Panel Discussion Questions, GAT ASM, Cardiff

July 2017

Panel members include:  
Dr Emma Plunkett, Chair GAT committee EP
Dr Paul Clyburn, President AAGBI PC
Dr Liam Brennan, President RCoA LB
Prof Kevin Carson, President CAI KC
Fatigue and wellbeing >
Brexit >
Workforce and training >
PA(A)s >
Perioperative medicine >
Promoting our specialty >
Miscellaneous >
Fatigue and wellbeing

Q) Given the earlier discussion - are there any plans to facilitate an increase in rest facilities, particularly AFTER shifts? Anecdotally these resources seem to be declining rather than improving.

EP: I agree with your perception about the reduced availability of rest rooms after shifts.  This is also my experience.  The standards for rest facilities are aimed at both facilities during and after a shift – we believe both are important.  We hope that the survey results; the AAGBI Fatigue and Anaesthetists guideline and the fatigue resources will help to improve these facilities.  We need our members to work with their departments and Trusts to help facilitate this and we will do what we can to help.  We will also work with other organisations – Royal Colleges, HEE, NHS Employers, the BMA and the GMC for example – to lobby for more widespread adoption of our recommendations. 

Q) Another issue is that the draw to just get home after a night shift is huge, so even though there might be facilities for rest, people take the risk.  

EP: I agree.  We call this “get-home-itis” and we understand that people just want to get home. We hope that if we can develop a culture where it is acceptable to sleep on rest breaks at night, then people will be more likely to be better rested during and at the end of shifts.  So shifts where people reach the end, utterly exhausted, should be the exception and not the rule.  We want easy access to post shift rest facilities so that people can have a quick nap before driving home or use another mode of transport.  This is after all, in the new junior doctor contract.

Q) What exists re: rest facilities in other shift working professions? (e.g. security, 24hr shops/petrol stations, factory workers etc)

EP: I don’t know the answer for the jobs suggested. We haven’t looked into those types of roles, I think because they are less comparable in terms of safety critical industries.  

Q) How do you think the college(s) should respond to the evidence on fatigue?

EP: We are working with the RCoA on this project and they are fully supportive. The Fatigue Group has representatives from the RCoA Council who are an integral part of the group. We hope the College can use its sphere of influence to help effect change.  We would like the standards for rest facilities to be part of the ACSA scheme.

LB: We are engaging with the leadership of NHS England, NHS Improvement and the Chief Medical Officers of the devolved nations to highlight the worrying findings from the fatigue survey

Q) How do you think we solve the issues raised by the fatigue surveys and low morale identified in the RCoA survey. 

EP: Good question.  Now we have quantified the issues we need to think about how to address them.  The Fatigue Group is working on educational resources and standards for rest facilities and will be helping to facilitate a standardised QI project that anyone can use in their Trust to help improve facilities and culture. The full report of the RCoA survey results is being written up and the Trainee Committee has been working hard at considering solutions and these will be part of the report. Personally, I think we have to foster a supportive culture at work, where we show appreciation for our colleagues, share our concerns and work together to improve our working conditions.  I think our strength lies in being a strong community, pulling together under challenging circumstances.  We need to value each other and one way to help this is to notice the positive things that are done and show gratitude for them. I think people find it hard when they don’t have control over their working patterns and conditions, and I think that is why the junior doctors’ dispute was so challenging.  I know the BMA continues to work to address these issues, with the Code of Practice and exception reporting. I think we have to use these to improve our working patterns. I am encouraged that both the AAGBI and RCoA continue to listen to their members. Everyone needs to play a role though. 

Q) Why were the results of the wellbeing surveys unexpected 

EP: I think the results were probably not altogether unexpected, although the numbers of trainees at high risk of burnout is higher than I have ever seen reported.  That really is a concern. The top 3 factors that affect people’s morale were lack of hospital beds; staff morale and rota gaps and that is probably as predicted.  The hospital beds and the rota gaps feel like issues that we don’t have the power to change, but perhaps we can help with the morale issue (see answer above).

LB: I don't think they were unexpected but the widespread and high levels of potential burnout were a big surprise. The College is currently putting together a full report of the survey findings along with an action plan of what we can do as an organisation to alleviate the problems highlighted as well as challenges to the wider health sector and key decision makers to address the problems. 

Brexit

Q) For Kevin Carson - How can we improve links with Ireland based trainees to mutually benefit trainees both there and in the UK?

