6th June 2016

Weeks with Bank Holidays in are still packed with activity: beginning to wonder what a "day off" might be like...

TPDs Training Day

Last Thursday, College Tutors and Programme Directors from HEKSS gathered in Croydon to hear updates on the curriculum and the changing face of postgraduate education in the current contract climate.

We heard from the Dean, Graeme Dewhurst, on recent GMC evaluations of our region and on the whole we did good. GMC @gmcuk have some specific requirements of us, number one of which is weekend supervision of trainees (already a box ticked in Surgical specialities). Number two is an obsession: banning the use of the term "SHO". No idea why they've got such a bee in their collective bonnet about that one, strikes me there are much higher priorities than that, but what do I know.

GMC Requirements

1. Weekend supervision of trainees

2. Abolition of the term "SHO"

3. Handover - formal time AND location

4. Rota gaps - impinge on clinical supervision of trainees

5. Excessive workloads negative impact on training

6. Feedback from incident reporting

As you can see, the majority of this requires engagement of organisations to make this happen, and will be a focus for the Guardian of Safe Working (see last post)

Appointments Advisory Committee

The following day I shot up the M6 to the very pretty cathedral city of Lichfield, Staffordshire

Not much time to look around, though plenty to see, as I was there as a College Representative for a Consultants Appointnent panel

I have been a representative on behalf of @RCSnews for a couple of years now, and it's a really interesting gig. This is the first time I've done a military one though, and they are set up a little differently

This gave me cause to reflect on the different goalposts the Surgical subspecialties set themselves to benchmark the standard at CCT. Of course I am familiar with the requirements in T&O: x2 closed loop audits, x2 first name publications in good quality journals, specified numbers of index logbook procedures all before you're 'allowed' to sit the Exit exam. 

I gather General Surgical specialities are placing less emphasis on the need to publish and audit, and this made me think - why do we make trainees do it?

Audit is an important pillar of revalidation, so getting into good habits is a reason I suppose but what I think self directed investigations of topics (and that's what most clinical research is) shows curiosity, interest in doing things better, providing best care for patients. 

CVs with no research projects or audit are what I would call 'old style' in other words CVs that would get posts 15-20 years ago. For a Chief Executive, that means employing like-for-like, a younger version of the retiring consultant (but with significantly less experience). Not exactly a winning scenario.

CVs that show some dynamism with service improvement projects, clinical research topics and engagement in self-audit suggests a dynamic appointment, someone who is going to drive the department forward, give added value. Much more appealing.

Anyway, congratulations to former South Thames trainee Jeremy Granville-Chapman @JGC_Ortho on his appointment at Wexham Park Hospital, Frimley Health @frimleyhealth

Surgeon of the Week

We've had an Appointments Panel of our own in T&O this week so it is my pleasure to introduce to you our latest Consultant colleague Mr Josh Jacob

Josh will be a familiar face as he is currently our Lower Limb Fellow and will shortly start with us as an additional Trauma Consultant. 

And finally...

Congratulations to Arshad Khaleel: the Chertsey Ilizarov Course has been formally recognised as an accredited Royal College of Surgeons course. This is no mean feat and demonstrates the quality of training meets the College standards for surgical education & training 

 

23rd May 2016

Guardian of Safe Working

Whilst contract discussions have been underway, even whilst awaiting the new ballot, the JDC has asked Local Negotiating Committees (LNCs) to support the process of recruiting a Guardian of Safe Working.

http://www.nhsemployers.org/~/media/Employers/Documents/Need%20to%20know/Jnr%20Dr%20guardian%20of%20safe%20working%2030%2003.pdf

This role is an important one. Whilst any 'senior person' can apply, it is expected it will be a doctor & someone with sufficient gravitas to gain the confidence of junior & senior doctors and management.

They will be responsible for collating quarterly reports on rota gaps & staffing needs, identifying where excessive hours are being worked and setting up the necessary changes to bring them back to contracted hours. Without breaking the locum cap or spending any extra money.

Fines are levied if a Trust does not resolve the issues and that money gets ploughed back into education & training (so it doesn't leave the Trust).

The Guardian is directly line managed by the Medical Director, but is required to be independent of the management structure. The advert is currently out, carrying an allocated time in the job plan of one session (4 hours a week).

