Recruit, retain and resolve · Recruit, retain and resolve ... Perioperative Journal Watch 29...

Recruit, retain and resolve

www.rcoa.ac.uk @RCoANews

SEPTEMBER 2017

SafeguardingPlus: a new source of information for anaesthetists

PREPARE for surgery: a paradigm shift

How your College is addressing workforce challenges

EVENTS CALENDARFurther information about all of our events can be found on our website.

www.rcoa.ac.uk/[email protected]

OCTOBERAirway Workshop12 October 2017G&V Royal Mile Hotel, Edinburgh£240 (£180 for trainees)*

Less Than Full-Time Matters (Joint RCoA/AAGBI event)12 October 2017RCoA, London£75 (£60 for trainees)*

Anaesthetists as Educators: Simulation Unplugged13 October 2017RCoA, London£220 (£165 for trainees)*

A Career in Anaesthesia: Foundation Year Students16 October 2017Park Plaza Leeds£45

Global Anaesthesia: A Platform for Development16 October 2017RCoA, London£80

UK Training in Emergency Airway Management (TEAM)19–20 October 2017RCoA, London£450

#GasHack21–22 October 2017RCoA, LondonFree of charge

NOVEMBERUK Perioperative Medicine Clinical Trials Network Autumn Meeting2 November 2017 Crowne Plaza, Manchester City Centre£45

UK Training in Emergency Airway Management (TEAM)9–10 November 2017Edinburgh Royal Infirmary£450

Anaesthetists as Educators: Educational Supervision13 November 2017Park Inn, York City Centre£220 (£165 for trainees)*

RCoA Winter Symposium: Excellence16–17 November 2017RCoA, LondonAll days: £395 (£270 for trainees)* 1 day: £260 (£195 for trainees)*

CPD Study Day17 November 2017Royal Hotel, Hull£200 (£150 for trainees)*

Leadership and Management: Working Well in Teams and Making an Impact22 November 2017RCoA, London£220

SALG Patient Safety Conference22 November 2017Manchester Conference Centre£215

Anaesthetists as Educators: Anaesthetists’ Non-Technical Skills (ANTS)24 November 2017RCoA, London£220 (£165 for trainees)*

Joint RCoA/AAGBI Clinical Directors Meeting28 November 2017RCoA, LondonBy invitation only

CPD Study Day: Evidence Base in Anaesthetic Practice30 November 2017RCoA, London£200 (£150 for trainees)*

DECEMBERFaculty of Pain Medicine 10th Annual Meeting: Core Topics in Pain Medicine1 December 2017RCoA, London£200 (£140 for trainees and nurses)

A Career in Anaesthesia: 16-18 Year Olds8 December 2017ManchesterFree of charge

Updates in Anaesthesia, Critical Care and Pain Management11–13 December 2017Royal Welsh College of Music andDrama, CardiffAll days: £490 (£370 for trainees)* 1 day: £195 (£150 for trainees)*

*Delegates must be RCoA registered trainees to be eligible for the discounted rate.

Book your place at: www.rcoa.ac.uk/events

For more information and to book visit www.rcoa.ac.uk/events

16–17 NOVEMBER 2017

RCoA, London All days: £395 (£270 for trainees)* 1 day: £260 (£195 for trainees)*

This November, the RCoA Winter Symposium will bring together over 20 world-class speakers for two days of thought provoking and engaging topics across anaesthesia, perioperative medicine, critical care and pain medicine.

With the theme of Excellence, the programme will focus on how to improve patient outcomes, discussing controversial topics such as the ‘weekend effect’ and fasting times. With 10 CPD points available, the Winter Symposium will provide you with food for thought for your own personal development, offering the chance to learn and interact with the experts whilst networking with delegates from all areas of the profession.

This year’s event will offer valuable insights into the cutting edge of the specialty through succinct, punchy presentations. There will also be the opportunity to have discussions with speakers and delegates at dedicated Q&A sessions.

Last year’s event sold out, and with limited availability, you should book soon to avoid disappointment.

