Posts Tagged ‘WTD’

Four in ten juniors on understaffed rotas

By Mike Broad - 23rd February 2010 4:01 pm

A shortage of junior doctors is threatening to compromise clinical standards, the BMA has warned.

A survey by the junior doctors’ committee reveals that four in ten juniors are working on understaffed rotas following the introduction of the Working Time Directive.

Frontline services like emergency have been the hardest hit, an analysis of rota vacancies shows, with six out of ten of the doctors working in A&E reporting rota gaps.

JDC chair Dr Shree Datta said: “It is clear that it is an everyday experience for junior doctors to be working on inadequately staffed rotas. Given that inadequate staffing levels have been identified as a major factor in the delivery of substandard care - it is essential for patient safety that this problem is taken seriously.”

The BMA survey, which received over 1,500 responses, also shows that four out of ten vacancies were for specialist trainees with at least five years of experience. The majority of rota gaps reported were for juniors who have completed their foundation training years.

Since the WTD was introduced last August, there has been mounting evidence of junior doctor shortages and reduced opportunities to receive teaching and training.

A survey by Remedy showed a high level of rota non compliance among juniors. Then a large survey among surgical trainees showed that two thirds felt training was being compromised. And there was further evidence of record numbers of junior doctor vacancies as more people were required to fill rotas.

Only 273 of 6,646 clinical rotas were granted a two-year exemption from the 48-hour week by the government, with juniors being allowed to work 52 hours instead.

Dr Datta is calling on the government to address the understaffing of rotas.

She said: “It is hugely alarming to that find so many doctors are working in teams short of experienced doctors. In settings like A&E, which is experiencing the highest levels of understaffing, it is especially critical that experienced specialists are on hand to make the decisions that can mean the difference between life and death.

“Clearly many hospitals are struggling to cope with the introduction of the 48-hour week. Running understaffed rotas cannot be the answer. Hospitals need to look more closely at how they organise their rotas. They need to look at reducing unnecessary bureaucracy and inappropriate work so that healthcare teams can offer patients the high quality care they deserve.”

The government asked Medical Education England to conduct a review of medical training post-WTD and is due to report later this year.

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Will the WTD review get to the truth?

By Mike Broad - 6th January 2010 5:23 pm

As far as the government is concerned, the implementation of the 48-hour for juniors has had no impact on either clinical care or the training of juniors. When the Working Time Directive (WTD) is criticised, the stock response is that there’s no evidence to suggest they’ve been compromised.

They have, however, acknowledged juniors’ concerns about their training and, back in July, at the eleventh hour, asked Medical Education England (MEE) to conduct a review.

It’s been a long time coming but, just before Christmas, MEE announced the review was underway. MEE has appointed Professor Sir John Temple, former president of the Royal College of Surgeons of Edinburgh and chair of the Specialist Training Authority, as review chair.

Sir John and his expert group will soon be listening to oral evidence, and this will include focus groups and face-to-face meetings. A final report is due to be presented to the health secretary by April.

Evidence is now the big issue. The government believes the PMETB Survey of Trainees for 2009 supports its current position. There is, however, a growing body of evidence which contradicts this just not from ‘official’ sources. 

A survey by Remedy showed a high level of rota non compliance among juniors. Then a large survey among surgical trainees showed that two thirds felt training was being compromised. And then there’s the small matter of record numbers of junior doctor vacancies as more people are required to fill rotas. Are you telling me this isn’t compromising care?

Sir John needs to cast far and wide in his search for evidence. Often ignored, frontline doctors have important stories to tell. Mr Peter Mahaffey, consultant surgeon in Bedford, recently dropped me a line. He said: “There can barely be a senior consultant surgeon anywhere who hasn’t witnessed the extraordinary reduction in practical skills amongst trainees and more frighteningly the relative helplessness of new consultant colleagues fresh from this neutered training.”

He was responding to an article by Mr Munchi Choksey, consultant neurosurgeon at University Hospitals Coventry and Warwickshire NHS Trust, which criticised the Royal College of Surgeons for not having done more to resist the implementation of the WTD.

Sir John has to get beyond the usual suspects and canvass frontline opinion. The acquiescence of many of the profession’s representatives, including many of the royal colleges and the BMA, has brought the profession to this crisis point.

