UK accreditation in transoesophageal echocardiography (TOE) commenced as a joint venture between the Association of Cardiothoracic Anaesthetists (ACTA) and the British Society of Echocardiography (BSE) to advance safe practice and set standards. 1 The 10th examination is hosted later this year and we describe in this editorial how accreditation has become established among TOE practitioners. Miller 2 promoted the idea that assessing a clinical skill requires more than the mere test of knowledge and this is particularly relevant with a complex skill like TOE. He argued that acquisition of (in this case echocardiographic) information, the analyses and interpretation of (echocardiographic and clinical) data, and translating the information into a diagnosis (writing a report) are integral to skill assessment. Formulating a management plan remains the domain of clinicians, and not necessarily the echocardiographer, hence this is not assessed. Competency in TOE is inferred by the practitioner demonstrating sufficient knowledge, skill, and judgement to acquire accreditation. Accredited practitioners should be able to competently perform and report a comprehensive TOE in different clinical settings, as opposed to a basic or focused examination. Accreditation requires passing both the written examination and a practical competency assessment and there is no concept of partial accreditation. To date, 339 out of 468 (78.9%) candidates have passed the examination. The base speciality of candidates was anaesthesia (42%), cardiology (40%), echocardiography (8%), and other/unknown (10%). More than 200 logbooks have been submitted and 150 candidates are accredited in TOE. Approximately 15% of ACTA members are UK TOE accredited, but some members have pursued accreditation through European or other bodies instead and not all ACTA members perform TOE in their practice. In a recent survey of ACTA members, just under 30% of cardiac anaesthetists indicated that they were TOE accredited (personal communication, June 2012). The growth in the number of