Hospital Dr News


Workforce planners warn of funding cuts for specialist training

By Francesca Robinson - 28th August 2010 8:30 am

Financial pressures on the NHS are likely to hit funding for specialist training warns a report from the Centre for Workforce Intelligence (CfWI), the new national authority for workforce planning.

The report, the first from the Centre, makes recommendations on how many specialist trainees will be needed for the 2011 intake.

It identifies which medical specialties are at risk of over or under supply and highlights where trainees are unequally spread around the UK, outlining how training posts should be redistributed.

The CfWI suggests a small reduction of less than 1% of current places is needed. In a few specialties improved recruitment to training posts could result in higher numbers of doctors in specialty training in 2011.

But it warns that trusts needing to cut costs may be tempted to employ trust doctors. This would force trainees to achieve Certificate of Completion of Training (CCT) via the Combined Entry Programme Specialist Register (CESR) route.

It also fears that if the Multi Professional Education and Training (MPET) levy is reduced, strategic health authorities and deans will want to modify the report’s recommendations.

A spokesman for the Royal College of Physicians said they too were concerned that the CfWI’s recommendations will not be matched by sufficient funding, either by hospital trusts in employing newly trained doctors or by deaneries funding the training places. “Without this financial support, the opportunities these recommendations give the NHS will be lost and patient care will suffer as a result.”

But he said the report was a big step in the right direction for medical workforce planning in England. The RCP was pleased that it supported the recommendations of Sir John Temple’s report on the effects of the European Working Time Directive on medical training.

“The CfWI recommendations for maintaining trainee numbers in the medical specialties will help the development of consultant delivered care which can only be a good thing for patient care. Furthermore the CfWI has taken a very considered view of the skewed distribution of trainees in some parts of the country by using ‘weighted capitation’. This imbalance of both trainees and consultants currently has a large adverse affect on patient services. Correction of these imbalances is crucial to providing a fair health service for all,” said the spokesman.

Bill McMillan, head of medical pay and workforce at NHS Employers, also welcomed the report. He said: “It is critical that the correct number of doctors are trained in the specialities and geographical areas where they are most needed to avoid the risk of either a shortage or significant over-supply, both of which can be expensive, demoralising for doctors and affect patient care.”

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Consultant “didn’t break data protection rules”

By Francesca Robinson - 8:20 am

A senior diabetes consultant who was sacked for gross misconduct after faxing patient records from her hospital to a community clinic has been exonerated by the GMC.

The South Warwickshire General Hospitals Trust (SWGHT) accused Dr Shirine Boardman of breaching patient confidentiality when she sent the names and contact details of more than 80 diabetes patients to her secretary at the Apnee Sehat NHS clinic in Leamington Spa.

Boardman’s aim was to invite the patients to a structured education programme to help them manage their diabetes. She was acting in according with NICE guidance. At the time all trusts had a statutory requirement to provide this patient education.

The award winning Apnee Sehat clinic (meaning “our health” in Punjabi) was a pilot service set up by Warwickshire Primary Care Trust to provide clinical care and help to disadvantaged members of the Asian community. Boardman led the establishment of the project in 2007 as part of her employment contract with Warwick Hospital.

But the SWGHT complained that Boardman made an unauthorised transfer of confidential data from the trust in breach of GMC guidance, the Data Protection Act and the trust’s data protection policy.

The case was sent to the Information Commissioner for an alleged criminal breach of the Data Protection Act in July 2008. Shortly afterwards Boardman was sacked. The decision was later upheld by an employment tribunal.

But the Information Commissioner dropped the case and the GMC has now scrapped a fitness to practise hearing saying that Boardman acted “solely to benefit patients”.

Dr Keith Brent, deputy chairman of the BMA’s consultants committee, said: “There seems never to have been any question that Dr Boardman was anything other than a good clinician providing good care to her patients.”

Dr Sue Roberts, former government diabetes tsar, comented: “The dismissal of Dr Boardman was fundamentally unreasonable in that it disregarded good medical practice in the treatment of diabetes.”

Boardman, who has four clinical excellence awards and has won four national awards for her work, said she had been shocked by the speed with which she had been sacked.