He also needs to park the knighthood, retain his independence and be prepared to tell the health secretary some hard truths about the impact of the 48-hour week, as I’m sure a rigorous evidence search will reveal.

Will this review simply re-arrange the deck-chairs on the Titanic? I hope not. Tomorrow’s patients also deserve confident, highly trained and experienced hospital doctors. 

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Interview: Mr John Black, president of the RCS

By Mike Broad - 8th December 2009 10:08 pm
Mr John Black, president of the RCS

Mr John Black, president of the RCS

Hospital Dr invited Mr John Black, president of the Royal College of Surgeons of England to answer 12 questions and complete a half finished sentence…

1. What is the biggest challenge the profession faces? 

“Restoring all that has been thrown away in the modernisation fervour of the last decade. An awful lot of babies have gone out with the bathwater. Basic sciences and acquiring factual knowledge have to be restored to the medical school curricula; in postgraduate training, educational theory has to be replaced by classic apprenticeship; and whatever the health care model the country chooses it must be based on achieving the best outcomes not irrelevant targets and political expediency.” 

2. When did you last laugh and why?

“Last weekend my two-year-old granddaughter was asked if she was tired and replied: ‘I’ve had a long day!’”

3. What are the RCS’s priorities over the next year?

“To restore continuity of care to patients, so that they are referred electively or as emergencies to a single consultant and their team, who look after them throughout the entire hospital episode. This means reforming Choose and Book, removing the target culture if not all targets, and getting rid of the European Working Time Directive for surgeons.

“On the training side we need to support MEE in restoring the intensity of training. This means acknowledging that competence is not enough. It is just the start after which comes experience until the doctor is confident and safe to work independently.”

4. Which person influenced you most as a doctor and why?

“No single person stands out from the many amazing surgeons and people I have worked for and with.”

5. When were you most in danger?

“When an operating light fell from the ceiling a few hours before I was due to start operating. It seemed funny until we heard that it happens several times a year throughout the world and is usually fatal to both patient and surgeon.”

6. How will royal colleges maintain their relevance?

“By continuing to set the very highest standards for practice and training and then to work ceaselessly with politicians and everybody providing healthcare to make sure they are achieved. There was an overt anti-college agenda a few years ago, which has now gone. Colleges started long before politicians!”

7. What is your favourite piece of music?

“Where do I start? Perhaps one of the late piano sonatas, late quartets or the string quintet of Schubert. Mind you I’ve just been to the Birmingham Royal Ballet Nutcracker and can’t get the tunes out of my head! Mendelssohn’s Octet is playing as I type. Sorry, I can’t nominate a single piece.”

8. How can surgeons be encouraged to share their performance data?

“Very easily, as they all want to. The problem is selecting the best outcome measures and making sure they are risk adjusted.”

9. What is your guiltiest pleasure?

“White Burgundy.”

10. What are the hallmarks of an excellent surgical team?

“Just that, being a team. Losing the old fashioned ‘firm’ is one of the worst things that has been inflicted on surgical training. Only in a team of that size is there the bonding to guarantee optimum patient care and training, not to mention morale.”

11. What was your most embarrassing professional moment?

“A lot of the time when I was a trust medical director, pretending to be a manager in areas where I knew nothing. I was fine on the professional issues and things such as organising services, but all at sea on a lot of the rest. Clearly I was fundamentally a clinician.”

12. Of what achievement are you most proud?

“Managing jointly with a colleague, Phil Morris, to raise over £4m for the Education Centre at the new PFI hospital in Worcester. It was painful and a big worry for a couple of years, but now we have got there, as a freestanding charity, we have the key advantage of independence. The architect is also a genius and the building is distinctive.”

Finish this sentence: trainees working to a 48-hour week will…

…have a miserable time, be isolated and stressed by being flat out all the time, exhausted by night shifts, miss out on the training received by previous generations and, most of all, have to work in a fundamentally unsafe manner where they never see a patient through. By the way, this insane legislation is designed to make their lives better!

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Should the royal colleges be tougher on twaddle?

By Mike Broad - 25th November 2009 9:42 am

Mr John Black, president of the Royal College of Surgeons, recently contacted the members and fellows about its campaign for an opt-out from the Working Time Directive. After describing trainees as exhausted and demoralised, he calls on surgeons to influence MPs and prospective parliamentary candidates in the run up to next year’s election.

