Call for Abstracts: The West Midlands Research Collaborative presents the inaugural: National Research Collaborative Meeting

Incorporating ROSSINI Trial launch Friday 4th December 2009 Hyatt Regency Birmingham ( Click here for more details)

“There is an absolute commitment to support the NHS in achieving compliance with the EWTD by 1 August 2009.” “Trust Boards will want to understand the risks and that action is in place to remedy any potential breaches. The NHS Employers’ website provides more information about the substantial financial and penal consequences if remedial steps are not taken.” These are the words of David Nicholson, the Chief Executive of the NHS, in a letter sent on July 9^th to all NHS Trust Boards and Chief Executives. In other words, a 48 hour week on 1^st August, or else. I quote this letter to demonstrate the pressure being applied to NHS managers and staff to comply with the directive.

The profession will face major challenges over the coming months and all surgeons will have to show exceptional professional judgement and integrity. I am sending this letter now to update you with what is going on, and to advise you on some basic principles for dealing with what is about to happen.

As you know the College and the vast majority of surgeons believe that a 48 hour week for surgeons in the NHS is a major threat to safe patient care which will result in very thin medical cover with multiple handovers, and will devastate standards of training. In addition, the College knows from its surveys that it is not deliverable because the doctors to staff paper compliant rotas do not exist. My estimation is that fewer than half of all rotas will be truly compliant on August 1^st. We have made this point repeatedly over the last six months to the Department of Health, to Ministers, to MPs and to the general public through the national media. We have also, working with the trainee organisations, offered a solution, the surgical opt-out to a maximum of 65 hours, which would solve the problem permanently, allowing a safe service, good training and an optimum life style for trainee surgeons. It is a matter of regret and frustration that government has not listened.

So what is likely to happen on August 1^st? As the deadline approaches, we are already seeing Trust managers trying to paper over the cracks as their inability to recruit extra doctors becomes apparent. Junior surgeons are finding their training sessional time being transferred to providing out of hours service cover and are being told that they must not enter their hospital for more than their official 48 hours. However, patient safety always comes first and surgeons will never abandon a sick patient to comply with a European regulation. When unscheduled extra time is worked in such circumstances the usual tactic is to pay the hours back later from elective sessions, which means even fewer training opportunities. Some of the pressure being applied, to make sure that diary cards do not show average hours worked as more than the magic 48, has moved from persuasion to bullying. Yet the government have been very assiduous in retaining the right of an individual to opt out, and work in excess of 48 hours, while still subject to the rest break rules. They realise that internal locum working is the only way that many services will survive.

I must emphasise that the individual opt-out is and must be voluntary. Individuals cannot be asked to opt out, they must volunteer. If trainees are asked to do an internal locum to fill a gap on a rota and have not opted out the extra hours will be counted as part of their 48-hour week and will be taken from their time for elective duties. Those individuals who do decide to opt out must ensure that they have a revised contract to reflect this. They should also clarify whether the extra work is for service or training, and make sure the employer provides full indemnity. This should be in writing.

Consultants are also bound by the EWTD and need to request an opt out if after 1^st August they wish to work in excess of 48 hours a week. They too should ask for a new contract to reflect the agreed opt out, should clarify their position with regard to rest breaks (which is complex), and make sure they have full indemnity. I believe that very few consultants have opted-out, the majority believing unrealistically that the EWTD does not apply to them or that they can ignore it. Consultants should also be aware that if to achieve a 48 hour week a trainee is made to cover extra service duties at the expense of training, the trainee’s educational contract may well be broken, which could lead to withdrawal of trainees from the unit. I can only ask that consultants do all they can to preserve some sort of training in these difficult circumstances. I suspect that fulfilling elective waiting time targets will be at the bottom of the list of priorities.

The most important thing the College asks of you is that you maintain honest accurate records of what is going on. If a junior doctor works longer than the rota hours to look after a patient, write this down and do not be bullied into pretending that it did not happen. We will be providing yet more evidence to those who are not listening that the 48-hour week is undeliverable. If in your opinion inadequate cover or a rushed handover have harmed a patient, fill in an incident form. It is your duty as a doctor.

I find it difficult to believe that the Department of Health still apparently believes that 48-hour working can be delivered in 10 days time. These are very difficult times, but I remain confident that a long-term solution meeting the aims of surgeons will be achieved. Meanwhile, put patient safety first and speak and record the truth about what is happening in your hospital. The College will be circulating a questionnaire and I ask you to reply to it in full. Trainees will be receiving a complementary letter from ASiT or BOTA also asking for information. Please reply, as the more evidence we have the better.