It has taken her two years to do the research to understand the NHS data protection laws, to obtain information from the trust through Freedom of Information requests and to get the right legal experts and witnesses to help her fight her case.

“I don’t think in medical school or specialist training anybody ever told me the kind of trouble we could get into as doctors. The minute something goes wrong it’s enormously important to get the right advice from the right people because a lot could have been done to save me before I was dismissed,” she said.

Peter Bottomley, the Conservative MP for Worthing West, has raised Boardman’s case in Parliament and is calling for the individuals at SWGHT who made the complaint to account for their actions. If this does not happen he says he will be pressing health secretary Andrew Lansley to conduct a review.

He would also like the case to be investigated by the Equalities Commission. He said: “It is now clear Dr Boardman was right and they were wrong and their allegations and smears were unjustified. In my experience no male or no white consultant has ever been treated like this.”

A trust spokesman said: “The trust’s actions were in the best interests of patients as the breach of patients’ confidential information is a serious matter and one which patients themselves also take very seriously.”

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Religious beliefs shape end-of-life decisions

By Mike Broad - 27th August 2010 12:16 pm

Atheist or agnostic doctors are almost twice as willing to take decisions that they think will hasten the end of a very sick patient’s life as doctors who are deeply religious, research reveals.

The study in the Journal of Medical Ethics also suggests that doctors with a strong faith are less likely to discuss this type of treatment with the patient concerned.

Nearly 4,000 doctors responded to the survey and they were asked about the care of their last patient who died, if relevant, including whether they had provided continuous deep sedation until death, whether they had discussed decisions judged likely to shorten life with the patient, their own religious beliefs, ethnicity, and their views on assisted dying/euthanasia.

The specialties targeted included those in which end of life decisions would be particularly likely to arise, such as neurology, elderly care, palliative care, intensive care and hospital specialties, and general practice.

Specialists in the care of the elderly were somewhat more likely to be Hindu or Muslim, while palliative care doctors were somewhat more likely than other doctors to be Christian, white, and agree that they were “religious”.

But, overall, white doctors, who comprised the largest ethnic group among the respondents, were the least likely to report strong religious beliefs.

Ethnicity was largely unrelated to rates of reporting ethically controversial decisions, although it was related to support for assisted dying/euthanasia legislation.

Specialty was strongly related to whether a doctor reported having taken decisions, expected or partly intended to, end life. Doctors in hospital specialties were almost 10 times as likely to report this as palliative care specialists.

But irrespective of specialty, doctors who described themselves as “extremely” or “very non-religious” were almost twice as likely to report having taken these kinds of decisions as those with a religious belief.

The most religious doctors were significantly less likely to have discussed end of life care decisions with their patients than other doctors.

These attitudes were reflected in support for assisted dying/euthanasia legislation, with palliative care specialists and those with a strong faith more strongly opposed to it. Asian and white doctors were less opposed to such legislation than doctors from other ethnic groups.

The author Professor Clive Seale, from Barts and The London School of Medicine and Dentistry, concludes that the relationship between doctors’ values and their clinical decision making needs to be acknowledged much more than it is at present.

He said: “One potential response to the findings about the influence of religious faith is to suggest, as other have done, that religious doctors disclose their moral objections to certain procedures to patients so that patients can choose other doctors if they wish. This assumes that religiosity is the ‘exception’ to be set against the non-religious ‘norm’. It is equally plausible to argue that non-religious doctors should confess their predilections to their patients.

“After all, the data show some religious faith is held to by almost half of the medical population and approximately two-fifths of the general population. Whether religious or non-religious, it would seem advisable that doctors become more aware of how broader sets of values, such as those associated with religiosity or a non-religious outlook, may enter into their decision-making in end-of-life care.”

Read the full study.

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Review of Clinical Excellence Awards launched

By Mike Broad - 21st August 2010 8:28 am

The government is to review the Clinical Excellence Awards system across the UK with a view to making them more “affordable”.

Health secretary Andrew Lansely has asked the Review Body on Doctors’ and Dentists’ Remuneration to lead the review and it will report by July 2011.