RCoA WINTER SYMPOSIUM:Excellence

#RCoAWinter

CPD credits 10

Joint RCoA/Tri-Services Anaesthetic Society Annual Scientific Meeting12 December 2017RCoA, London£200 (£150 for trainees)*

Regional Anaesthesia Workshop (Joint RCoA/LSORA)13 December 2017RCoA, London£240 (£180 for trainees)*

Regional Anaesthesia Symposium (Joint RCoA/LSORA) 14 December 2017 RCoA, London£200 (£150 for trainees)* Book both the workshop and symposium and save £100 (£70 for trainees)

JANUARYPrimary FRCA Masterclass 9–12 January 2018RCoA, LondonAll days: £305 1 day: £80

Final FRCA Revision Course15–19 January 2018RCoA, LondonAll days: £395 1 day: £95

Book your place at: www.rcoa.ac.uk/events | 1


ANAESTHESIA 2018International Meeting of the Royal College of Anaesthetists22–23 May 2018 British Museum, London

Early bird rates available now! First 50 places save 15%www.rcoa.ac.uk/anaesthesia

Bulletin | Issue 105 | September 2017

Contents

Recruit, retain and resolveHow your College is addressing workforce challenges

SafeguardingPlusA new source of information for anaesthetistsPage 26

PREPARE for surgery: a paradigm shiftThe impact of a new pathway on patient empowermentPage 30

The 2016 contract and exception reportingA view from the frontline on the implementation of junior doctor contractsPage 32

Shared decision making in practicePart one of a new series on improving patient consultationsPage 34

Research in perioperative medicine: anaesthetists and surgeons working togetherInter-specialty collaboration is leading to higher quality perioperative researchPage 14

The President’s View 4

Elections to Council 8

Dr Jean-Pierre van Besouw 9

News in brief 10

Guest Editorial 14

Confessions of an ACSA virgin 16

Planning for a new CPD Online Diary 17

Faculty of Pain Medicine 18

Faculty of Intensive Care Medicine 19

SAS development 20

Technology Strategy Programme 22

Quarterly research reporting to drive quality improvement 23

The College governance review 24

Perioperative Journal Watch 29

Strengthening the College’s AAC role 36

‘Crossing the Rubicon:’ musings of a jobbing anaesthetist on the RCoA Council 38

Stealth anaesthesia 40

RCoA 25th Anniversary essay prizes 42

A decade of change 48

Senior Fellows Club 49

ARIES Talk: Fatigue 50

College Tutors Meeting 2017 Poster competition winners 52

John Walmsley Warrick 55

As we were... 56

Letters to the Editor 58

Report of meetings of Council 59

Notices and adverts 63

College events 69


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Welcome to the September Bulletin.

This month’s Bulletin is dedicated to the memory of our immediate past President, J-P van Besouw (see page 9) who sadly passed away in July.

In writing this editor’s introduction every two months, I get to read about the successes of all the high-profile College projects reported in the Bulletin which have directly benefitted from J-P’s expertise and professionalism. This issue is no different. These include our Anaesthesia Clinical Services Accreditation (page 16) scheme which started at the end of his first year as president in July 2013, our perioperative medicine programme (pages 14 and 15, 29 and 34 and 35) which he launched in 2014, our National Emergency Laparotomy Audit (page 23) which began under his presidency, and our examinations activities for which he was an FRCA examiner for 13 years and Chair of the examinations committee for three years. J-P’s work is all around us and continues to strengthen as each year passes.

He was an inspirational leader, visionary, mentor and friend. He always made us laugh, he always made us think, such a talent.

From the editorProfessor Monty Mythen

“Giving it large on my last day as President”

Dr J-P van Besouw RCoA Council, 18 September 2015

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The President’s View

RECRUIT, RETAIN AND RESOLVEHow your College is addressing workforce challenges

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Dr Liam Brennan, President

In public health the ‘causes of the causes’ is an area of discussion which drives considerable debate. There may be a clear causal understanding of how a habit, such as smoking, leads to poorer health outcomes, but what are the social and economic factors which drive variation in outcomes between people with the same habit? As recruitment continues to challenge our specialty, maybe it is time to borrow from public health to better understand and address the growing workforce issues we face.At the time of writing we have just received the latest anaesthetic trainee fill rates for August 2017.

