Top 14 (couldn’t fit in 10!) Tweets from #Quality2013

Would be interested in people’s thoughts on this list – please do comment!

Submission to “Shape of Training” Review

The Shape of Training Review is looking at potential reforms in the structure of Medical Education in the UK. As I was not part of any organisation, or acting in a representative capacity, my response is a more personal reflection on the key issues in post graduate medical education in the UK at present (and hence the reason for adding it to my blog!)

My key recommendations were as follows (followed by responses to each of the questions)

1) The training of Doctors is not seen in isolation of the potential large upheavals needed in acute and community care. Any significant changes in training pathways must be future proofed to be able to flexible to changing patient demographics and service requirements.

2) HEE and the (National Commissioning Board/ NHS England) should agree a joint strategy and policy for proportion of care delivered by health care professionals in training.

3) The AoMRC should produce a joint statement on watershed roles between specialties in relation to service delivery and education. This would inform the specialty/generalist debate started by the RCGP.

4) If this review is to alter the CCT (certificate of completion of training) as an endpoint the views of trainees and newly qualified consultants must be heard during oral evidence.

5) A core group of Stakeholders including but not restricted to the FMLM, Academy of Medical Sciences, Academy of Medical Educators and  Health Policy Groups should meet to plan a strategy for expanding the Walport scheme beyond academic training.

1. Over the next 30 years, how do you think the way patients are cared for will change?

 It is unlikely that despite advances in technology (heart surgery, prosthetics, drug delivery etc.) the fundamental nature of health care professional interaction with their patients will alter. There will always be a need for face-to-face contact, communication skills demonstrating empathy, examination skills that elucidate key findings and an ability to make decisions based on clinical, social and ethical factors.  Regardless of the state of finances, political systems or even the construct of the NHS training doctors in good patient interaction, history taking, examination and technical intervention will be no less needed than it is now.   It is likely that more practice will happen via teleconference, closer to patients home or by non-medically trained practitioners. This does not diminish the need for well trained medical staff with core skills in history, examination and management.

2. What will this mean for the kinds of doctors that will be needed in primary care? In secondary care? In other kinds of care?

What is almost certain is that doctors will work in different ways and with different medical devices. Therefore as well as maintaining high standards of care doctors will also need to be able to respond to a rapidly changing technological arena.   The changing demographic of the population will mean a breaking down of divisions between primary and secondary care and re-thinking of this arbitrary divide. The concept of a community specialist or a hospital acute generalist are likely to become increasingly common. It is vital that the Royal Colleges are flexible and engaged with workforce needs to avoid ‘silo’ roles developing and there being inflexibility in career pathways.

3.  What do you think will be the specific role of general practitioners (GPs) in all of this?

The fundamental right to see a health care professional regarding a range of health issues, at a local level, who has a skill set to manage minor illness but be simultaneously cognisant of serious and rare disease is unlikely ever to be allowed to diminish by the general public and profession alike. Regardless of the changes made to delivery of care to patients requiring ‘admission’ GPs will need to retain a breadth of experience and expertise. This will be the only way to ensure quality care is received in the most relevant location for patients.

4. If the balance between general practitioners, generalists and specialists will be different in the future, how should doctors’ training (including GP training) change to meet these needs?  

The foundation curriculum has helped to some extent but we are still not entirely clear on the attributes we would like all doctors to have. We are also tied to a system that means everyone has experience of acute medical care. It is right and proper that this is the case but it has meant hospitals have always had their basic service commitments fulfilled by an excess of doctors at a junior level (but who often only perform very basic tasks or tasks beyond their competence – Collins Report)   If the balance of doctors is to change; the environment in which doctors can learn the requisite skills to move from having knowledge (medical student) to applying practice (foundation doctors) to delivering care (specialty trainees) will need to change as well. This does not just involve curriculum alteration but will require a system wide evaluation of the deployment of foundation doctors in the acute care system.

5. How can the need for clinical academics and researchers best be accommodated within such changes?  

I contributed to this question on behalf of the Academy of Royal Colleges Trainee Doctors Group. Please see their response as well.