Black writes: “The only way to circumvent this damaging legislation is political will…There are several avenues open to the next government to solve the problem, which we have pointed out repeatedly.

“It was encouraging to hear the shadow foreign secretary William Hague mention on national television the College’s concerns about EWTD, and that his party if elected intended to act. However we cannot predict the result of the election and now is the time for individual surgeons to make it clear to individual politicians of all parties just how important this issue is to surgical practice in the NHS.

“I am therefore asking you all to press our case with Members of Parliament and Prospective Parliamentary Candidates. The more who are approached…the more likely the issue is to rise up the political agenda and be solved, regardless of the result of the election. The critical tactic is to give them your personal experience of the attempts to reduce hours, and tell them how catastrophic it has been for patient care and for the training of future consultants…”

It concludes: “This personal approach to politicians is the latest step up in our campaign to free surgeons from the bonds of EWTD. The more Fellows and Members join in, the more likely we are to succeed.”

One surgeon - Mr Munchi Choksey, consultant neurosurgeon at University Hospitals Coventry and Warwickshire - was unimpressed by the communication. Here’s his reply to Mr Black:

“You raise some interesting issues. First, I would point out that trainees have never had it easier. When I began neurosurgical training in 1984 as a registrar (having passed the more difficult, unstructured, unpoliced and often unfair FRCS) there were 64 registrars and 16-18 senior registrars. There were about 100 consultants. There were virtually no new consultant posts - one per annum at the most.

“We all did 1:2 rotas, with no prospective cover, no compulsory time off for teaching, with a roughly 1 in 4 chance of making it through the system. You needed to publish original papers (24 in my case), and an MD was nearly de rigeur. Life was tough…

“By paying credence to the whining of trainees, you turn them into a bunch of sissies. Surgeons need to be tough; the public expects it. Trainees have always moaned.

“I agree that the implementation of 48-hour working has been a disaster. The Americans now regard British neurosurgical training as pitiable. Our traditional advantage - a wealth and depth of operative experience never equalled or exceeded in the developed world - has been thrown away. 

“The best course of action: abandon EWTD, or get the next - hopefully Conservative government - to opt out. The Germans have done this de facto: which is very unusual as normally the Germans make the rules in Europe, the French protest about them, the British obey them and the Italians ignore them.

“Next, we must re-open the borders to trainees from the sub-continent. They speak English, have been brought up to be tough in a very British ex-colonial medical system, and would gain from the exposure to high-tech medicine.

“The reason the Royal Colleges have lost their traditional stranglehold on post-graduate medical education is partly due to their reluctance to stand up to the government and challenge their ridiculous, bureaucratic and arbitrary edicts that they produce with no evidence base whatsoever. There is not one shred of objective evidence that revalidation, for example, will produce better doctors. Where are the randomised controlled clinical studies? Why are you not fighting the rising, ever-metastasising, tide of poly-twaddle that is engulfing the profession, and destroying the very things that made British medicine admired the world over?

“When I came to Britain 40 years ago, the profession was solid, tough, difficult to enter, with high standards of internal discipline and complete control over patient care…You are the president of a great and august institution, with justifiable pride in its forebears. Were John Hunter to have read your letter, he would be turning in his grave.

“Get tough - your profession needs inspirational leadership. Yours sincerely…”

Do you think a more confrontational approach with government should be adopted? editorial@hospitaldr.co.uk

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College seeks to extend juniors’ training

By Mike Broad - 23rd November 2009 10:42 am

The College of Emergency Medicine wants to extend the duration of training for the specialty because there is now insufficient time to develop experienced consultants.

It is due to submit an application by 23 December to the Postgraduate Medical Education and Training Board to extend higher training by a year.

Currently, emergency medicine trainees do two years of Acute Care Common Stem (ACCS) followed by four years in specialist training (ST3 to ST6). The intention is to add an additional ACCS year.   

Dr Wayne Hamer, consultant in emergency medicine and chair of the training committee at the college, explained that the request is because the ACCS curriculum and assessment system is large and complex and the trainees need this additional time. 

Dr Don MacKechnie, vice president of the College of Emergency Medicine, said the gradual reduction of hours over recent years - with the reform of training and WTD - had compromised the volume of cases doctors working in emergency medicine handled.