The data shows a slight reduction in CT1 and ST3 fill rates of around 1% and 3% respectively. But in my view the data prompts more questions than the UK-wide figures answer.

Why are CT1 fill rates in North East England 100%, but at ST3 the rate is just 67%? What are the shared characteristics of areas as geographically diverse as London, South West England and Scotland which lead to a 100% CT1 fill rate across the board?

I want us, as a College, to lead a full examination of the issues driving, or in many cases perpetuating, this variation, and to explore the ‘causes of the causes’. Do trainees in certain parts of the UK feel excluded by

geographical constraints from the training and education opportunities they would like to take advantage of? Outside of the confines of the NHS, are the economic factors like house prices limiting trainees’ options to live and train where they would like to? And what are the sociological impacts of longer life expectancy, and an increase in pensionable age, on the motivation to develop careers which are different to the careers of anaesthetists of the past?

The answers to these questions rely on practical steps to better understand the issues by engaging with the people affected by them in the areas where the problems seem most pronounced. I am pleased to say that the College has already made progress with this, and I am also buoyed by some of the work we will be undertaking as we go forward.


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The plan of action Last year, representatives from the College visited Newcastle and Aberdeen, where there have been sustained difficulties in recruiting at ST3.

Many comments focused not on anaesthetic or NHS issues but rather the historical and cultural identity of an area. Attendees noted the perception of Aberdeen’s high living costs – a hangover from its North Sea oil and gas heyday – and highlighted that Newcastle continued to be viewed by some as ‘the good time place’ to train, but not to stay.

Hearing views first-hand is the fastest route to improvement. For example, the one-site rotation initiative in Aberdeen was a positive strategy that might be worth considering in other areas of the UK, providing stability for those individuals with families who are keen to settle in an area for a reasonable length of time. The success of these visits in Aberdeen and Newcastle underlined the importance of engaging on the door-step and I am pleased to say that we will be doing more of the same.

From September this year we will be working with Health Education England to run events in the North East, Yorkshire & the Humber and the East Midlands to explore some of the underlying reasons for the recruitment challenges in these areas. The aim of the events, to be attended by a range of stakeholders including anaesthetists of all grades, clinical directors and Human Resources managers, is ultimately to develop tailored local action plans for each area.

Alongside this work with HEE, the RCoA Workforce Advisory Group is currently looking at attrition-rate data, with the intention of running a survey among core trainees; the survey is being developed at the time of writing. The work will build on existing workforce data and help strengthen the case for our call for an increase in CT1 and ST3 numbers.

A new recruitment modelTo support improved efficiency and facilitate greater choice in the recruitment process, from 2018 a new model will be introduced. At the time of writing it is expected that the Single Transferable Score (STS) system will be implemented, but the details of the system are still under consideration.

Under the STS system applicants make one application to a central portal with a single national ranked list generated from interviews conducted at a reduced number of centres accross the UK. With the interviews conducted to a common standard, applicants can then be considered for a placement in any UK School of Anaesthesia. With this model, an important consideration is how the devolved nations would engage in UK-wide recruitment, and this is currently being resolved.

The impact of fill rate deficitsWhen regions cannot fill their anaesthetic training places, the impact on departments includes increasing workloads and gaps in rotas at all grades, all of which risk further fuelling the low morale gripping the NHS. Our last census [http://bit.ly/RCoACensus2015] showed that 98% of respondents relied on internal locums to cover trainee and SAS rota gaps. An alternative, taking on external locums to plug these gaps, is costly and unsustainable in the longer term, as is the reliance on consultant staff ‘acting down’ to fill on-call rota gaps in nearly half (48%) of anaesthetic departments.