It is important to differentiate between the need to train the whole medical workforce in the core principles of research, related ethics and good clinical practice (GCP) and those who will become established academics with a full or partial whole time equivalent research brief. It should not be the case that there is a clear divide between the two but ignoring the needs of either group risks jeopardizing both the strong UK academic standing in medicine and ultimately patient care. Currently there remains an artificial, and sometimes stereotypical, divide between those with a clear research interest and those without. This is not aided by poor awareness of where to seek advice on academia and research. A recent survey of paediatric trainees revealed only a third were able to identify who their local regional academic advisor was and other surveys of specialties suggest similar results.

The creation of the Walport training scheme has transformed the ability of a core group of potential academics to learn and develop research skills. However, as with all pathways, there is the potential to reduce opportunities to those uncertain about careers choices in their early clinical years. Any system of developing a future academic workforce needs to be cogniscent of the fact that research interests develop over time, that certain specialties have optimal and suboptimal periods of undertaking substantial research endeavors and that for many pursuing a long term academic career is not viable or desired.

In developing a new training structure the following should be considered:

i. It should be the responsibility of LETBs (in England), Deaneries (elsewhere in the UK) and Colleges, in collaboration, to establish fail safe mechanisms for trainees to access individuals and resources to advise on research and academic careers.

ii. Mechanisms for advancing and assisting those with potential and a clear interest must exist at all levels of training e.g. Medical School MB-PhDs, Foundation Year Academic Programmes and Academic Clinical Fellow/Lecturer posts.

iii. It should always be possible, but not necessarily an individual guarantee, to be able to undertake research activity within a training programme even if an accredited research pathway is not being undertaken.

iv. The concept of OOPE should be expanded to be able to undertake small research projects, as well as QI initiatives and education fellowships. These should be considered distinct from OOPR which should be reserved for those on research degree programmes. LETBs should ensure that work force planning and service needs allow for a number of OOPEs to be always available across specialties for those with an interest in research, but without funding, to undertake activity which may lead to a higher degree but also allows for return to clinical work without prejudice.

6. How would a more flexible approach to postgraduate training look in relation to: 6a.  Doctors in training as employees?

Doctors have traditionally been employed by their trust. Employing doctors at a regional (or even national level) would enable great flexibility in rotations and remove issues with multiple CRB checks and some parts of induction.

6b. The service and workforce planning?

 The fundamental problem with developing a flexible and dynamic training programme is that it is designed around service needs rather than vice-versa. It is clearly not simple to suggest that trainees are placed into training posts once the service needs have been met. But it would be possible over the next decade to start thinking about the need to make this change. It will not be possible to allow a flexible training programme if for example only one OOPE is available at any given time.  A debate on “extra-curricular” training i.e. skills in education, research, leadership and policy development must be had. One to determine why it is current training is felt to be inadequate to develop these skills (as evidenced by the high number of requests to undertake such activity) and secondly to understand how important they are in sustaining a high quality medical workforce in the future.

6c. The outcome of training; the kinds and functions of doctors?

 Is this question asking whether it is possible to have an endpoint of training that doesn’t produce an independent practitioner (whether GP or Consultant)?  Decisions made by junior doctors to apply to specialty or VTS training is made on the basis of reaching the consultant or GP end-point. Ensuring flexibility in training must always bear this in mind, and while some trainees, wish to undertake SASG roles there is no convincing evidence that this is their primary intention (further research is clearly needed in this area). The public also have a clear understanding of what a consultant or GP is. Therefore a flexible approach to training would still need to maintain a clear standard to achieve at its completion. The definition of a independent, unsupervised practitioner is a standard that is clear to all who aspire to do it and regulate its attainment.

6d. The current postgraduate medical education and training structure itself (including clinical academic structures)?

6d and 6b are integrally linked. There already exists a huge flexibility in the system from anaesthetics trainees being supernumerary in the first few months, to the cohort of medical director clinical fellows and also the integration of academia as evidenced by the Walport scheme. The ACCS programme has demonstrated, as will hopefully the broad based training pathway, how rigidity can be taken out of current training programmes to the benefit of trainees.   Perhaps no new flexibility is needed just an increased opportunity for trainees to partake in the experiences on offer. This is entirely dependant on service need and its potential reconfiguration.