“Emergency medicine is a broad church and you can never get too many cases to improve your understanding,” he said. “We’ve just lost too many hours out of the system for the trainees to acquire those competencies they require to become consultants in the specialty.”

Medical Education England were asked by the government earlier this year to review the WTD and its impact on training and appointed Professor Sir John Temple as their review chair. He’s due to report early next year.

A number of other colleges are believed to be considering applications to extend training but are awaiting the outcome of the review.

Dr Richard Marks, head of policy at pressure group Remedy, commented: “The calibre of British consultants in the past was based on their breadth of clinical experience, and appointment to the grade signified that a level of expertise had been reached.

“Modernising Medical Careers set out deliberately to shorten the length of training and narrow the breadth, and it is surprising that it was so widely supported. The shortening of hours has exacerbated the situation. We welcome the planned move by the college to extend training, and hope other colleges will consider doing the same.”

Remedy called on PMETB to be proactive and review all the training programmes they approved a few years ago in the light of the new working and training patterns.

PMETB said the request would receive consideration when it was received. Hamer said if PMETB decline the request the college will still look to expand ACCS to three years and cut higher training by a year to accommodate it.

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Will immigration changes add to recruitment woe?

By Dr Shree Datta, chair of the BMA's junior doctor committee - 17th November 2009 12:55 pm

Last week saw Gordon Brown get tough on immigration.

In the Daily Mail, we heard that the government was cracking down on immigration starting with a curb on doctors. Self sufficiency should be the goal of workforce planning, but are we really there yet?

My previous blog on rota gaps highlighted the problems many junior doctors have working on understaffed rotas and the fact, which even the Department of Health acknowledges, that part of the rota gaps problem is due to a previous crackdown on immigration.

Predicting the numbers needed to staff the NHS is complicated and whilst we may have competition for jobs in some parts of the country, other parts may have problems recruiting the doctors they need to deliver services to patients.

Earlier last week I was talking on BBC Radio Cumbria about the North Cumbria University Hospitals NHS Trust. This trust is recruiting junior doctors and consultants from India because they can’t find home grown candidates, which clearly illustrates the problem with a heavy handed approach to immigration. My worry is that this will affect the quality of care patients in the NHS are getting and the amount of training that junior doctors are exposed to - leaving them ill-equipped to be the consultants of tomorrow.

Of course, as with most government announcements, there seems to be very little policy behind the rhetoric but in his effort to sound tough on immigration Gordon Brown must not ignore the fact we need a flexible system that does not leave the NHS short of doctors.

The BMA’s junior doctors committee is working to ensure that international doctors are able to take up the posts they are offered without being hindered by the red tape that surrounds visa applications. With 2010 around the corner, it’s very much a case of watch this space to see how the immigration changes on top of the European Working Time Directive affect junior doctor recruitment.

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Record numbers of junior doctor vacancies

By Francesca Robinson - 13th November 2009 9:04 am

Evidence of a worsening junior doctor recruitment crisis following the introduction of the European Working Time Directive has come to light this week.  

Jobs4medical, an online recruitment service, announced that it has a record number of doctor vacancies on its site.

It is currently advertising 7,500 locum and permanent doctors’ positions, which also includes consultants and GPs.

The highest number of vacancies posted on the site for secondary care are in accident and emergency followed by paediatrics and psychiatry.

Vicky Scott, operations manager at Jobs4Medical, said: “We have seen a huge increase this year in doctors’ positions. We are getting feedback from recruiters that it’s very difficult to recruit doctors into these roles. We are finding that the movement isn’t there in the market that there was a year ago or maybe even eight months ago. It has got worse since August.”

Across Cumbria there are currently between 16 and 20 specialist junior doctor vacancies. Recruiters from the North Cumbria University Trust recently travelled to India in a bid to recruit 10 new juniors.

In an interview on Radio Cumbria junior doctor committee chair Dr Shree Datta said: “There are shortages throughout UK and we need to look at why…there are these shortages. What it means is that junior docs on the shop floor working harder than they otherwise would be. Tired doctors are not the best doctors.”

Reports are also coming in of the way that recruitment problems are beginning to impact on services. Hospital managers in Wales recently decided that adult brain surgery will be permanently centralised in Cardiff because of the nationwide shortage of junior doctors.