It is important, however, to separate the operational challenges from the personal choices that we see more doctors exercise. In his speech to the NHS Confederation conference in June 2017, the Chief Executive of Health Education England, Professor Ian Cumming, highlighted the fact that younger doctors are, increasingly, no longer wishing to work the same full-time working pattern that has been the status quo for previous generations.

Equally we know from our 2017 survey of SAS doctors [http://bit.ly/RCoASASWorkforce] that in some instances family and work/life balance informed career choices, with some respondents noting that the decision to be an SAS doctor was specifically to avoid adopting a contract which, to quote one of the respondents, is ‘not compatible with good quality family life’.

I am clear that the College has a key role to play in resolving recruitment challenges such as access to sub-specialty training, the quality of opportunities, and burdensome administration, all of which drive considerable geographical variation in trainee anaesthetic fill rates. While adapting to an increase in less-than-full-time working patterns may bring additional challenges for employers, this cannot and must not lead to a narrowing of the career pathways and lifestyle choices available to doctors throughout the UK.

ConclusionIn a recent speech (http://bit.ly/2tLOXiE), the Chief Executive of NHS England, Simon Stevens, cited an 1822 parliamentary report on railway pioneers

Hearing views first-hand is the fastest route to improvement


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George and Robert Stephenson, which concluded that the adaption of the steam engine ‘for the purpose of locomotion’ was the flight of a ‘distempered imagination’.

In 2017 a more ‘tempered’ but no less imaginative approach is needed to address the challenge of how we attract and retain people from all backgrounds in order to maintain a sustainable NHS.

We know that students starting medical school as part of the government’s commitment to 1,500 new places will not complete specialty training until 2032, and that action is needed before then to ensure those new doctors arrive in a service still on track.

The recruitment of new medical associate professionals, including Physicians’ Assistants (Anaesthesia) and Advanced Critical Care Practitioners, could augment the existing clinical workforce, but proper statutory regulation needs to be put in place to realise the potential of these roles. Ensuring that staff from the European Economic Area (EEA) are able to continue their vital contribution to the health and social care system is a pivotal part of Brexit, and this could be coupled with increased flexibility of immigration rules to better facilitate the recruitment of doctors from outside the EEA to meet the needs of our NHS.

Finally, fostering new ways of working for older members of the specialty so that they continue to deliver safe and effective perioperative care until they are potentially well into their seventh decade will be the other major workforce challenge for the future – an issue discussed in a previous issue of the Bulletin [http://bit.ly/2tHtF7p].

Many of the recruitment challenges we now face as a specialty are the result of falling short on understanding many complex and multi-layered issues. A more rigorous, proactive and action-oriented approach, addressing what drives the underlying difficulties, is the only way of effecting the positive change for the future. There is much more to do, and much more we will do, but I am encouraged by the positive role the College is already playing in helping to shape that future.

Bulletinof the Royal College of Anaesthetists

Churchill House 35 Red Lion Square London WC1R 4SG

020 7092 1500 www.rcoa.ac.uk/bulletin | [email protected]

@RCoANews /RoyalCollegeofAnaesthetists

Registered Charity No 1013887 Registered Charity in Scotland No SC037737

VAT Registration No GB 927 2364 18

President Liam Brennan

Vice-Presidents Jeremy Langton & Ravi Mahajan

Vice-Presidents Elect Ravi Mahajan & Janice Fazackerley

Editorial Board Monty Mythen Editor

David Bogod Council Member

Simon Fletcher Council Member

Jaideep Pandit Council Member

Krish Ramachandran Council Member

David Booth Lead College Tutor

Joanna Budd Lead Regional Adviser

Kate Tatham Trainee Committee

Emma Stiby SAS Member

Carol Pellowe Lay Committee

Gavin Dallas Head of Communications

Mandie Kelly Website & Publications Officer

Anamika Trivedi Website & Publications Officer

Articles for submission, together with any declaration of interest, should be sent to the Editor via email to [email protected].