7. How should the way doctors train and work change in order to meet their patients’ needs over the next 30 years?  

There have been few fundamental reforms of medical education since the Flexner report at the beginning of the last century. Of course nominology has altered, the training time frame has been adjusted and curriculums have been completely revised. But the core nature of medical training has stuck to some fundamental principles: At medical school a framework of basic science and key skill sets in each of the specialties learned. In the early years doctors clerk new patients and perform routine day to day care.  As they progress skills widen with experiences in clinics and theatres while greater responsibility is placed on leading juniors and making decisions.   Both the Temple and Collins reports highlighted current issues with this approach.

1) The need to provide a constant 24/7 general acute service was reducing learning opportunities once the core skills sets of dealing with acutely unwell patients had been learnt.

2) Supervision from supervisors was inadequate.

Neither report mentioned another issue with current education policy: “one size does not fit all in medical education”. Although generic skills are vital it cannot be the case that the training of a surgeon should match that of a psychiatrist. The current debate on working hours has always been flawed in its approach that everyone needs 56+ hours or that all patients are potentially unsafe unless we are rigid with 48 hours.   A surgeon may get rest at night and have their learning enhanced by operating on the patient they saw the night before whereas it would be catastrophic for a neonatal SpR who will have had little rest on a night shift in a tertiary NICU to have to continue onto an out patient clinic.   It should not be for this review to determine the individual needs of each specialty and I don’t think it intends to. However recommendations on training pathways must be flexible to individual specialty needs and in keeping with current workforce policy and regulations.

8. Are there ways that we can clarify for patients the different roles and responsibilities of doctors at different points in their training and career and does this matter? 

This does matter but requires national co-ordinated action. If each LETB/Trust etc. choose a different method it would cause confusion.

9. How should the rise of multi professional teams to provide care affect the way doctors are trained?

Currently there is little work done on assessing health care professional interaction and learning in a post graduate medical education context. Simply encouraging engagement will have little training benefit unless some core competencies can be defined. The rise of MPT in more integrated services will mean this area must be explored.

10. Are the doctors coming out of training now able to step into consultant level jobs as we currently understand them? 

Yes they are – there is little evidence of serious harm although it is clear the support given by colleagues is much improved from a decade ago.   The problem for this review of post graduate medical education is that it depends on the concept of a consultant/GP remaining static otherwise the end product will not meet the current health system requirements.

11. Is the current length and end point of training right?

Interesting question as the length of training is substantially different between specialties. Despite not feeling confident many trainees do feel competent to be consultants (anecdote I’m afraid!) although this maybe biased because they have deliberately extended their training. Qualitative and Quantitative research in the patient and personal outcomes of specialty trainees who have completed training entirely according to the pathway i.e. ST1-6 with no breaks and are no consultants is needed.

12. If training is made more general, how should the meaning of the CCT change and what are the implications for doctors subsequent CPD? 

This is an interesting question as it implies training may be made more general. What if the question were if training became more specialist?   As stated previously a CCT should remain as the benchmark to reach when you can be an independent practitioner. If less specialty accreditation was on offer the meaning of the CCT should remain unchanged. It would be possible post CCT to pursue education in more specialist areas but this would not devalue the important or relevance of CCT.

13. How do we make sure doctors in training get the right breadth and quality of learning experiences and time to reflect on these experiences?

HEE and the Commissioning Board must meet and re-appraise the core duties of junior doctors in providing acute care. Although it is not necessary in all specialties and environments it is quite clear that Emergency Medicine is suffering from trainees having little time to do anything other than constantly see patients. Although this is clearly a fundamental part of their training, only reflection and mentoring can avoid poor habits becoming ingrained and learning from mistakes turned into a positive experience.

14. What needs to be done to improve the transitions as doctors move between the different stages of their training and then into independent practice? 

The introduction of accreditation of educational supervisors will be instrumental in improving mentoring of doctors and providing better and more comprehensive cover of their transitions. It is vital that the GMC are robust in their processes to ensure that standards remain high.

15. Have we currently got the right balance between trainees delivering service and having opportunities to learn through experience?  