Quality & Safety Half Day 

Thursday afternoon was Educational Half Day, and in T&O it was a really good one.

Our Trauma Fellow Tim Iliopoulos presented some really good work demonstrating benefits of early transfusion (on day of admission) to our NOF patients to improve their outcomes.

 Our ST3 Natasha Morrisey presented an audit that showed patients over 65 years did much better than you'd think with an ilizarov frame & Foundation Drs Rosie & Sophie did an excellent job of clearly presenting the M&Ms.

🎉Congratulations Corner🍾👏🏻

Absolutely delighted to hear the news this week that our Senior Registrar Kieran Gallagher has passed the Exit Exam and can add FRCS (Tr&Orth) to his collection of letters

Kieran has let us viva him to distraction, which I know has startled some of our junior colleagues but that really is how the Exit Exams go: as soon as they ask candidates to sew the answers on a lace pillow in fluffy pink wool with flowers & kittens then we'll take it down a notch. But until then... 

16th May 2016

Final sign offs

Much in demand this week as it's that time of year again: eportfolio provisional sign-offs. It's also the time to really think about what you want to do next. 

With so much uncertainty surrounding the contracts, it is no surprise that many want to wait and see what happens before committing further to a career in medicine. 

More promising is the news that the 5 day 'pause' for renewed negotiations between NHS England & the JDC has been extended into a second week.

http://www.theguardian.com/society/2016/may/13/junior-doctors-and-goverment-extend-contract-talks

Good News

This week AJ Jibawi who has been a locum with us, accepted the substantive appointment as Consultant Vascular Surgeon 

AJ is a regular fixture round the Surgical LFG table and it is good to see his commitment rewarded with this post.

He joins Barun Majumdar & Magdy Moawad (seen above) as the more recent appointments in Vascular Surgery, all of who are fully engaged with training here @ASPHFT.

More Good News

Congratulations also this week to Young-Seok Cho, current a Core Trainee in T&O, who has heard this week that not only was he successful at obtaining a T&O Registrar training number but also securing his first choice Deanery - @HEE_KSS. 

Hopefully that means we'll see him back again in the future, on the registrar rota.

Forthcoming Attractions

Might seem a way off for BOA Congress is coming up fast upon us http://congress.boa.ac.uk/

This year it's in Belfast and you still have a couple of days left for the early bird discounts 

9th May 2016

SCReaM if you want to go faster...

This week I got to play the part ... of a Surgeon. I took part in some simulated operating theatre emergencies as part of the SCReaM Course.

Initially a project between @ASPHFT & @RoyalSurrey, Surrey Crisis Resource Management is an initiative to manage theatre emergencies in a safe, effective team-driven way. Led by anaesthetist Dr Rob Menzies, we got out head mikes on and heard about a ready-reference guide that from July will be available in every theatre.

These guides allow team members to have protocols for all the possible differential diagnoses of for example bradycardia, hypovolaemia, local anaesthetic toxcity and more, without having to keep all the details in your head (and maybe remember them wrong)

We had an awesome sim dummy to work with, who had pulses, lips that went blue, blinking eyes and everything

... all linked up to an iPad anaesthetic machine to give us all heart attacks as it went into VF.

This is a really good initiative: having been in theatre when challenges have occurred before knife got anywhere near skin, this is a staggeringly good way of ensuring there's no panic & no forgotten steps. If you have an opportunity to take part, do. 

Sam Simmonds Meeting

This Friday saw the annual Sam Simmonds Meeting, this year hosted by Brighton & Sussex University Hospitals @BSUH_NHS with Mr Ben Rogers at the helm @BenedictARogers. Each of the Hospital groups that make up the rotation take turns to host what has become a pretty big meeting of around 250 surgeons. We've long outgrown post-grad lecture theatres and this year we met at the Ashdown Park Hotel @AshdownPark in the sunshine 

This event is the only occasion where T&O surgeons, both trainees and consultants, from the South West Thames Orthopaedic rotation can get together. The morning session is made up of Registrar presentations and our own Mr Sohail Yousaf presented his work on civilian traumatic amputations

The afternoon session is made up of invited speakers and this year we heard from the CEO of the British Orthopaedic Association @BritOrthopaedic on the progress of "Getting It Right First Time" (GIRFT). All Trusts are about to receive their second visit to see if they are performing as expected or if they are outliers from the mean. This is hugely important work in standardising care across England & Wales.

