21st March 2016

This week I'm heading off to Leeds for the T&O HST National Selection Interviews. These take place in the less than luxurious surroundings of Elland Road with its bizarre statue of Billy Bremner looking like a hottentot with yellow hair (?!) 

Approximately 500 applicants are interviewed for roughly 100 posts: we heard a couple of weeks ago that the number of interview days was being cut from 4 to 3 because fewer applications had been received than anticipated.

There are two reasons to travel the very, very long way: the first is to provide manpower as each of the four stations requires two consultants and around 150 candidates are interviews per day.

The second is to be up-to-date with the format of the interviews so as to better advise our trainees going up for them next time. There are always adjustments year on year and as it's been four years since I last did it, I thought it was time.

This week the voting forms for @theBMA Council elections have dropped on the mat. It was such an enormous document containing mission statements from all the candidates standing for the 18 posts. This one caught my eye... 

It's hard to pick who to vote for do why not vote for the people you know!! It's a start.

How to Improve Morale

Clare Gerada's piece in the BMJ from earlier this month:

http://careers.bmj.com/careers/advice/How_to_improve_junior_doctors%E2%80%99_morale_and_wellbeing?utm_source=Email&utm_medium=Email&utm_campaign=BMJCareers_GPnewsletter&utm_content=morale&utm_term=

The Problems:

• "A lack of team working and continuity of care

• Terrible shifts designed by computers and not fit for humans to work

• Rotations that take no account of a doctor’s personal circumstances

• The inflexibility of run-through training

• A fear of litigation and a blame culture that is endemic in the NHS."

  The Solutions?

  "Restore the places where doctors can meet and learn and reflect together in groups

  • Establish a national leadership and support programme, so that at pinch points in a doctor’s career they can come together and reflect in a safe, residential space

  • Provide lifelong access to careers counselling and rotations that acknowledge that people can change their mind along the way or even just want to take time out and do something differently

  • Provide confidential support and counselling services for all doctors

  • Provide rotas that acknowledge that doctors are human and have personal relationships with others.

  It is also important to recognise that the whole NHS workforce is demoralised and it would be a mistake to focus solely on the problems facing junior doctors."

A Salutory Lesson

If you use Social Media, you must make sure you read the GMC guidance on best practice: http://www.gmc-uk.org/guidance/ethical_guidance/21186.asp 

You may have seen this story in the press: http://www.dailymail.co.uk/news/article-3470910/A-E-doctor-ran-foul-mouthed-Twitter-account-ranted-neurotic-patients-crippling-NHS-bulls-call-outs-posted-string-anti-Islamic-messages.html

This week, the Medical Practitioner Tribunal Service (MPTS) suspended A&E Consultant Dr Christian Solomonides for the inappropriate use of his Twitter account. The full judgement is here, and well worth a read: http://www.mpts-uk.org/static/documents/content/Dr_Christian_Michael_SOLOMONIDES_4_March_2016.pdf

Forthcoming Attractions

Basic Surgical Skills Courses get booked up quickly, and they are an essential requirement for Core Surgical Training posts. The following courses are in @HEE_KSS:

14th March 2016

This week's blog is a bit 'all about me'. Consultants need to take some time too, to recharge the mental batteries, learn new things, be inspired again. It's also good to take even the briefest time-out from the day job to remind yourself what lit the flame in the first place.

Tuesday: Senior Women's Event, RCS

Tuesday, International Women's Day, saw the Senior Women's Event at the College @RCSnews. 'Senior' before anyone gets cheeky, means 'Consultant' or 'Associate Specialist' - not Elderly.

Many of us were early members of WIST: Women in Surgical Training, a group set up by the College in collaboration with the Department of Health in 1991, to encourage women to stay in Surgery & support training options such as flexible, less-than-full-time-training.

Here are surgeons Claire Murphy @leedsmurph, Laurie Baxter @baxterlaurie and Professor Averil Mansfield

By the 2000s I had fallen out of love with WIST (it got a bit cliquey and seemed to have taken a direction that wasn't particularly relevant to me) but more recently rebadged as 'Women in Surgery' and under the inspirational leadership of Laurie Baxter @baxterlaurie there has come a recognition that it's not just the medical students & junior trainees that benefit from support: consultants need it too.

Laurie had organised an amazing programme with phenomenal speakers. This is Liz Ball @Liz_ORiordan.

