certificate of Completion of Training) after a successful specialist registration application. Specialist Certifications from across the EU are deemed as equivalent by the GMC, and therefore a straightforward application can be made.  

NHS Positions in the NHS without CESR 

It is important to note that you attain more senior histopathology roles in the NHS, such as a specialty doctor (SAS), specialist grade or a locum consultant without being on the Specialist Register. 

Similarly, overseas doctors do not require CESR before moving to the UK to work in the NHS. 

In these NHS roles, you will have better pay and responsibilities that are more appropriate to your level of experience compared to a trainee. While working in these positions, you can collect evidence of your competences, particularly those specific to the UK histopathology curriculum. 

These positions also facilitate a faster route to the UK than the CESR route, which can take a substantial amount of time. 

FRCPath for Specialist Registration 

Whilst it is always beneficial pathologists to complete FRCPath, overseas doctors looking to join the Specialist Register do not necessarily need to have completed the Royal College postgraduate exams. 

The standard test of knowledge in the CCT curriculum are the FRCPath exams, so passing these exams confirms the attainment of the competencies of the Histopathology Curriculum

FRCPath is only a requirement for doctors looking to attain Specialist Registration via the CCT route. 

However, if CESR applicants have not successfully completed these exams, they must provide alternative evidence that demonstrates equivalent knowledge to histopathologists who have passed the FRCPath exams. 

Even if the competencies covered by the exams require something that someone in your position would not routinely undertake (in your sub-specialty for example), you must still provide evidence of it – as the evaluators will not make assumptions outside of the evidence presented. 

CESR Equivalence Process 

Equivalence describes the process of assessing an overseas applicant’s training and experience against the current histopathology training programme requirements, in order to be awarded CESR. 

The equivalence process involves submitting a written body of evidence to the GMC, consisting of: 

  • training and/or competence 
  • skills and knowledge 

The Royal College of Pathologists will assess each application against the relevant Curriculum before providing a recommendation to the GMC, who will then make a decision. 

Please note that Equivalence procedures are the responsibility of the GMC. Applications are made through their Certification Department and initial enquiries should be directed there. 

Evidence Requirements for CESR in Histopathology 

Skills & Experience: The evidence provided for a CESR application in histopathology must cover the knowledge, skills, and qualifications to demonstrate the required competencies in all areas of the Curriculum for Specialty Training in Histopathology. If evidence is missing from any area of the curriculum, the application may be unsuccessful. 

Capabilities in Practice: The Royal College of Pathologists has divided the Training Curriculum into 11 different Capabilities in Practice (CiPs) – each comes along with its own descriptor and guidance on where such CiPs would be evidenced. 

Applicants are required to gather evidence by area of competence and attach this under the relevant section of the online application. 

Generic CiPs 

  1. Able to function effectively within healthcare and other organisational and management systems to deliver consistent high-quality patient care. 
  2. Able to work within ethical and legal frameworks across all aspects of clinical practice. 
  3. Communicates effectively and is able to share decision making, while maintaining appropriate situational awareness, professional behaviour and professional judgement. 
  4. Maintains patient safety at the forefront of clinical working. Can utilise quality improvement activity realistically within the constraints of the role. 
  5. Able to contribute to and support research. 
  6. Behaves as an educator in the context of the role and promotes educational culture. 
  7. Able to self-appraise, learn and adapt. 

Histopathology-specific CiPs 

  1. Able to demonstrate leadership and management within the laboratory setting for the benefit of patient care. 
  2. Able to use laboratory and other services effectively in the investigation, diagnosis, and management of patients, relatives, and the deceased. 
  3. Able to manage and contribute to a multidisciplinary team effectively. 
  4. Able to take, manage and interpret pathological specimens accurately and safely, mindful of risks to self and others. 

Audit and Governance: You are required to submit evidence of your active leadership in audit, including evidence that you have completed at least one audit cycle.

Currency of evidence: Your evaluators will be looking for evidence of current competency, generally defined as within the last five years. If you have completed training before this point, it is crucial that you provide evidence of maintaining competency across the whole area of the curriculum.  

The GMC asks that only evidence that is strictly relevant is sent as it will help them to process the application quicker. The guidance on compiling your evidence will help you to decide what is relevant and what is not – you can find this on the GMC website here

As a general guide, the GMC usually expects to see about 800-1000 pages of evidence, divided into four different domains, reflecting those of Good Medical Practice. The GMC recommends that you apportion the evidence provided as shown below: 

Domain 1 - Knowledge, skills, and performance 

Domain 2 – Safety and quality 

Domain 3 – Communication, partnership, and teamwork 

Domain 4 – Maintaining trust 

Please note, you cannot compensate for evidence lacking in one area by providing more evidence in another area. 

The full list of evidence required for each domain can be found on the GMC website here

The Cost of CESR Applications 

All histopathology applying for Specialist Registration must pay a fee. For CESR, this fee is £1,676. For CESR-CP and CCT, the cost is £439. 

How long does it take to complete a CESR in Histopathology application? 

The GMC estimate that it can take between six and eight months to receive a decision, from the date you submit your CESR application. 

As there is a substantial amount of evidence to gather for a CESR application, the process of preparing all the necessary documentation and applying for CESR can take even longer than this, and a typical candidate will usually set out to complete this within 1 – 3 years. 

It is worth noting that more senior histopathologists, such as consultants, are more likely to have achieved all the competences outlined in the curriculum. 

The indicative period of training for a CCT in histopathology is five years, so it is highly unlikely that you would achieve the competencies required for a CCT in a shorter period of time. Therefore, CESR is not suitable for more junior pathologists. 

#IMG Tips 

  1. Research/think about the types of evidence you will need and begin to gather your evidence well in advance of making your application.  
  2. Gather evidence prospectively – this is much easier than retrospectively trying to pull together the evidence under additional pressures. 
  3. Make sure that your evidence is of the highest possible quality and is current – you will be assessed against the most recent curriculum.  
  4. Ensure that the evidence you collect demonstrates your competence across the whole of the histopathology curriculum, not just your sub-specialty.    
  5. Remember to refer to the most up-to-date Histopathology Specialty Training Curriculum and Specialty Specific Guidance for the evidence requirements in your specialty.  
  6. Create a CESR ‘to do list’ with sections under the 11 CiPs headings – organise your evidence directly into these sections to manage your progress. 
  7. Do not submit original documents – all your copies, other than qualifications you’re getting authenticated must be accompanied by a proformas signed by the person who is attesting to the validity and accuracy of your evidence (your verifier). 
  8. Ask an IMG Connect recruitment specialist about NHS histopathology posts with CESR support. These are not always advertised by the Trusts, but we can help you to find a role which aligns well with your career goals in the NHS. 
  9. Join the IMG Histopathologists community – as well as support on Royal College exams, our online community of international pathologists and dedicated pathology recruiters offers guidance on other aspects of working in the UK, including finding NHS posts and CESR. 

Getting started 

Many pathology IMGs likely haven’t completed a UK-approved training programme, but you could be eligible for Specialist Registration with the GMC via the CESR route. Take a look at our guide to CESR Applications for Histopathology for more information on how to apply and what to expect. 

If you have any further questions about Specialist Registration, your route to the UK, or would like guidance in finding NHS histopathology posts which offer CESR support, please get in touch with us here.  

Follow us on social media through the links below for regular news and updates on the Royal Colleges, relocating to the UK and working in the NHS: 



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