We also hold the Consultants' Meeting where we hear about the state of training which continues to be tinged with gloom. There is concern that there will be unfilled posts at CST & HST in August and all Trusts are hoping to attract a smaller & smaller pool of applicants for Trust grade positions.

Good to see women Consultants well represented. Feels like we might be knocking on the door of 10% of the Consultant body of E&W...

Hip Surgeons Ms Kate Gill @RoyalSurrey with Ms Sam Hook @westernsussex

Paediatric Orthopod & BOA Council member Ms Karen Daly @StGeorgesUni, Ms Natasha Morrisey HST @ASPHFT & Hand Surgeon Ms Becky Owens @FrimleyHealth

Hand Surgeon Ms Shamim Umarji @Shami_Umarji @StGeorgesUni coping well being photobombed by Mr Anthony Sakellariou @FrimleyHealth

Forthcoming Attractions

In this section I have previously highlighted courses coming up that may be useful for CPD. This week I want to draw your attention to e-learning.

The L-word ("leadership") has traditionally made my heart sink and my eyes roll but it is a mandatory part of training so I must suppress my cynicism. It is also usually the part of trainees' portfolios that's most likely to have tumbleweed rolling through it so any opportunity to fill that gap should be embraced.

Have a look at this e-learning programme: http://www.e-lfh.org.uk/programmes/leadership-for-clinicians/

It may help you get started and even interested in the subject.

25th April 2016

NTS Survey

The abiding memory of this week has been getting to grips with the Red Flags from the GMC NTS Survey @gmcuk.

The Survey is still on going but two types of issue, if raised, require an emergency response from the Trust. In practice this means the response is rapidly delegated to the College Tutor with responsibility for that area of education. These issues are Patient Safety and Bullying & Undermining.

It is disappointing to hear that a trainee has felt Undermined via the medium of the anonymous NTS survey because it inevitably means it is too late for me to help them in real time. 

The Red Flag that popped up in T&O seems to have come from a particularly robust trauma meeting in the last three weeks of the attachment & by the time it surfaced through the Survey changeover had already happened and the trainee is lost in the wind.

Bullying & Undermining is endemic in the NHS, reportedly affecting 1:3 healthcare professionals. You'll know from a more recent paper drawn from the NHS Staff Survey results @ASPHFT came in the bottom third of Trusts for Staff happiness - but what is being done to address this?

It's a difficult problem. The Trust has a 'Dignity in the Workplace' Policy which will guide you but it may seem a daunting process. For trainees of any discipline, there is the shadow cast by concern that 'making a fuss' might jeopardise future references or employment. There's no denying that's a big issue and you may look on it as perhaps a four month attachment you've just got to power through & put behind you. But I put it to you that is not solution: it is a waste of valuable training time, a waste of talent and a risk, a very high risk that communication breakdowns such as this leave open the possibility of patient safety issues not being communicated either.

I have started completing Datix on 'challenging staff behaviours' on behalf of trainees just to get the bally things logged. I've done it three times so far, the first two keeping the trainees' names anonymous at their request & the third with their name in as they were quite happy for a number of reasons to go formal. 

Haven't heard any more about any of them, which is disappointing but not surprising in the case of the anonymous entries as the Trust cannot get into the nuts & bolts of the problems without talking to the complainant. 

But I will keep trying for you so if that's something you want to consider if you've experienced challenging behaviour, let me know.

The Trauma Meeting

Other things we're doing - the Trauma Meeting is on the move. It's now in Fracture Clinic, a huge big space in comparison with the pressure cooker of a tiny room we were trying to shoehorn us all into. 

This is a temporary solution till we find a space nearer to theatres & Swan. Clinics still need to start on time and the room needs to be reset so having a space closer to the activity of the day makes more sense.

Consultant of the Week

Once our next two appointments come to pass (hope June) we will have enough bodies to man a Consultant of the Week roster, freeing someone up from elective work to stay on site at SPH, do a teaching ward round and an afternoon #clinic. This should give the longed-for continuity, availability, education & decision-making that we've all wanted but couldn't get agreed upon as we couldn't take the hit in the 18 week pathway (losing the elective commitment every time someone's on call).