KC: I would suggest the following initiatives:

  • Exchanges / forums between GAT and CAT groups
  • Provision of common educational events
  • Development of common modules, e.g. professionalism
  • Recognition of cross border training by both IMC and GMC , e.g. Welcome PhD programme 

Q) What is the RCoA view on giving assurances that EU nationals will retain training positions post Brexit? (Disclosure - German by Nationality)

Q) Regardless of Brexit, are there any data on UK trained Anaesthetists (consultant or more junior) leaving for other countries? 

LB: The College is clear that colleagues from the EU are vital and very welcome members of our specialty here in the UK. As far as training is concerned I would be surprised if there was any suggestion that those EU nationals currently in training would have there training time curtailed. I am leading an Academy of Medical Royal Colleges group focussing on Brexit issues and we can raise this concern via that forum.  As far as leaving the UK is concerned we know that around the time of last year's junior doctors' dispute there was an upsurge in people requesting a certificate of good standing with the GMC which is often a prelude to planning to work overseas. There are no anaesthesia specific figured but anecdotally we know that some trainee and consultant/SAS anaesthetists have and are planning to leave the UK.

Workforce and training

Q) Any update on the consultantcontract and implications for anaesthesia?

PC: There is little information about the progress of negotiations on the consultant contract. The recent general election caused a suspension of negotiations and it would seem that the Government are keen to avoid further confrontation with doctors over contracts. At this time, it would appear that any new agreed contract would not be imposed (unlike the trainee contract) and existing contract holders would be offered an opportunity to convert from the existing contract.

Q) Do the panel feel the new trainee contract will be as detrimental to training as we fear? 

EP: I’m just not sure at the moment.  I’m worried about the newly designed rotas and I’m worried that rota gaps will increase and that is going to be detrimental to training.  There are some positive points though.  I like the principle of an individual work schedule which explicitly states what you can expect to achieve in a placement.  

Q) Dr Carson, new 6 year run-through Specialist Anaesthesia Training Scheme in Ireland is well regarded among trainees in Ireland, but from some older anaesthesia consultants it's 'too short with not enough experience' - is the College happy with end product?

KC: Yes, we are happy with 6-year programme, in fact, it could be considered long by some standards – elsewhere in Europe where 4 years is the norm, but the onus is on us to ensure that the training is a high quality experience.We need to look at our training critically and provide adequate exposure in an appropriate environment and using modern methods of teaching such as simulation and professional medical educationalists.We may need to offer more support to junior consultants being mindful that expectations are now higher, both professionally and from patients and families.

Q) Are there plans to rekindle the Anglo-Irish exam link and reinstate the equivalency of the MCAI and the FRCA final examinations

LB: I am afraid not. The regulation of the examinations as tests of knowledge for award of the UK CCT rests with the GMC and not the RCoA or the CAI. It was the GMC who changed policy and resulting in the change to the long -standing reciprocity in relation to examinations between the two countriesKC: The GMC only recognises the RCoA examinations and UK training for awarding of a UK CCT. However, not all candidates sitting the tests of knowledge are pursuing the award of a UK CCT. The CAI have requested that the RCOA re-explore the recognition of a pass in the Irish Part 1 examination to satisfy the criteria for entry to the UK final examination, as a pass in the RCOA Part 1 exam allows candidates to be admitted to the Irish Final Fellowship. 

Q) Anaesthetists are known as 'trainees' prior to CCT. Other specialities tend not to use this term. Does that change the impression of us that we are in some way not fully competent?
LB:
The College prefers to use the term 'anaesthetists in training' to emphasise that you are fully-qualified doctors but continuing to train as a specialist in anaesthesia.

Q) What do the panel think about the term "trainees" or "junior doctors" - does this come across as derogatory? 

LB: I refer to my answer above. Personally I dislike the term 'junior' and avoid using it. Unfortunately the term junior doctor is used widely, including by the BMA itself so it will need a concerted effort by everyone if we want the terminology to change.EP:  I don’t think we’ve got the terminology quite right at the moment and I suspect it is confusing for patients.  I don’t really like the term “junior doctor” or “trainee” either, as I don’t think it represents the level of experience very well.  I’m also not keen on the term “doctor in training”, which is used sometimes, perhaps more by LETBs.  So what is the answer?  It would be good to know what works in other specialties and what patients and the public find useful.  I always quite liked the term registrar but I recognise that that is no longer used.  I agree that it will need a profession wide approach to change this.

PA(A)s 

Q)What are your feelings on the introduction of anaesthetic physician assistants who are now being appointed?

Q)PA (A) - Friend or foe? 

Q)We need to better understand PA(A)'s, their role and realm of practice to be able to judge their current and potential future involvement  

Q)PA(A) - if they can't prescribe how can they give an anaesthetic???