The government says the DDRB will work closely with a range of ‘external stakeholders’, including NHS organisations, the BMA and the independent committees which make awards in the devolved administrations.

Lansley said: “We want to continue to reward and recognise those individuals who give outstanding patient care and go beyond the call of duty, but we must ensure that the system is effective and affordable. The NHS must recognise its responsibilities in the current financial climate as the largest public service in the country and this review will ensure that Clinical Excellence and Distinction Awards are in line with other public sector pay and incentive schemes.

“A more transparent and sustainable awards system will allow the NHS to focus its resources to benefit patients and drive up standards to give us a health service that delivers outcomes among the best in the world.”

CEAs are intended to financially reward consultants who perform over and above the standard expected of their NHS role. They’re given for a range of achievements, from research and innovation through to an outstanding commitment to quality of care and leadership. They are consolidated into pay and are pensionable.

The review will consider the need for incentives to encourage and reward excellent quality of care, innovation, leadership, health research, productivity and contributions to the wider NHS.

There is already a freeze in place on the cash amounts of Clinical Excellence Awards for 2010/11, which was recommended by the DDRB earlier this year. That freeze will continue for 2011/12 and 2012/13.

Consultants did not receive a pay rise for 2010/2011 and are now subject to a two-year pay freeze.

Dr Mark Porter, chair of the BMA’s consultants Committee, commented: “The BMA will engage with this review, which provides an opportunity to highlight the value of award schemes to patient care. These schemes exist to promote quality, efficiency and innovation across the whole NHS, all of which are key aims of the recent health White Paper.

“It is worth noting that Clinical Excellence Award Schemes have already been subject to review in recent years, with the conclusion that they are beneficial to the NHS. The innovative practices and research activity that they encourage not only benefit patients, but also frequently save the NHS money and bring benefits to the economy.”

The number of CEAs handed out nationally was halved in the 2010 round. Only 317 national awards have been given to senior doctors in England and Wales in 2010 in comparison to 601 in 2009.

In 2009-10, the NHS paid £202.2 million to consultants for Clinical Excellence and Distinction Awards, of which 564 consultants received new awards, totalling some £20m. Most of the expenditure on the scheme funds existing awards.

Who received a national CEA in this year’s round? Read more.

Read more on the value of CEAs.

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CEAs are slashed for the highest performers

By Mike Broad - 11th August 2010 4:47 pm

The number of clinical excellence awards handed out nationally has been halved in the 2010 round.

Only 317 national awards have been given to senior doctors in England and Wales in 2010 in comparison to 601 in 2009.

The ACCEA, which runs the awards scheme, has blamed reduced affordability.

There are 12 levels of CEA with the highest three levels - silver, gold and platinum - being awarded nationally. Level 9, or bronze, can be awarded locally or nationally. A bronze recipient is paid £35,484 a year, silver £46,644, gold £58,305 and platinum £75,796.

CEAs are intended to financially reward consultants who perform over and above the standard expected of their NHS role.

In the 2010 round, the Advisory Committee on Clinical Excellence Awards received 1065 applications for bronze, 820 applications for silver, 183 applications for gold and 138 applications for platinum awards. Of these 317 were given awards, with 189 receiving bronze, 84 silver, 23 gold and 21 platinum.

The highest profile doctor to receive platinum in this round was Lord Ara Darzi, author of the former government’s influential High quality care for all: NHS Next Stage Review Final Report. Another well-known doctor was Jonathan Fielden, the former chair of the BMA’s consultants committee, who received a silver award.

A spokesperson for ACCEA said: “There are fewer awards this year than in the past few years. This is a result of reduced affordability in the light of the fact that fewer consultants have left the scheme - through retirement or for other reasons - than anticipated, reducing the funds for reinvestment as well as wider financial constraints.”

The level of CEA awards were frozen for 2010-2011.

Dr Mark Porter, chairman of the BMA’s consultants committee, said: “This is a matter for regret - it’s highly disappointing that so many talented and dedicated consultants have missed out on awards because of factors entirely beyond their control. The scheme exists to ensure that quality care is promoted across the NHS, not just in a few centres of excellence.