Now however the LETB Visit highlighted to senior Board members that off-site on call as poor practice, and the perceived lack of senior decision-making commented upon as part of the Red Flag, we have the external support to put this plan into practice.

So let's see. It may help. It may not. But if you can, tell someone (your AES for starters) if you are feeling pressured at work so we can change things for you in time. It is such a shame to lose the training opportunity.

Competition

To celebrate the centenary of Lord Lister’s death and to recognise the significant contribution that he made to medicine and surgery, The Royal College of Surgeons of England and Johnson & Johnson are offering the annual RCS/J&J Lister Essay Prize Award.

The task is a 2,500 word essay on this topic: "What would Lord Lister have thought of the Shape of Training recommendations regarding the future of NHS surgical training and patient care?"

18th April 2016

Introduction, not Imposition

Last night's breaking news was on the meaning of words.

http://www.theguardian.com/society/2016/apr/17/pressure-mounts-on-jeremy-hunt-over-handling-of-junior-doctors-dispute

Closer analysis is more sobering. The words may have changed from 'imposition' to 'introduction' but the Contract is still set to come in nonetheless. 

It has always been the case that the Contracts will be introduced by the Trust CEOs. Indeed that is why many junior doctors, including our own @ASPHFT wrote directly to their CEOs asking to stall the imposition until more details/ talks could be provided.

Whilst theoretically Foundation Trusts could have some autonomy and stick to the Current Contract, they are under enormous pressure from Health Education England to toe the line. Chris Hopson, CE of NHS Providers, composed this response to the question 'could CEOs resist imposition':

https://www.nhsproviders.org/news-blogs/news/nhs-providers-response-to-letter-from-junior-doctors

The sinister paragraph is this one: 

"We are aware that there have been suggestions that individual foundation trusts may choose not to introduce the new contract. However, as has been covered in the media, trusts have been advised by Health Education England (HEE) that a situation where local employers effectively offer different terms will not be acceptable. In particular, implementation of the national contract will be a key criterion for HEE in making its decisions on future investment in training posts."

In other words, behave or we'll take your trainees away.

Clearly if enough Trusts delayed or deferred imposition, HEE would be stuck as trainees have to go somewhere, but are there sufficient CEOs brave enough to stick their head above the parapet?

There might be, if the endgame is to secure enough doctors for their particular Trust in August. 

Already HR departments are receiving enquiries from August starters to see if they can start in July and get on to the existing contract. This cannot be the case at ASPH btw: everyone whose contracts are being extending are being warned in writing that they will be changed onto new contract in August.

Rota gaps have left some hospitals desperate. You may have read about Chorley A&E closing at night as neither substantive appointments nor locums could be recruited to allow safe staffing.

http://www.bbc.co.uk/news/uk-england-lancashire-36038598

Locum cap-busting rates are being offered all over the place to get last minute shifts covered: I noticed London surgical trust grades posts advertised with additional funding for MScs. It does seem a very short step to offering local contracts.

I've mentionned before the drop in applications this year at CST & T&O HST interviews. This seems reflected in other specialities and fill rates (successful applicants taking up an offer) seem to be low in some parts of the country.

I think 'nervous for August' is an understatement. 

 

LNC Meeting

This week saw another sitting of the LNC (Local Negotiating Committee). Any idea what that is? 

LNCs are made up of elected local representatives (BMA members) who negotiate – and have the authority to make collective agreements – with local management on behalf of medical and dental staff of all grades. 

Your LNC is made up of elected Consultants, Associate Specialists and your elected Junior Doctor BMA reps as well as our BMA Industrial Relations Officer Cathy Taylor. We meet with Trust representatives, usually the Deputy Medical Director, sometimes the Medical Director, and Human Resources. 

On the agenda this week was the Junior Doctors Contract. Timescales are such that the Trust feels obliged to start planning for new starters in August. Clearly rota design works best with involvement from the people who will be manning it. However as the BMA's position is not supportive of this contract it was not appropriate for us to make any comments.