 No (The Temple and other reports demonstrate this)   Confusion has been created by the belief that trainees either deliver service or they don”t. In order to learn doctors must see patients in a supervised manner. However currently some patients are dependant on trainees for the care they receive i.e the medical assessment unit staffed overnight by an ST4 and two ST2s. It is entirely reasonable for learning experiences to take place in this setting. Unfortunately pressures on acute services will mean those doctors will see patients in a way that ensure throughput rather than learning opportunity. The same unit with additional SASGs, nurse practioners and consultants takes the pressure off, especially junior staff, meeting trust targets as well as meet the needs of their curriculum.  As stated previously changes in population demographics mean the Health Service must examine who is providing patient care and what is a sustainable way of delivering education. The two are intertwined but should not be dependant.

16. Are there other ways trainees can work and train within the service? Should the service be dependent on delivery by trainees at all?

See question above. Service entirely independent of trainees would be a tough financial and workforce ask. The review of Emergency Medicine by the Department of Health is a good example of work that could be performed in all specialties to review the delivery of acute (and community) care.

17. What is good in the current system and should not be lost in any changes? 

Clear steps from Novice (Foundation) to Expert (Consultant)  A defined end point  The ability to undertake OOPE and OOPT.

18. Are there other changes needed to the organisation of medical education and training to make sure it remains fit for purpose in 30 years time that we have not touched on so far in this written call for evidence?

The Walport system has transformed academic training. Although there are still some bugs to be ironed out the inception of protected out of clinical time is clearly beneficial. This principle should and could be applied to Medical Education, Leadership and Management and Health Policy.  Leadership and Management, especially in the light of Francis, have been neglected for decades in the training of junior doctors. It is vital if we are too develop a generation of consultants and GPS who can transform services and deliver high quality care that this is remedied. The FMLM response to shape of training has clear recommendations in this regard.

Simultaneous Safety: Purposeful Physiological Detection

The Million Pound Challenge was a new event at the International Forum of Quality and Safety in Healthcare #Quality2013. Judges included Donald M. Berwick, Fiona Moss, Helen Bevan, ‘e-patient’ Dave deBronkart and JoInge Myhre.

The challenge: Junior health care staff to pitch an idea for what they would do with One Million Pounds to transform healthcare. Four finalists were shortlisted for presentation. The video of my presentation is here:

I was very humbled to be not only shortlisted but win the award with my idea for a multi-purpose saturation probe. In  summary the technology exists to not only calculate oxygen saturations and heart rate, but also temperature and respiratory rate from the same device. These four measurements together, adjusted by an internal microcomputer for a designated age range, could be used to simply display a green, amber or red light to given an impression of the patients health. This would NOT replace clinicians judgement but would support health care professionals and potentially those without significant medical training to make decisions on patient care. The probe would be powered by a small solar panel enabling its use in the developed and the developing world.

My presentation is attached. I am not a big fan of bullet points but the general sense is there.

A picture of my mock of what the device would look like is below (click on it to expand):

Annotated Picture of Monitor

So what turned out to be a ‘back of packet’ scribbling seems to have caught peoples attention. Could this really be taken forward?

To do this I need the help of the world-wide health community.

Do you work in medical technology industry?

Do you have a friend who is expert in solar panels?

Can you program algorithms into motherboards?

Would you like to just simply help!

Please get in touch by commenting on this blog. This is a real opportunity to change the world. Don’t just believe me. Donald Berwick said so….

I’m in the business of medicine, but do I really want medicine to be a business?

Today is the beginning of a new era in the NHS. For supporters of the Health and Social Care Act it represents the implementation of a necessary shift to cope with rising demand and cost:

“[6] The main aims of the Act are to change how NHS care is commissioned through the greater involvement of clinicians and a new NHS Commissioning Board; to improve accountability and patient voice; to give NHS providers new freedoms to improve quality of care; and to establish a provider regulator to promote economic, efficient and effective provision.” [explanatory notes for Health and Social Care Act]

For its detractors, it is popularly described as the end of the NHS and an entire political party has arisen as a result. The debate has often been extremely heated but generally confined to those already in touch with medical “politics”. Anecdotally  (I have no supporting evidence for this) wondering around the corridors of a random english hospital may not find you many staff with a clear knowledge of the details of what has happened on 1st April 2013.  It is this lack of knowledge that may explain, despite some of the vitriol, why contributions by members voting on the Royal Colleges support for and against the bill last year were not that impressive.