All contributions will receive an acknowledgement and the Editor reserves the right to edit articles for reasons of space or clarity.

The views and opinions expressed in the Bulletin are solely those of the individual authors. Adverts imply no form of endorsement and neither do they represent the view of the Royal College of Anaesthetists.

© 2017 Bulletin of the Royal College of Anaesthetists All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, of the Royal College of Anaesthetists.

ISSN (print): 2040-8846 ISSN (online): 2040-8854


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Nominations for election to the Council of the Royal College of Anaesthetists are now open. Vacancies were announced in July in the news section of the College website, in the President’s e-newsletter, and can be viewed at www.rcoa.ac.uk/election2018 along with details of how to stand.

Council election timetable28 September 2017 Nominations close

This year there are the following vacancies on Council:

■ 5 Consultant members of Council

■ 1 Trainee member of Council

■ 0 Staff and Associate Specialist members of Council.

Fellows who wish to be nominated to stand are invited to download and submit forms available from the College website. The website gives further details of standing for Council and the commitment required.

All completed nomination forms must be received by the chief executive’s office by 5.00pm, 28 September 2017.

28 September 2017 Finalisation of members’ details for ballot

Fellows and members who have changed their email address are requested to give notice to the membership team by emailing [email protected].

6 October 2017 Announcement of candidates standing

The names of the candidates and which category of vacancy they are standing for will be published on the College website.

20 October 2017 Ballot distributed

Ballots will be sent electronically to the email address registered at the College and by post to those who have requested a postal ballot.

4 December 2017 Election closes

Ballots must be returned to Electoral Reform Services by 5.00 pm.

5 December 2017 Result announced

The election results will be declared via the College website as soon as possible following the ballot count. The results will also be published in the President’s e-newsletter and the College Bulletin.

13 March 2018 New members will be admitted to their first Council meeting.

ELECTION TO COUNCIL 2018

Nominations for Council close on

28 September 2017

Contact Information: Rose Murphy, Chief Executive Office Manager, Telephone: 020 7092 1612 or Email: [email protected]


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It is with great sadness that I informed the College’s fellows and members in mid-July of the passing of Dr Jean-Pierre van Besouw, who was President of the College between 2012 and 2015.Affectionately known as ‘J-P’, many will know that he had been ill for some time, but all who knew him personally will remember him fondly for his wit, kindness, personal support and dedication to the College and our specialty.

During his tenure as College President, J-P significantly modernised and raised the profile of the College. His presidency saw the introduction of the hugely successful Anaesthesia Clinical Services Accreditation scheme, a quality improvement project that in just three years has been taken up by one-third of all UK anaesthetic departments.

Other notable College contributions include championing perioperative medicine, by launching the College’s vision document Perioperative Medicine: The Pathway to Better Surgical Care in 2014. J-P was also instrumental in promoting the HQIP-funded National Emergency Laparotomy Audit, which is due to release its third Patient Audit Report later this year. This project receives 100% engagement from all hospitals in England and Wales which perform emergency bowel surgery and is credited with improving patient outcomes and providing significant cost savings for the NHS. For 13 years he was an FRCA examiner, and he chaired the examinations committee for the last three years of that tenure. J-P was also a contributor and reviewer for a number

of anaesthetic journals, a member of the BJA Editorial Board and a Director of the BJA.

J-P’s wisdom and leadership were sought by many national organisations and, until the onset of his illness, he combined these responsibilities with his clinical duties as a consultant cardiothoracic anaesthetist and honorary senior lecturer at St. George’s University Hospitals NHS Foundation Trust. A consultant at St George’s since 1990, he recognised the increased burden of disease and complexity of post-operative care for cardiac patients. He introduced a two tier of on-call consultant cover to support emergency surgery and cardiac intensive care which is now established as the norm in the specialty. His most recent local appointment was in 2014 as an elected staff governor to St George’s as it progressed towards becoming a Foundation Trust.