If you haven't read her blog, go now immediately and do it: http://liz.oriordan.co.uk/ 

Liz is a Breast Surgeon, and last year discovered she had breast cancer. Her unique viewpoint, brilliantly written, is a must-read for healthcare professionals and patients alike.

This is Stella Vig @svig2 Consultant Vascular Surgeon and Surgical Tutor at Croydon University Hospital. 

Stella is a superstar: an active and vocal supporter of Junior Doctors she was among many Consultants who marched against the Contract in October alongside Humphrey Scott & myself. She organised the letter signed by 1000s of Consultants to Jeremy Hunt and she is standing for College Council, so PLEASE VOTE.

I could go on and on about the fabulous awesome women I met and caught up with, the brilliant keynote speech from BBC's Anita Anand @tweeter_anita in the fascinating story of Sophia: Princess, Suffragette, Revolutionary 

... but it will stretch this blog for pages & pages so if you're interested scroll back through my Twitter feed @surgicaltutor. It was a great day.

Wednesday: Junior Doctors Strike

Cold wet weather couldn't dampen their spirits: this time the action was for two days but it hasn't diminished support from our patients and the public who have listened to the arguments and read the facts. Really good to hear all the positive comments from patients in clinic after they'd come past the picket line. No negative comments at all, in case you were wondering.

Friday: Trip to Munich

On Friday after work a group of us Upper Limb surgeons flew over to Munich to the new training facilities purpose built by Arthrex. It will come as no surprise that we're always keen to practice & try out new techniques & products and this cadaveric lab is state of the art 

This leads me on to...

Surgeon of the Week

About time I showcased Consultant Orthopaedic Surgeon Rohit Gupta 

Rohit is the Godfather of Upper Limb Surgery @ASPHFT. He has not only trained & supported all of us who have since joined the Trust but is a national and international trainer, teaching via live surgeries and cadaveric demonstrations.

In Munich, we were joined by Ioannis Polyzois and our Upper Limb Fellow Paolo Consiglieri 

And Finally...

The Department of Health published this document this week:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/506143/League_Table.pdf

This league table was derived in part from the NHS Staff Surveys published in February so our position (209/230) is not a total surprise. 

I do think it would be constructive to hear your thoughts as to how the culture here could be improved. Consultants inevitably have a different viewpoint as generally it is the Consultants who report issues. If you've not had the response you expected from reporting a problem, and/or suffered consequences yourself, you're discouraged & may not do it again, which is awful for safeguarding patients.

And don't forget, you're moving Trusts & Deaneries every 12-24/12. You'll have experienced different cultures & practices elsewhere & that insight is really helpful. 

You may have come across the phrase 'normalisation of the abnormal" - Consultants in post for years can get inured to poor practice/culture, particularly if they've felt they've failed to make change. They can fool themselves that it's normal to feel ignored or unheard, pointless to raise concerns. This is dangerous.

If you have any thoughts on this I'd love to hear from you via trust email and in complete confidence as you wish.

7th March 2016

This week I'm answering the question...

What goes on at Ashford Hospital?

Plenty, as it happens. If you are thinking about a career in Surgery and you don't spend some time at Ashford, you are really missing out.

Ashford Hospital is where we do our planned surgeries. This is where pretty much all elective Orthopaedics takes place but we are not alone: you'll find Bariatrics, Upper GI, Breast and Eyes. There's no Urology, and none of the headline Vascular stuff but we still have vascular surgeons coming across for their veins & hernias and the odd Colorectal surgeon too.

I ran around theatres on Tuesday to get a snapshot of activity: here's Theatre 4

...getting ready for our team briefing. Mr Chana was in Theatre 2:

where I noticed he'd pinched my trauma specialist Ronald (2nd from left) which is not on Rishi!! Theatre 5 had more than a touch of the Cylons about it as Dean Michael, Josh Jacob & Karthick had their exhaust helmets on in preparation for joint replacement surgery

... before Dean went for an aseptic game of peek-a-boo where's he gone...?

... there he is!

The beauty of Ashford as a working environment is that it is planned. Beds are ring fenced for elective patients, there are no bed meetings or moves, discharges are organised from pre-assessment clinic... It's all very orderly. 

And there is time to teach. 

It's easy for those working here to feel that all the hard work isn't seen. All of the hoopla all of the time is around St Peter's: for example, no Team Briefing from the Board ever takes place here, none of the Grand Rounds or Staff Meetings. I look on that as a good thing though: there's no drama and we don't get distracted from the fun part of the job, looking after patients.