Some Good News

I want to leave you with some cheery news, and that's @ASPHFT has been nominated for an award: http://www.ashfordstpeters.nhs.uk/latest-news/1505-trust-shortlisted-for-quality-of-care-award

Ashford & St Peter’s Hospitals NHS Foundation Trust has been shortlisted for the 2016 CHKS Top Hospitals Quality of Care award, for demonstrating a commitment to delivering outstanding performance in providing a safe hospital environment for its patients.

4th April 2016

National Selection T&O

Just before Easter, consultants gathered from all over the country at Elland Road stadium for three days of interviewing.

This is the fourth year that entry to Higher Surgical Training has been determined nationally rather than locally. There's lots to be said for it, creating a level playing field, as well as some downsides ( a low score could have you training far from home) but it is here to stay and for the interviewers it is quite hard core.

72 Consultants are required each day, with another 14-18 for Quality Assurance & stand-ins. Each Deanery sends up about 20 volunteers which means a joyful chance to catch up with old friends.

Numbers of applicants have really come down this year. In 2012 there were over 550 applicants for 103 posts. This year there were 320 applicants for 180 posts. Applications are open to anyone to fits the entry criteria and if they are eligible they are given an interview so approximately a quarter to a third won't make the cut-off. This means for the first time not all the training posts might be filled.

Here we have SW Thames alumnus Tom Clare (Cons in Dudley) with South West London TPD Dom Nielsen & @ASPH's Constant Busch

The set-up of the interview stations this year was six circuits, each made up of Portfolio, Clinical (made up of Clinical Anatomy and Clinical Knowledge), Interactive and Communication, Technical Skills and finally the Presentation and Handover Case Prioritisation station. If that all sounds incomprehensible, here is the Applicants' Guide: http://www.yorksandhumberdeanery.nhs.uk/media/784499/t_o_applicant_handbook_2016.pdf

You get some clues as you arrive at the stadium that something Orthopaedic is afoot... 

Candidates for each circuit have their documents checked then start the cycle moving from station to station on the bell till all five are done.

The stations are set up in the boxes which are of different sizes so you can be quite cozy... 

... or quite spaciously set out 

It is always wise (I'd have said mandatory) to let your educational supervisor and Surgical Tutor know you're going up for HST interviews. A second pair of eyes over your portfolio and some practice interviewing can really help, particularly so that none of the real interview experience comes as a surprise on the day.  

Communications is the weirdest one, as an interviewer. We have to sit silently and watch the two scenarios play out, scoring but not speaking even if you have loads of questions. Clinical (Anatomy) & Technical Skills are my favourites: can quickly see who's got their hands dirty and who's not. Mind you, I was relieved to see the day I was interviewing Clinicsl it was Upper Limb, not Lower Limb onthe  table...

Leeds is a long way away and to take three days out is a big chunk of clinical time so it'll be another two or three years before I do this again but at the very least I feel updated on the process and better able to support trainees approaching higher training. 

"Proportionate means of achieving a legitimate aim"

More details of the #juniorcontract are out, including the Equality Impact Assessment, which acknowledges it disproportionately disadvantages women. Some powerful responses from senior women leaders are here:

Medical Women's Federation @medicalwomenuk

http://medicalwomensfederation.org.uk/about-us/news-blogs-competitions/432-mwf-response-to-equality-impact-assessment

RCS @RCSNews & RCP @RCPLondon Presidents

http://ow.ly/10aSso

RCS Ed @RCSEd

https://www.rcsed.ac.uk/the-college/news/2016/april/equality-analysis-and-the-junior-doctors-contract.aspx?utm_source=Internal&utm_medium=socialShare&utm_campaign=Twitter_Share

RCPath @RCPath

https://www.rcpath.org/discover-pathology/news/president-s-statement-on-the-junior-doctors-contract-and-equality-analysis.html

Roy Lilley's Analysis

I don't know if any of my Consultant colleagues read this blog, but just in case, I attach health analyst Roy Lilley's excellent summary of the Contract issues:

http://campaign.r20.constantcontact.com/render?m=1102665899193&ca=b1b8db09-7531-4372-9079-3a39999e623b

Post script

As I am on annual leave this week, there won't be a blog on Monday. We'll have new teams and new people and I hope to get right on it to help settle everyone in.