Dr Richard Lewis, Welsh secretary of the BMA, said the shortage of middle grade and junior doctors in Wales could be contributing to the higher number of complaints about medical staff.

Complaints about hospital services have risen by 15%. Among these two-thirds were about inpatient and outpatient care and another one in 10 about accident and emergency. More than half concerned medical staff.

“We have a shortage of junior and middle-grade doctors and that undoubtedly puts pressure on those staff who are trying to deliver a good service,” he said. “But when we have an under-doctored workforce, there will be increasing pressure on the ability of services to deliver.”

Rural and outlying areas are having the greatest struggle to fill posts. NHS managers in Scotland are currently relying on temporary cover to maintain their complement of junior doctors at Caithness General Hospital. Since August the hospital has been unable to fill three of the nine permanent posts. 

A BMA spokesman commented: “Clearly the problem is getting worse. The trouble is much of the evidence is currently anecdotal. It’s an evolving picture because there is a problem with the quality of the data because, for example, there are issues with junior doctors working more hours and falsifying their hours because they want access to training. 

“It is difficult to get a handle on the exact impact the EWTD is having but clearly the shortage of junior doctors is going to be putting pressure on the system particularly where there are recruitment problems already.”

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“The next generation will not be up to it”

By Mike Broad - 11th November 2009 1:12 pm

It’s a truism that every generation of consultants thinks their trainees will not be as good as them. The view is often that they do fewer hours, see less cases, seemingly show less understanding and appear less committed.

This week two research papers support this prejudice.

The first, in the BMJ, suggests that it takes about 20,000 hours of practice for a surgeon to master the specialty: 10,000 hours for the cognitive skills and 10,000 hours for the manual.

This equates to 4,000 hours a year over a five-year training programme.

The authors suggest that under a 48-hour week juniors are clocking up about 2,300 hours a year making it 11,500 over a five-year period.

They quote the classic sociological analysis of surgery Forgive and Remember, which states: “Surgery is a body contact sport, there is no question about it. You can’t be a good armchair surgeon.”

I think you can probably guess their conclusions.

Can you train a physician effectively in 11,500 hours of practice? I’ll leave that one for you to decide, but the quiet acceptance of the 48-hour week by the non-surgical royal colleges speaks volumes. 

The second research paper this week highlighting the frailties of the next generation was to be found in the pages of the journal Health Policy. It examined senior doctors’ perceptions of whether their medical graduates were ready to become doctors.

The answer was a resounding “no”. Consultants and SpRs in two teaching hospitals gave less than flattering feed back on a wide range of practical and clinical skills, from the ability to perform basic respiratory function tests to prescribing and advanced communication.   

The authors in part blame the GMC guidance - Tomorrow’s Doctors - for not being more prescriptive about the skills newly qualified doctors require.

Should we smile at this time honoured tradition of underestimating the younger generation, or should we be genuinely worried?

After all, the good old bad days weren’t that good. The hours might have been longer, the commitment necessarily high, but who knows what the standards were like at times.

Of course, the other big difference was that medicine itself was simpler 20 or 30 years ago. Modern medicine is infinitely more complex and interventional, which creates another problem.  

At the same time as working hours are being reduced and training re-modelled, practice is advancing and becoming more technical and specialist. And that’s without even considering the impact of the downturn on the NHS and how that will affect training and staffing budgets in the future. Or, more consumerist and demanding patients.

This level of change is the problem and we should indeed be worried about our future standards of care. 

Few organisations are fronting up to the problem in public. In an increasingly consultant-led and delivered healthcare system, we are in real danger of having under-cooked trainees. Improved training techniques and use of technology are only going to go so far. There isn’t going to be a significant extension to work hours once more regardless of what government is in power. 

So the answers lie in either an extension to training or the creation of some half-arsed sub-consultant grade. I know which I think is better for both the profession and patients.

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Shifts damage communication and continuity

By Mike Broad - 6th November 2009 11:28 am

Poor communication is a significant factor in patient deaths in an emergency or urgent setting, a confidential review into the care of over 3,000 terminal patients finds.

In 13.5% of cases a lack of communication both between different grades of doctors within clinical teams, and between different clinical teams and other health care professionals was noted.