For example, in my clinic room in the Rowley Bristow Unit at St Peter's there is a constant stream of people coming in and out with questions and problems that can't wait. At Ashford, there's none of that and I can really get on with working with the patients & teaching the St George's medical students. It's lovely.

Surgical LFG

This week saw the Spring Meeting of the Surgical Local Faculty Group. We has lots to discuss after our Deanery visit, highlighting what we're doing right and what we could do even better on. 

We heard first from Mark Hinchcliffe @MarkH_work who is heading up the "Be The Change" initiative.

This is the philosophy that small projects can and will generate improvements for patients and staff and how the Trust can support everyone in seeing their ideas through by helping through the blocks. 

We heard from the Trainee reps and had HR present to listen first hand to the issues and we had some robust discussions on how to improve the trainee and trainer experience. 

I am optimistic that the issues for training highlighted by the Deanery visit will be taken notice of and for example job planning for trainers will at last acknowledge the commitment of this terrific bunch of engaged consultants

Forthcoming Attractions

This looks interesting: created and run by Core Trainees @CLF_London and headlined by Oliver Warren, Consultant Colorectal Surgeon @DrOliverWarren 

28th February 2016

LETB Visit

This week saw our LETB @HEE_KSS visit. Surgery, Medicine & Anaesthetics/ICM were being assessed and I'd like to thank all the trainees & trainers who came along to share their thoughts with the visiting team.

It was one of those rare opportunities where I get to see all my CSTs in one spot (bar Seok who was on nights)

L=>R Dan, Aphiwat, Kamran, Asad & Sophie

It was also a chance to catch up with fellow trainers, another rare event which highlights to me how much we work in our own little silos with hardly any interaction between the directorates. 

We made the most of it and of course we'll have a full debrief next week at the Surgical LFG but I can give you the main points here.

Surgery on the whole came out ok, generating a supportive training environment. General Surgery did good from the trainees, feeling well supported with good handover. T&O had highlighted the situation the on call consultants are in, either being off site during that on call day and/or off site the following morning at Ashford, & this was queried by the visiting team as not best practice. This ties in with uncertainty from the visitors over whether all the patients have a consultant review every day - ironically the weekend is the time they are most likely to have a consultant review within 24 hours whereas weekdays with elective pressures that may not be the case. Probably not what Jeremy Hunt would expect to hear.

The 50% reduction in Educational Half Days was also brought up as a negative as was the lack of training time allocated in consultant job planning. The biggest message was the weight of service provision at the expense of education and a perceived disconnect between service & education 'at senior board and divisional level'.

I'm really grateful to everyone to came to give their views and help us improve the training environment here. A full report I believe has gone to the Chief Executive, who I think has to provide a response in five days. I have video of the Surgery part of the feedback (saved me making notes!) which I'll show at LFG on Thursday.

Mind the Rota Gap

On Weds March 2nd I'm going to take a snapshot of medical staffing in Surgery for the 24hrs. I want to know how many substantive posts we have and how many locums/gaps. I'll repeat this in April, after the Locum Cap comes fully into action, to see if we have an increase in gaps. The Cap is intended to block locum earning at 55% above the substantive rate. In practice this means a reduction of ~£10 an hour.

I would love to know the data in other specialities. If you can help with that, that would be great. It is a fairly political audit, but an audit with a closed loop in a month nonetheless so come and talk to me.

There is a perception on social media that with the cap the same across the board locums will prefer the less busy specialities leaving gaps in eg A&E harder to fill. 

Already there is anecdotal evidence of Cap-busting rates on offer. I saw one Trust is offering £60 per hour for FY2 cover. True market forces in action, you could say.

Follow the hashtag #mindtherotagap for news on gaps emerging all over the place and how other Trusts are responding to the crisis. For example Addenbrookes has closed its books to new cardiology referrals as they have insufficient doctors to treat the ones on their books in a timely fashion.

NHS Staff Survey 2015

Results of the survey done at the end of last year are now out:

http://www.nhsstaffsurveys.com/Page/1044/Latest-Results/Acute-Trusts-A-to-I/

Tutors of the Week

The best bit about Friday was that I got to meet and brainstorm with @jbbince Dr Jackie Ince, College Tutor in Medicine, seen here with Tayo Johnson, Foundation Programme  Director

It could be quite dangerous if we meet more often as we fired loads of ideas off each other and made great plans to change the world. 

And finally...