“We have strongly protested on behalf of individual applicants, and will continue to express our belief in the value of CEAs.”

Some trusts have also put pressure on their consultants to forgo their CEAs in order to help local finances. And, in Scotland, there has been a strong campaign to scrap the scheme.

Stephen Campion, chief executive of the HCSA, commented: “CEAs, and their predecessor merit and discretionary points, are an integral and long-standing element of hospital consultants’ salaries and terms and conditions of service.

“They are not ‘performance bonuses’ as some uninformed critics have argued. But we know from the leaked document prepared by the Foundation Trust Network earlier this year that they are seen as a target to cut consultants’ pay in order to save money. That the number of national awards has been slashed by 50% this year on the grounds of affordability raises a number of questions about the integrity of the scheme itself.”

The 2011 round of CEAs will open in September and close on 10 December 2010. The ACCEA says that all consultants currently holding an award who received it in the 2007, 2002, 1997 or 1992 rounds should be ‘reviewing’ in the coming round.

Read a full listing of the 317 doctors who received national awards in 2010.

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Union threatens legal action over white paper

By Mike Broad - 4:46 pm

Public sector union Unison is preparing to take legal action against the government over the white paper Equity and excellence: liberating the NHS.

The union says that NHS chief executive, Sir David Nicholson, is pressing ahead with plans that have neither Parliamentary approval nor legal backing.

The move centres around the status of the white paper, which recommends abolishing SHAs and PCTs and creating GP consortia which would lead on commissioning.

Unison has accused Nicholson of pre-empting the result of the consultation and subsequent Parliamentary process by writing to SHAs, PCTs and other providers with a series of “actions that we need to start now”.

The largest public sector union says it is unlawful to propose a series of far reaching, top-down changes to the NHS without giving the public, patients and interested parties, including Unison, a proper opportunity to have their say about the proposals.

Unison’s letter to the government warns that at unless the union gets a satisfactory response, urgent Judicial Review proceedings are on the cards.

Karen Jennings, head of health at the union, said: “The Government’s White Paper will change forever the NHS as we know it. These sweeping changes were not part of any party manifesto and it is outrageous that these changes are being brought in without consulting the public, patients, staff and unions.

“The NHS Constitution enshrined in law the right to consultation and yet, in writing to NHS managers, Sir David is working on the premise that the consultation is only about the best way to achieve pre-determined outcomes - this makes it nothing more than a paper exercise and a sham.”

In response, a Department of Health spokesperson said: “The White Paper sets out a stable structure for the long-term future of the NHS. It gives NHS staff and the patients they serve a clear sense of direction and purpose. The Government is engaging fully with the public, healthcare professionals, local authorities and unions on how its proposals will be implemented.

“The government has already launched public consultations, on specific elements of the White Paper, and further documents will be published this year. NHS Chief Executive, David Nicholson has written to encourage the NHS to begin locally led consultations and take first steps on the implementation of the White Paper, without pre-empting the wider consultation. Many reforms are also subject to Parliamentary approval as part of the Health Bill.

“Through the proposed changes, healthcare professionals and patients will have more power to shape, lead and deliver local healthcare services, away from the control of central Government.”

The BMA has adopted a position of ‘critical engagement‘ over the white paper.

Read a blog on the white paper and another.

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“Government should ban strikes by NHS staff”

By Mike Broad - 9th August 2010 12:18 pm

The government may have to ban strikes by NHS workers, an influential employers group has said.

It comes as Prime Minister David Cameron warned that services the public “genuinely value” will fall victim to the coalition’s spending cuts and that he could not place “a ring of steel around every service and every job”.

The Chartered Institute of Personnel and Development said the government faces a number of “high stake options”, such as banning strikes, as public sector unions prepare to take action against spending cuts.

Other policy options open to the government include legislation to require the parties involved in public service disputes to take part in compulsory arbitration prior to industrial action and changes to balloting requirements so that ballots should be counted separately for each employer.

The CIPD paper points to research which suggests just 16% of public sector employees say they trust their senior leaders.