J-P also previously held the role of President of the then-named Association of Cardiothoracic Anaesthetists, through which he modernised the Association by strengthening areas of performance review, standards and benchmark setting and workforce and service planning. J-P was also Vice-Chair of the Academy of Medical Royal Colleges between 2013 and 2015 where he led on training and education issues.

The College’s membership, staff and Council have lost a tremendous friend, colleague and leader. It is also clear from the tributes received that J-P was held in enormous esteem by the wider specialty and across the whole of the health sector, who join with us in mourning his passing.

Our thoughts remain with his wife, Liliane, and all of his family at this very sad time.

Dr Liam Brennan, President

Dr Jean-Pierre van Besouw1957-2017


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News in briefNews and information from around the College

25th Anniversary updateWith four months left in the College’s 25th Anniversary year, there are still plenty of opportunities to be involved in the numerous celebratory events and activities being held across the UK.

World Anaesthesia Day 2017 will be celebrated at the College on 16 October, when we will welcome a variety of speakers to our event Global Anaesthesia: A Platform for Development. The programme will explore key themes affecting the delivery of safe anaesthesia on a global scale. In the evening, the College will also host a talk on the History of Anaesthesia by Dr David Wilkinson at the Old Operating Theatre Museum and Herb Garrett, London Bridge.

Science on Screen at the Barbican on 17 October will feature Green for Danger a war-time ‘whodunit’ and romance set in an operating theatre. Dr Tom Clutton-Brock will introduce the film and discuss the significant advances in anaesthesia since the 1940’s.

We continue to release our ARIES Talks, with topics ranging from ‘Anaesthetists and space’ by Dr Kevin Fong, to ‘Fatigue and the anaesthetist’ by Dr Mike Farquhar and ‘Changing the way we think about organ donation’ by Dr Paul Murphy.

More information on upcoming events, activities, and ARIES Talks can be found on the 25th Anniversary website (www.rcoa.ac.uk/rcoa25).

YEARS

Post-election: the dust settled and then the storm beganPolitical parties are now gearing up for the annual conference season and it could be a difficult trip to Manchester for the Prime Minister, with polls suggesting that some Conservative activists have an eye on a new leader.

The election result brought with it a new programme for the Government and we welcomed the draft Patient Safety Bill (http://bit.ly/2uPPdx5) included in the Queen’s Speech, with its stated aim of ensuring the independence of the Health Service Safety Investigation Body, by establishing the Body in statute.

More ambitious plans to change the way the internal market operates in the NHS, which would require amendments to the Health and Social Care Act (2012), look to have been shelved for now.

When the Prime Minister stood outside No.10 in July 2016, her speech suggested that she would be a PM for life chances, not life sciences. A little more than a year later, stunted by issues such as social care and criticism of the new personal independence payments, it looks increasingly as though life sciences and medical research may move up the list of priorities, as the industrial strategy becomes a central part of the Government’s plans for ‘UK PLC’ post-Brexit.

The College is well-placed to promote our research initiatives, such as the next phase of the National Emergency Laparotomy Audit, and policy and public affairs activities will be supporting this work going forward.


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Interested in helping produce our national guidelines?

Guidelines for the Provision of Anaesthetic Services (GPAS) forms the basis of recommendations produced by the College for healthcare managers and anaesthetists with responsibilities for service

delivery. Chapters are developed using a rigorous, evidence-based process, accredited by the National Institute for Health and Care Excellence (NICE). To date, eight chapters have been developed using the NICE-accredited process, with a further five going through the process for the publication of GPAS 2018. By the publication of GPAS 2019, it is anticipated that all chapters in GPAS will have been developed using the NICE process.

How do I get involved? The College is currently recruiting Chapter Development Group (CDG) members for the following chapters:

■ head and neck surgery

■ vascular surgery

■ pain management

CDG members support the authors in development of the GPAS chapters by commenting on drafts. CDG members include subject-matter experts, clinical directors, at least one lay member to represent the interests of patients, anaesthetists of all grades, and College staff.