College Total Voting Members Number of Respondents Votes against the Bill Response Rate
RCPL [1] 25,417 8,878 6,092 (69%) 35%
RCPCH [2] 10,289 1,492 1,184 (79.36%) 14.5%
RCGP [3] 33,837 in England nearly 2,600 completed responses 90% support withdrawal of Bill 7.7%

Independents have attempted to explain the detail (this summary from is good). There is also a visual timeline of events via the Kings Fund.

A great many commentators have put their hats into the ring about what will happen in the future. I am neither experienced or wise enough to do this. As a trainee, albeit a relatively senior one, I have been disappointed about the level of information given to the future workforce about the changes. It is is a complex area, the Health Act is a huge piece of legislation with arguments of recent terminology on the section 75 amendment making the area even more confusing.

What is without doubt is new ability to widen opportunity for any “provider” to deliver services for patients. I don’t think I am naive about healthcare as a business. The NHS has always run to accounts, tendered and has paid private companies to deliver operations it was falling behind on. But I am old enough to remember a day when there was one National Rail Service. I don’t know if it was true that ‘nationalisation’ was not providing effecient, cost effective services but rail is now clearly a competitive business, even though the trains are often not competing for the same track. However, as a regular train traveller, I know my experiences between the companies are often very different, that even if they do run on time it is at a cost or comfort detriment and I certainly don’t know who best embodies the rail service.

I ask myself is this really how I want to see the NHS?


1. Results of RCP Health and Social Care Bill Survey. (last accessed 1st April 2013)

2. RCPCH votes for Government to withdraw the Health and Social Care Bill. (last accessed 1st April 2013)

3. RCGP members support withdrawal of the Bill, says RCGP survey. (last accessed 1st April 2013)

A number counter that works within Powerpoint

This great little customisable presentation was put together by Craig Sayers in response to a request I had put out via twitter

(it did help he also happened to be my best man)

The presentation is need for something I am doing to feedback on NHS Change Day  but I suspect a counter mechanism may be useful for other presenters. Just to note it won’t work in Powerpoint for Mac 2008 (I’m trying to find out if it works in 2011!)

If you want to change any of the settings you need to go into Visual Basic from within Powerpoint.  Do this either by pressing F11 or double clicking on the Start Counter button on Slide 1 when editing it (not from within the slideshow).  You should then see a text editor-type box with the code in it.  I’ve added little comments (in green) to show which numbers need changing to do different things.  Just alter a number then close the Visual Basic window.  Next time you start the slideshow it should make the alterations.”

A huge thanks to Craig Sayers for putting this together (and providing the editing instructions)

Please send any feedback to @damian_roland or @tonythepianoguy

The presentation can be found here: Powerpoint Counter

Consent Cam: Want? Need?….Can?

It all started with the following tweet:

and in no time at all the enthusiasm for all things #FOAMed found ourselves with a number of volunteers, a catchy 4’D’ mnemonic courtesy of Mike Cadogan and a working title “ConsentCam”

  • Dissemination: the power of global conversation through #FOAMed
  • Discussion: it marks the starting point for a conversation which can continue on twitter and through blogs, then onto #SMAC2013 so that a global perspective can be obtained
  • Development: the seedling inclination to pursue a random thought can be magnified with altruistic assistance
  • Deployment: this may well result in a collaboration which leads to the production of an essential element for medical education provision

An neat summary can be found here – please do contribute to the ongoing discussion and upload your consent forms to the dropbox!

Just wanted to answer a few questions which have sprung up during the process which I thought might be useful to clarify.

Do we want this?

The proof of the pudding for me is the fact that as soon as you mention consent, apps and patients on social media you are guaranteed to get a reply. Not always constructive I may add but the debate is there. Health care professionals want to be able to share key learning points with others and audio-visual media represents a great way of doing this. If you can find me a clinician who wouldn’t want a quick way of taking a picture and obtaining patient consent with regulatory approval then I will pledge to dance the funky chicken on a live you-tube feed on #nhschangeday

Do we need this?