The hard-hitting report by the National Confidential Enquiry into Patient Outcome and Death also reveals two-fifths of patients received ‘sub-standard’ care, highlighting problems with the involvement of patients and their families, continuity of care and a lack of senior input, particularly at night.

Deaths in acute hospitals: caring to the end? finds that a coordinated handover of patients between night and day staff only occurred in a quarter of the teams, prompting calls for new systems that enable clinical teams to have a better understanding of a case throughout a hospital stay.

More prompt review of patients by consultants is also urged. The report claims there was a clinically important delay in the first consultant review in 25% of cases.

The report’s author said: “Change in the hospital team structure over recent years has seen individual clinicians become transient acquaintances during a patient’s illness rather than having responsibility for continuity of care.

“Staffing arrangements and shift working have also been shown to be disruptive and with the implementation of the European Working Time Directive, this disruption is likely to continue and to impact on the training of tomorrow’s doctors.”

In 16.9% of patients who were not expected to survive on admission there was no evidence of any discussion between the health care team and either the patient or relatives on treatment limitation. In 21.8% of cases DNAR orders were signed by very junior trainee doctors.

Mr John Black, president of the Royal College of Surgeons, blamed multiple handovers. “This report highlights the loss of proper team working in hospitals, resulting in dangerous failures of communication which make it harder and harder for clinicians to provide safe care for patients,” he said.

“The problems revealed in this report date from 2006 and 2007, when the NHS was already struggling to meet the demands of a 56-hour working week. Now that, in theory, everyone in the NHS is working for only 48 hours the situation in the country’s hospitals can only have worsened.”

The college called for an opt out from the WTD so that ‘proper’ clinical teams can provide on-call cover throughout a 24-hour period.

Read the full report.

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Surgical trainees between a rock and hard place

By Ed Fitzgerald, president of the Association of Surgeons in Training - 4th November 2009 11:06 am

Surgical training has come a long way in a short time. I type this as I take the fast train up to London this morning, where I’m joining a meeting to review the new curriculum for general surgery with PMETB.

The curriculum, the ISCP website, and the Schools of Surgery supporting training in England, have all done much to revolutionise surgical training in recent years. Arguments remain about trainees shouldering the costs of this, and considerable frustration surrounds the hoop-jumping, user-unfriendly ISCP training website. However, there can be no doubt that surgical training has now been pushed to its rightful place at the top of the agenda.

The elephant in the room remains the working hours in which this training package is delivered, and the deleterious impact of the Working Time Directive. The arguments surrounding WTD have been recited many times - that frequent handovers and the lack of continuity of care harms training and patient safety, and that the skeleton (increasingly non-resident) cover does likewise. The rise of the shift system takes trainees away from both their firms and also core day-time training opportunities, amplified by the unnecessary forced ‘zero hours’ following on-calls.

Surgery finds itself in a particularly vulnerable position. As a post-graduate craft speciality, the apprenticeship model falls short when restricted working hours prevent trainees from learning their craft. Despite what some non-surgeons argue, no amount of high-technology simulation can replace this (and in any case, no-one is proposing to fund this).

So trainees now find themselves stuck between a rock and a hard place. Although the framework that supports surgical training has seen major development in the past decade, at the coal-face there has been little change in how hospitals facilitate training on a day-to-day level within the NHS. A reduction in working hours against this backdrop is disastrous.

The volume of survey responses received by ASiT and BOTA is testament to the strength of feeling generated amongst surgical trainees by this issue. They value their training, and they see it deteriorating in front of them day-by-day. Worse still, they find themselves in the unenviable position of skating around the rules and coming in to work on days off in order to progress their training. This unregulated ‘grey rota’ is not safe, not sustainable, and no way to train a modern surgeon in the 21st century.

A compromise on working hours is not the complete solution for surgical training, and no-one is suggesting it is. Professor Eraut’s recent report flagged up many problem areas. Other initiatives will be required, such as concentrating training in the hands of dedicated trainers, and concentrating trainers in units accredited and funded for this. However, the pace of change in the NHS is painfully slow and any such modernisation will take many years to approve, fund and implement.

We must take a pragmatic view of the NHS we are currently faced with. An increase in hours is vital to enable adequate training within these current constraints. Only in this way can we prevent creating another lost tribe of surgical trainees without the skill, confidence and experience to give our future patients the care they deserve.

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