You may remember late last year @ASPHFT hosted the Regional Heat of "Are You Cut Out For It?" the surgical skills competition for @RCSnews the Royal College of Surgeons (England). The two we judged to be the best that night, Ana & Jen, were in the Finals at the College on Saturday where they were Runners Up! Very proud of them both 

22nd February 2016

This week I met with Ace Thindal @athindal who is part of the team rolling out electronic medical records @ASPHFT @Your_eMR

We're used to a paperless working environment in the private sector, so this system feels very comfortable but of course on a completely different scale. It was a great opportunity to play around with the system and have some tiny input into making it even more friendly to work with. 

Responses to Contract Imposition

The general drift has been negative regarding the Health Secretary's decision to impose a contract. I have collated a few responses here

Patients' Association: http://www.patients-association.org.uk/wp-content/uploads/2016/02/press-release-imposing-new-junior-doctor-contract2.pdf?platform=hootsuite

Surgical Royal Colleges Joint Statement @RCSnews: 

http://www.rcseng.ac.uk/news/surgical-royal-colleges-joint-statement-on-the-junior-doctors2019-contract?utm_source=&utm_medium=&utm_campaign=#.VryiFqNFCB8

Royal College of Physicians @RCPLondon https://www.rcplondon.ac.uk/news/rcp-deeply-disappointed-breakdown-negotiations-and-imposition-contract

Association of Anaesthetists @AAGBI: http://www.aagbi.org/news/aagbi-response-imposition-england-junior-doctors-contract

RCGP @rcgp: http://www.rcgp.org.uk/news/2016/february/rcgp-response-to-government-decision-to-impose-junior-doctors-contract.aspx

Psychiatry @rcpsych: http://www.rcpsych.ac.uk/mediacentre/pressreleases2016/imposedjnrdoctorscontract.aspx?theme=mobile

... and my personal favourite, BOA @BritOrthopaedic: http://www.boa.ac.uk/latest-news/boa-statement/

A summary of the 2016 contract is here: 

http://www.nhsemployers.org/~/media/Employers/Documents/Need%20to%20know/1516%20PO07314%20%20Summary%20JD%20OFFER%20%20Final%20version%20180216.pdf

Surgeon of the Week

Meet Orthopaedic Associate Specialist Alastair Cameron-Smith, seen here with Theatre Practitioner Sabina Khadka: 

Alastair has been a fixture at @ASPHFT since his SHO days at the old Ashford Hospital. Alastair has always welcomed trainees to his operating theatre & last year received a Highly Commended runner-up certificate in the 2014 Surgical Trainer of the Year Award. He is also a qualified pilot.

Forthcoming Attractions

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Trainee Voice Sessions

RCS @RCSnews is developing a programme of Trainee Voice Sessions to run alongside its current Regional Events Programme. Sessions will be held across the UK either as part of existing events or as stand alone session. These sessions aim to help us:

• Understand the concerns of junior doctors and their experience of training and their work environment.
• Improve the quality of surgical training and support surgical trainees throughout the process.
• Continue to support trainees and how vital they are to the NHS. We believe the Government should do more to value their professionalism

The next event is Saturday 12th March: http://www.rcseng.ac.uk/surgeons/supporting-surgeons/regional/events/trainee-voice-sessions-1/london-and-the-south-east-trainee-voice-session-12-march

This Saturday it's the RCP Medical Careers Day. This is a good opportunity to see what's out there that might grab your interest https://www.rcplondon.ac.uk/events/rcp-medical-careers-day?platform=hootsuite

15th February 2016

An introspective post this week: it has been a rather depressing week not only nationally but locally and this page is the upshot...

I am grateful to Dr Alice O'Neill, @alicerawding, for drawing the first topic to my attention 

Whistle-blowing 

We should do it, right? We are obligated to speak up if we see unsafe practice or patients at risk, aren't we?

In Domain 2 of "Good Medical Practice" the GMC @gmcuk highlights the need to respond to risks to safety:

1. 24. You must promote and encourage a culture that allows all staff to raise concerns openly and safely.^1, 11
2. 25. You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised.
   

Read the story of Dr Chris Day, @drcmday, and then have a long hard think:

http://www.newstatesman.com/politics/health/2016/01/junior-doctors-arent-just-going-strike-theyre-trying-warn-us

This is actually a question we ask at Core Surgery Interviews: what would you do if the next doctor on shift doesn't turn up? Never imagined it would have this result in real life.