Using audio-visual media to enhance medical education has been happening since even before we had VHS (thats a long time for those who have never actually seen a video cassette). Discussion fora, blogs and publications abound on the use of photos to highlight key clinical signs (although probably need to be clear that the evidence of clear benefit of video does still need demonstrating!). Is it an absolute necessity that a simpler way of simultaneously consenting and taking pictures is found – probably not. Would it transform resources such as very much so.

Can we do this?

The appetite for #FOAMed extends to peoples own time and resources. The increasing use of hack days to create bespoke health care devices and an appetite for app development at a government level means the market is awash with individuals willing to give for free their skills to make ConsentCam a possibility

Are we allowed to do this?

This is probably the only significant issue so far. As long as patient confidentiality is not breached or impinged and the data is secure it should be possible to gain approval. There will be initial caution, and potentially some critics, but the very production of guidance on audiovisual records and social media by regulators such as the GMC means engagement is more likely to happen now than ever before.

So -please do comment on the life in the fastline blog and lets make the first #FOAMed inspired, designed, produced and utilised app a reality

Was Clare Balding right? (and was it relevant I was slightly wrong)

One of the great things about blogging is the permanency of your thoughts. Ideas and thoughts developed on a train journey are often lost forever but if you can encapsulate them in writing they are always available for ongoing reflection. Comments on your work are a functional way for this reflection to be forced upon you but I’d be interested to know how many other bloggers review their material, amend, maybe even comment their now changed views?

With this in mind a while back I posted on the Network site (@thenetwork001) a brief piece on an event that occurred during the Olympics “Was Clare Balding right? Adequacy versus Aspiration”. For those outside the UK Clare is a well respected BBC journalist and presenter. It’s short enough to share below:

During the Olympics Clare Balding apologised to the nation, “I am sorry we can only offer you a bronze.” her words after Rebecca Adlington’s performance. There was an instant twitter and email response with a prompt, and sincere, apology. In a different event, but with a similar theme, a number of commentators during the games made reference to counterfactual thinking on how actually getting a bronze maybe better than a silver.

The post-Darzi drive for Quality remains a powerful influence in commissioning, service delivery and outcome metrics. Appreciating quality has rarely been defined in terms of Gold, Silver, Bronze and ‘placed’ an exploration of delivery of healthcare find being ‘placed’ a common place event. Take, for example, Medical Education; those despairing at the acquisition of a host of work-place based assessments find the target to achieve a fixed number at a minimum standard. Achieving a gold standard performance is not really an option. How about a service delivery standard? The four hour wait is one part of the Emergency Medicine clinical quality indicators along with unplanned re-attendance and left without being seen amongst others. Trusts stagger towards achieving each of the minimum required standards but it would be more than possible to cluster performance across indicators to enable ‘medals’ to be awarded for going the extra mile. 

How do you rate your own performance? – are you happy that the patient was treated efficiently or effectively? Perhaps just treated? Do you check that your contribution to their care was as evidence based as possible? Do you hope that a percentage of patients thank you specifically for your role in their care. 

Ultimately, as unsustainable as it may feel, are you happy with your bronze performance…

Reading back now, not sure I would change much, but I did get an e-mail from my educational supervisor (a line manager in a medical training sense) saying it was important I got my facts right. My immediate reaction was concern that I had mis-quoted Clare Balding! However, this was not the case – I had used the term “wait” instead of ‘target”. This may not appear to be a significant error to the casual reader but it is an important principle. The NHS four hour target is well known throughout the world. It is not a ‘wait’ though, the “target” is that the patient spends no more than 4 hours in the department from the moment they register (which includes the consultation, investigations and decision to either discharge or move to a ward). For some in the Emergency Department world the distinction is really important both for public perception and the fact the target is dependant on a number of factors outside of the control of the Emergency Department.

Ultimately this is a really minor point. However lets say I had said something very  incorrect – does this really matter? I have never had a comment on a blog from a member of my own institution, and one involved in my training. What questions does this raise about blogging (and wider social media) as a means of assessment or professionalism. Obviously stripping naked on a night out isn’t an ideal thing for a line manager to see, but what degree of error is needed in a quasi-professional social media to attract the attention of an educational supervisor? As Social Media closes the boundaries between work and home-life these questions are likely to continue to be asked.

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