Q)What is the panel's view on advanced nurse practitioners in critical care, who have limited skill scope, limited hours/oncall, higher pay but at times need supervised by anaesthesia + ICM registrars. Is this fair/respectful of our profession?

Q)Would the development of PAA further make the public less likely to know we are doctors? 

LB: The RCoA believes that non-medical qualified staff could help to mitigate workforce issues but only if these roles are properly regulated. Therefore, we strongly support the introduction of statutory regulation of Physicians’ Assistants (Anaesthesia) (PA(A)s) and Advanced Critical Care Practitioners (ACCPs).

LB: The RCoA currently administers a voluntary register and only recognises those PA(A)s who have qualified, having completed the approved UK training programme, and have subsequently been entered on the voluntary register. We would not support any advancement of the role without statutory regulation in place The RCoA, and the Association of Anaesthetists of Great Britain & Ireland (AAGBI), in collaboration with the Association of Physicians’ Assistants (in Anaesthesia), has drawn up an agreed scope of practice for PA(A)s.  

LB: While there is no voluntary register, the Faculty of Intensive Care Medicine (FICM) provides an Associate membership for ACCPs and believe that around 80% of practicing ACCPs are members of the Faculty.  Like PA(A)s the further development of the role of ACCPs is restricted by a lack of statutory regulation.  

PC: The issue of PA(A)s remains controversial to anaesthetists. Part of this comes from the fact that despite being in place since 2003, there are still relatively few of them and they count for less than 1% of the total anaesthetic workforce in the UK. As a result, few of us have experience of working with them and seeing for ourselves how they can integrate within the anaesthetic team. Many anaesthetists are suspicious because of the situation with independent CRNAs in the US. It is essential that PA(A)s remain a firmly integrated part of the Anaesthetic Team with appropriate scope of practice under the supervision of physician anaesthetists. It is also important to the specialty that the AAGBI and RCoA work closely together over the future introduction of regulation and any advancement of their scope of practice.

KC: There are no anaesthetist PA(A)s in Ireland. At present, PA(A)s only operate in the surgical specialty. There are a small number in practice in RCSI hospitals and private institutes assisting consultant surgeons.  If we were to consider introduction of anaesthetic PA(A)s in Ireland, it would be essential to protect the learning opportunities for trainees. CAI has sought representation on the PA Development Committee of RCSI. Currently, unlike other jurisdictions, staffing / employment levels are not a driver to employ these healthcare providers.

Perioperative medicine

Q) Perioperative medicine. Do we not already do a lot of this? Are we taking over the job of the surgeons/foundation doctors on the ward by taking on perioperative medicine?

LB: Perioperative medicine is not a new concept and aspects of it exist across the NHS. Recognising the central role of anaesthetists in perioperative medicine, in 2014 the College published its vision for its development:  ‘Perioperative medicine: The pathway to better surgical care’.  We believe that our initiatives in perioperative medicine, providing a clearer pathway of care from the moment the patient is considered for surgery until they have fully recovered, could provide improved patient care, shortened hospital admissions, and improved efficiency in the provision of surgical care.

LB: The College currently has 170 perioperative medicine leads based in hospitals across the UK, and two joint-Clinical Leads for Anaesthesia and Perioperative Medicine co-funded by NHS Improvement on the Getting It Right First Time (GIRFT) programme. Included in the Next Steps on the NHS Five Year Forward View document, NHS England has developed a 10-point efficiency plan which identifies the Getting It Right First Time (GIRFT) methodology as means of improving theatre productivity. So yes, anaesthetists have a key role to play in perioperative medicine, and perioperative medicine has a key role to play in the NHS.

Q) What is your take on the new perioperative medicine curriculum? Pros and cons. 

LB: This is something that had the support of a majority of our College membership, with three-quarters of respondents to our survey in favour of the initiative. We now have new units of training in perioperative medicine at core, intermediate, higher and advanced levels, For more information, the College has developed some FAQs covering various topics. These include how the units fit into the training programme, where the best learning opportunities are and who will sign off the units of training. 

Q) Perhaps developing the area of preoperative medicine will raise our profile as doctors? 

LB: We know from our research that the majority of patients and members of the public are already aware that anaesthetists are doctors.