Mike Emmott, CIPD employee relations adviser, said: “Trade unions have the power to disrupt only if employees trust them more than they trust management. The fundamental need is not to manage the trade unions, it is to manage the employment relationship and communicate the case for change.

“However it is also incumbent on the government to consider the policy options open to it for reducing the risk of disruptive and damaging industrial action by public service employees, such as banning strike action of those involved in the delivery of essential services. If the government was forced to go down this route it would be a sign of its failure to make the case for change to public sector employees.”

The report says 54% of public sector staff agreed that most people today are not willing to lose pay by going on strike.

Read the full report.

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Telemedicine requires better regulation

By Mike Broad - 5th August 2010 4:24 pm

Telemedicine should be regulated like all other forms of medicine and should meet the same safety standards, the Academy of Medical Royal Colleges has said.

Patients are currently unprotected under current UK regulations from mistakes made by telemedicine practitioners.

In a position statement, the Academy said that the Care Quality Commission should require all providers of medical services to ensure they can verify the qualifications and registration status of every doctor providing medical services to UK patients, wherever that doctor is located.

Telemedicine is the rapidly developing application of clinical medicine where medical information is transferred through interactive audiovisual media for the purposes of consultation, diagnosis and care when the provider and patient are separated by distance. Concerns have been voiced about the accountability of practitioners when they’re based outside the UK.

The Academy believes the verification of practitioners’ skills should include an individual assessment of their revalidation requirements.

Furthermore, all doctors providing services to UK patients, whether locally or remotely, should be registered with the GMC. Ultimately this should be a legal requirement, it says.

The Academy statement continues: “Healthcare providers should not rely on contractual arrangements between telemedicine companies and their employees, nor on indemnity provided by these companies, to guarantee the quality of patient care.

“Patients should be made aware if part of their care is devolved to a doctor working outside the UK. However, the UK-based healthcare provider who commissions a telemedicine-based service must remain legally liable for any damage that may arise as a result of poor medical care, whether delivered conventionally or by telemedicine. The UK-based healthcare provider must not be allowed to devolve this responsibility to a telemedicine provider.”

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‘No win no fee’ lawyers grow negligence claims

By Francesca Robinson - 4th August 2010 6:55 pm

Personal injury lawyers are being blamed for soaring clinical negligence claims which are spiralling at the rate of 10% a year.

A record £15 billion has been set aside for NHS claims, reveals the NHS Litigation Authority’s (NHSLA) annual report.

Some 6,652 clinical negligence claims were reported in 2009/10, a 10% increase over the previous year. This follows an 11% increase in claims in 2008/09.

The rise is blamed on the so-called ‘no win no fee’ market which allows claimants to litigate without any financial risk and proves very lucrative for solicitors who work on this basis.

A review of civil litigation costs by Lord Justice (Rupert) Jackson reported in January that the costs of conducting litigation have become significantly disproportionate to the benefits in many cases.

NHSLA chief executive Stephen Walker said that a city of London solicitor succeeding in a clinical negligence claim could bill at £450 per hour and seek up uplift of 100% as a success fee. This is significantly higher than the legal rates for the best defence lawyers that the NHSLA can secure at £205 an hour with no success fees.

“We can only hope that the courts will adopt the spirit of Lord Justice Jackson’s recommendations in considering costs issues,” he said.

The Jackson review has produced a blueprint for reform designed to bring costs under control and make them fairer. It recommends that success fees and after the event insurance premiums should be irrecoverable in ‘no win no fee’ cases (CFA - conditional fee agreements), as these are the greatest contributors to disproportionate costs.

The government is to consult on Lord Justice Jackson’s reforms in the autumn. Justice minister Jonathan Djanogly said that Jackson’s recommendations will be taken forward by the government “as a matter of priority” and that CFA reform should lead to significant costs savings, while still enabling those who need access to justice to obtain it’. He added that CFAs had played a role in giving access to justice but high costs under the existing arrangements had now become a serious concern, particularly in clinical negligence cases against the NHSLA.

But the Association of Personal Injury Lawyers plans to fight the proposed reforms. It argues that they would be detrimental to claimants. “Shifting costs onto claimants is a step backwards, and could disenfranchise many injured people from the justice system, because they simply won’t be able to afford to bring legitimate cases,” said a spokesman.