Juniors doctors have vanishingly little protection, despite the laudable efforts of Sir Robert Francis and every single thing we learned from the Mid Staffs episode. In fact, as Hunt is hellbent on destroying all safeguards in his imposed contract, junior doctors are now temporary workers with few rights, 'Guardian' or no.

And if that doesn't make you pause, here are some more (in)famous whistleblowing cases:

1) Radiology Manager Sharmila Chowdhury @sharmilaxx

https://benhansenhicks.wordpress.com/2016/02/13/my-name-is-sharmila-i-am-an-nhs-whistleblower/

2) Paediatrician Dr David Drew @nhswhistleblowr

http://www.telegraph.co.uk/news/health/9177143/The-toxic-treatment-of-Dr-Drew.html

3) Cardiologist Dr Raj Mattu

http://www.dailymail.co.uk/news/article-3443311/Branded-rapist-daring-NHS-whistleblower-brave-surgeon-sacked-exposing-needless-deaths-smeared-sex-attacker-bosses.html

... and 4) the granddaddy of them all, Dr Steve Bolsin, @SteveBolsin, the anaesthetist whose simple audit  blew the whistle on paediatric heart surgery in Bristol in 1995

http://news.bbc.co.uk/1/hi/health/1384854.stm

Makes terrible reading, doesn't it. I expect we all think that if we were faced with an untenable position, we would all speak up, safe in the knowledge that we would be protected by that loudly trumpeted "Whistleblowers Policy". Unfortunately we are learning that that Policy can readily be thrown out of the window and it is making for a very unhappy department.

I wonder if we'll find out just how unhappy when the embargo is lifted on the 2015 Staff Survey and it gets published in 23rd February. 

I always fill mine out, even though I'm aware it is a futile gesture. The majority of the returns I understand are filled out by non-clinical staff: there is a misconception that because the surveys are bar-coded responses can be traced back to the writer but that is not the case. At least, the things I've written have never come back to bite me. And obviously nothing has changed either.

The bar-codes are to allow Picker to chase up non-responders but it does have the effect in hierarchical clinical structures of putting people off or at the very least being guarded with their responses.

Junior Doctors' Contract

Hunt was always going to impose this, wasn't he. No matter what agreements Sir David Dalton made with @theBMA. Quite certain it will fail its Equality Impact Assessment as it is outrageously unfair to anyone on career breaks (eg maternity leave) but the enormous message it sends out about the disposability of the workforce is horrifying. Thank goodness he's commissioning an Enquiry into Junior Doctor Morale. How else will we have a clue as to why 54,000 educated intelligent people are unhappy (?!)

Goodbye of the Week

Sr Fletcher @12dargue wanted to steal away with little fuss after 29 years of NHS service. Ha ha. 

Obligatory departmental tea party followed by the much more traditionally Orthopaedic wake in the pub...

8th February 2016

Apologies for the short post this week but, for a change, it seems I've just done the regular job. And spent time with the family, doing those things that all too often get shelved for work activities. So this week no added extras, no bolted-on meetings or educational stuff, I just came in, did the clinics, ran the lists, went home. Rare.

Industrial Action

This photo from Saturday's Junior Doctors March is reproduced without comment:

This week we have the second Junior Doctors' Strike, on Wednesday for 24 hours. This will take the same format as the first one, with emergency work still covered. Learning from the first strike I can see the Trust has worked out a bit better what needs deferring and what can go ahead: many more patients will find they are unaffected by the action as day surgery and clinics go ahead as booked.

Surgical LFG March 3rd

The 4 monthly LFG is coming up soon. Please get in contact with your reps Sophie Wrigley & Holly Ni Raghallaigh  with topics or issues you'd like discussed. You might feel that you are all being frequently interrogated this month. Not only do we have our LETB Visit but also an RCS Flying Squad descended looking into the impact on training of having Physicians' Associates on the wards - and of course we're about to go into another cycle of the GMC NTS Survey.

It's all part of making sure the training experience is right for you: it's just unfortunate timing that it is all happening at once. Hope you don't get into questionnaire fatigue: apathy especially in the GMC Survey will not treat us kindly.

Surgeon of the Week

Time for the legendary T&O magician Mr David Elliott. Known for his ability to instantly materialise in any part of the hospital without seeming to move, Mr Elliott is a Trauma God.

Take a moment to hear him talk, on any topic but especially the principles of fracture management and suddenly the scales fall from your eyes.