Promoting our specialty
Q) Does the panel agree we need to promote the largest hospital specialty at undergraduate training to inspire the anaesthetists of tomorrow?
LB: You will see a new initiative led by the College in the near future which is a recommended framework for undergraduate education in anaesthesia, critical care, pain management and perioperative medicine.
KC: Generally, there is a lack of recognition by the public at large that anaesthetists are doctors.  We need to use every opportunity to promote the specialty and sub-specialities. We are currently seeking a change in terminology from ‘anaesthesia’ to ‘anaesthesiology’ and ‘anaesthetists’ to’ anaesthesiologists’.  If agreed, this will provide a significant opportunity for relaunch of the specialty and related sub-specialities as well as a major publicity drive.
PC: As anaesthetists, we already come into regular contact with medical students and well placed to teach important topics and skills such as airway management, resuscitation, recognition and management of sick patients and fluid management (to name but a few). We need to make full use of these opportunities to underline the importance of our specialty.
EP: Yes, definitely!  GAT is keen to further develop links with medical schools and foundation schools.  We already offer opportunities to support medical students and foundation doctors who are interested in pursuing a career in anaesthesia, such as poster categories at conference, prizes and bursaries and a getting into anaesthesia workshop at the GAT ASM.  This is something we all need to do together by engaging with medical students at work, during teaching opportunities and at regional careers fairs.  

Q) The Australian College has a national anaesthesia day, which runs across the country. Could we follow?
LB: The College promoted national anaesthesia day last October via a highly successful social media campaign - look out for another initiative this year

Q) A lot of great talks on trauma and pre-hospital medicine services this morning. Should our speciality and the AAGBI take on a leading role in trauma management and pre-hospital medicine, and make it an integral part of our training? 
PC: This is a good point. The AAGBI recognises the importance of both pre-hospital medicine and trauma anaesthesia – hence it featuring in the educational programme of our major conferences such as a session devoted to Trauma management at this year’s Annual Congress in Liverpool in September - Details here. AAGBI also recently published a guideline: Safer pre-hospital Anaesthesia in March 2017.
Miscellaneous
Q) What is the panel view on whistle blowing protection for all clinicians raising concerns?
EP: It is an aspiration for the NHS that we should be able to raise concerns without fear of judgement or blame, just as we should be able to report incidents in the same way.  If we are to achieve this, we need to be mindful of the effect of raising concerns on those around us, and do so in a sensitive and responsible way.  Similarly we need to respond to any concerns raised promptly, sensibly and without judgement.  I have seen sensible flow sheets to determine accountability and a “line in the sand” and I think this also applies in the NHS.  GAT have met and been working with the National Guardian for the NHS, who supports the Freedom to Speak Up Guardians in all Trusts. She will be talking at the Linkman meeting and the GAT ASM 2018.

Q) STP's - Just another money saving exercise (costing huge sums of money to implement) or any prospect of improved care delivery? 
LB:
You might like to read my take on STPs in the March 2017 edition of the College Bulletin.

Q) We have a set of consent points to cover consent on our anaesthetic forms. I have heard that ticking beside them does not count as consent. What's the stand on this with your legal team?
EP: Consent is a process and I think is best thought of a slightly separate from how you document it.  Consent for anaesthesia is usually given verbally and is only adequate if the patient has understood and retained the information about the procedure and the alternatives.  Many places use check boxes to help with documentation of consent and this is a recognised form of documentation. However, documentation only helps to provide evidence that the consent process has occurred - a series of checked boxes does not mean the consent process is adequate.  

Q) Is poor healthcare one of the major drivers for immigration from the developing world and should we be doing more to improve healthcare/anaesthesia internationally?
LB:
We are committed as a College to doing more to working in partnership with health education providers in multiple countries to develop high quality anaesthetic training and standards for local doctors and non-physician anaesthetists. We recently published our Global Partnerships Strategy and you can read more from me about what the College is doing to improve healthcare and anaesthesia internationally in the July 2017 edition of the College Bulletin.
KC: CAI has a long commitment to providing training and projects internationally, e.g. Malawi where we have provided post graduate training for 4 medical anaesthetists who have just completed their training.We have partnered with the Ministry of Health in Malaysia to develop a parallel training programme in anaesthesia to help mitigate the shortfall in postgraduate anaesthesia / ICU training with a view to providing consultant anaesthetists in areas where there is a current shortfall.We are always open to exploring new projects in this area.
PC: The AAGBI is committed to safer surgery and has a long tradition of working to improve the quality and safety of anaesthesia in low resource countries particularly in Sub-Saharan Africa. Following on from the success of the Lifebox for Rio fundraising campaign, we have started new initiative to raise money for SAFE-Africa, an educational project working in partnership with local anaesthesia societies to educate and train anaesthesia providers in low resource countries. You can find out more about Safer Anaesthesia From Education (SAFE) and how you can get involved or fundraise here.