MPS chief executive, Tony Mason, said increased life expectancy and the cost of care packages were also factors in driving up costs.

“Every year we have seen a significant increase in legal costs. It is not unusual for claimant legal costs to exceed compensation payouts in clinical negligence cases. In some lower value cases we see costs five to ten times the value of the compensation awarded. For cases in the last five years in England and Wales where we have paid compensation of up to £100,000, claimant legal fees were more than 90% of the damages paid out. Patients deserve fair compensation, but we must do something to stem the tide of excessive legal costs.”

Jill Harding, head of claims at the MDU, said: “Doctors may be concerned to hear about the 10% increase in the number of NHS negligence claims. It is important to point out however that an increase in claim notifications is not an indication of a decline in medical standards.”

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Working Time Directive is “spectacular failure”

By Mike Broad - 1st August 2010 9:19 pm

Surgeons’ representatives have called the working time directive “a spectacular failure” following new research suggesting care has deteriorated since its introduction a year ago.

Eighty per cent of consultant surgeons and 66% of trainees say that patient care has deteriorated under the working time directive.

The Royal College of Surgeons, Association of Surgeons in Training and British Orthopaedic Trainees Association are all campaigning for a 65-hour week, which they believe offers the best balance between adequate training opportunities, good patient care and work-life balance.

The survey’s results - taken from 980 surgeons covering all nine surgical specialties in England as well as those based in Scotland, Northern Ireland and Wales - compare unfavourably to a similar research undertaken last year.

Sixty five per cent say their training time has decreased - a quarter more than in October 2009.

More than a quarter of senior surgeons are no longer able to be involved in all of the key stages of a patients’ care, compared to 18% in 2009.

Two thirds of trainees have reported a decline in training time in the operating theatre and 61% of consultants report that they are operating without trainee assistance more frequently since the directive was introduced in August 2009.

Forty one per cent of consultants and 37% of trainees reported ‘inadequate handovers’.

This follows Hospital Dr research which showed that shift working and multiple handovers top the list of problems doctors face in delivering good care.

Almost three quarters of trainees and two thirds of consultants are consistently working more than the permitted hours. Over half of trainees say they cover rota gaps which result in them working in excess of their contracted hours, compared to 44% in 2009.

One consultant surgeon, who responded to the survey, said: “The European Working Time Directive has been a training disaster. We are raising a generation of demotivated, demoralised and poorly trained surgeons. The UK will pay for this and regret it for at least 30 years.”

Mr John Black, president of the Royal College of Surgeons, said: “To say the European Working Time Regulations has failed spectacularly would be a massive understatement. Despite previous denial by the Department of Health that there was a problem, surgeons at all levels are telling us that not only is patient safety worse than it was before the directive, but their work and home lives are poorer for it.

“The new government have indicated they share our concerns, but there is not a moment to lose in implementing a better system which would enable surgeons to work in teams, with fewer handovers and with the backup of senior colleagues.”

Mr Charlie Giddings, president of the Association of Surgeons in Training, said: “The survey shows that 12 months after the full implementation of the WTD there has been little progress with improvements to quality of training or to the quality of life of trainees and the subsequent impact on patient safety.

“New innovative solutions are required rather than the minor short-term tweaks that artificially produce compliance at the expense of training and patient care, which trusts have attempted so far.”

A spokesman for the Department of Health said: “The health secretary will support the business secretary in taking a robust approach to future negotiations on the revision of the European Working Time Directive, including maintenance of the opt-out.

“We will not go back to the past with tired doctors working excessive hours, but the way the directive now applies is clearly unsatisfactory and is causing great problems for health services across Europe.”

Meanwhile, additional RCS research suggests that the proportion of NHS patients having to wait longer than the 18-week target for non-emergency surgery had almost doubled from 1.5% 18 months ago to nearly 3% in March 2010. It blames the WTD.

Commenting on the findings, Royal College of Physicians president Sir Richard Thompson said: “We are not providing the service or the training that we require. I cannot over-emphasise the damage to service provision and to training.”

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