John Black

20^th July 2009

At present there are 126 trainees on the West Midlands General Surgery training scheme and this has previously been run as a region wide scheme with trainees undertaking posts in sequential years in Coventry, Hereford and Stoke.  This places a significant burden on the trainees.  The scheme has in the past had a single programme Director and the burden of supporting such a large number of trainees as we move to ISCP is unsustainable.  To try and create a more structured and personal training scheme, the region is to be divided into 3 areas.  The hope is that most trainees will spend the first 4 years of their clinical training in a single area attached to an Intermediate Years Programme Director.  During this period they will then confirm their career intentions having been allocated a programme which will provide 2 years in the field they hope to specialise in, while having been exposed to all the aspects of General Surgery.  The fourth year will see liaison with The Later Years Programme Director in delivering a specialist programme to meet the career aspirations of the trainees. 

The 3 areas are Warwickshire and Worcestershire; Birmingham and the Black Country; and Staffordshire and Shropshire.  The Warwickshire and Worcestershire area covers Coventry, Nuneaton, Warwick, Redditch, Worcester, Heartlands and Good Hope Hospitals.  Staffordshire and Shropshire covers Stoke, Stafford, Shrewsbury, Telford, Burton and Wolverhampton hospitals.  The Birmingham and Black Country covers City, Sandwell, Queen Elizabeth, Selly Oak, Russell’s Hall, Walsall and Hereford hospitals.  This gives a roughly equal split of posts.  It is likely that the split will require revision as experience with the programmes develops.

The 4 Programme Directors have now been appointed.  Mr Peter Blacklay will be taking up the role of Programme Director for the Warwickshire and Worcestershire area.  Mr Funso Adedeji is the Intermediate Years Programme Director for the Stoke and Stafford area, while Mr Rajiv Vohra is the Intermediate Years Programme Director for the Birmingham and Black Country area.  Mr Alan Jewkes will take up the post of the Later Years Programme Director once Mr Blacklay has received hand over.

The first task, which the Intermediate Years Programme Directors have started, is to meet all the trainees.  From this a plan of how the trainees will be best allocated across the 3 areas will be developed for those in the Intermediate years.  At the same time a review of the training posts will be developed to identify those which will form the core of the Later Years programme which will then enable the Intermediate Years programmes to be identified. 

These 2 tasks are critical to the delivery of the third, which is designating the placements for the rotation in October.  This will be a separate process from the RITA/ARCP process as the regular meetings between the Programme Directors and their trainees will have allowed the areas of special need to be identified.  The RITA/ARCP process will now occur in September when the trainees have completed their posts and both they and their trainers can provide a complete assessment of their year in training.

We will see significant changes over the next few years as working time limits are implemented and patient demands grow.  With the likely creation of a separate SAC in Vascular surgery, the subsequent re-organisation of training in that discipline will have an impact on all trainees.  In addition, the need to ensure robust training in the area of specialist interest and sufficient exposure to be competent in the care of the acute surgical patient will be a significant challenge.

In addition to the changes in the supervision of training and a revision to the system of placements, there is a need to put in place a formal teaching programme that will deliver 6 teaching days annually with each area contributing 2 to the scheme.  To this end we are seeking to identify 3 Educational Leads to develop a programme that will run over 4 years to cover all aspects of the curriculum and prepare trainees for the intercollegiate FRCS examination.  This will require the support and involvement of both the trainees and the trainers.  It is envisaged that this will become mandatory, although it will take time for Trusts to put in place mechanisms that ensure that a safe service can be maintained in the absence of the trainees.  The Later Years trainees will have specialty specific training needs.  Work will be required to establish what is and what should be delivered in the Deanery and what can only be accessed elsewhere.  This will form a framework for establishing teaching programmes appropriate to the sub-specialties in conjunction with the Specialty Association representatives.  In addition, the Educational Leads will have a role in delivering training for the trainers in the ISCP assessment methodology, something which all areas of surgical training will increasingly use to deliver assessments through.

To support the trainee locally there will be Area Educational Committees which will include the area Programme Director, the Educational Lead, a representative from each hospital in the area and a trainee representative.  These Committees will be responsible for implementing local delivery of training and working with Trusts to ensure training needs are addressed.  These Committees would then have representation on the Specialist Training Committee which will oversee the whole programme, including the Later Years trainees who will work across all the areas as required to refine their training.

The first steps have been made in implementing this agenda but there remains much to be done.  The aim is to start the teaching programme for the Intermediate Years trainees at the beginning of the next rotation.  The support of the trainers and trainees is key to creating a training scheme that can meet the challenges that the next few years hold.