If you are interested in getting involved, please contact the GPAS co-ordinator via email at [email protected] or telephone: 020 7092 1572. For further information please visit www.rcoa.ac.uk/gpas.

We look forward to hearing from you.

Autumn and Winter ConferencesAfter a successful summer conference season, during which more than 400 delegates travelled to Belfast for the Summer Symposium and College Tutors Meeting, and more than 200 trainees attended our Primary and Final revision courses, our attention is turning to our autumn series of events.

Autumn kicks off with the Updates in Anaesthesia, Critical Care and Pain Management event on 6 to 8 September, which will cover a variety of topics including preparing patients for major surgery and a survival guide to a coroner’s inquest.

Over 16 and 17 of November the Winter Symposium returns, with the theme of Excellence. The programme will focus on how to improve patient outcomes, with discussions including topics such as the ‘weekend effect’ and fasting times. The Winter Symposium will provide food for thought for your own personal development, offering the chance to learn from and interact with experts while networking with peers from all areas of our profession.

This event is closely followed by the Safe Anaesthesia Liaison Group Patient Safety Conference, this year to be held in Manchester on 22 November.

Make sure you also save the date for our new flagship international conference, Anaesthesia 2018, which will be held at the British Museum in London from 22 to 23 May 2018.

BJA retains no.1 statusThe Impact Factor of the British Journal of Anaesthesia (BJA), the oldest and largest independent journal of anaesthesia, has risen for the fourth consecutive year to 6.24. This means the BJA, which is the official journal of the College sent to all fellows and members, retains its position as the number one anaesthetic journal in the world.

Last year, the BJA’s Impact Factor was 5.62, a rise of 15 per cent from 2015’s Factor of 4.85. Retaining top spot in the global anaesthesiology listing is a tremendous achievement for the whole editorial and production team. Thanks also go to fellows and members, who have online and print access to the BJA and who contribute by reading and supporting the journal.


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The FRCA Examinations updateCongratulations to all those who passed the Final FRCA SOE examinations which took place in June. 246 out of 389 candidates were successful and the 63 per cent pass rate is consistent with results from recent years.

Our new ‘Computer Based Testing’ project is due to commence in September 2017. Our aim is to move the Primary MCQ, the Faculty FPMRCA and the FFICM MCQ exams from the current paper-based process to a computer-based solution by March 2019. Computer-based testing refers to a system of assessment whereby exam candidates answer questions at a computer terminal, normally in a certified test centre.

An MCQ pilot exam will be run prior to ‘going live’. Prior to the first scheduled computer-based tests in 2019, potential MCQ candidates will also be given the opportunity to sit a Primary FRCA MCQ in the computer based format as a formative test. This will not count as a formal attempt.

The Final FRCA Written examination will remain in the current paper-based format for the foreseeable future, to allow the Final Board of Examiners to monitor the new Constructed Response Question examination before moving it to the new computer-based format.

To help exam candidates know what to expect when they arrive at Red Lion Square, the College has recently completed work on a 3D model of the OSCE and SOE exam which will be accessible through the College website from early September. This new resource will give exam applicants the opportunity to take a virtual tour around the OSCE and SOE floors before their exam day. Users can navigate around the exam rooms by simply clicking and dragging the mouse to explore the 3D model to help prepare themselves for their exam.

NHS and training opportunitiesThe College hosted its second New to the NHS meeting on 17 July, which provided an opportunity for newly appointed doctors in SAS and MTI grades to network with colleagues from across the UK.

The format for the day is specifically developed to help newly-appointed anaesthetic doctors understand their role and responsibilities and how they interact with the NHS. The event involved a combination of lectures and workshops, including a discussion about adapting to a new role in their new environment. Louise Robinson from the General Medical Council provided an overview of its role, the standards, and the relevant guidance.

This meeting is part of the College’s efforts to support Medical Training Initiative (MTI) and Specialist and Associate Specialist (SAS) doctors as valued members of the College.

Please see the College’s Events Calendar (http://bit.ly/2rnAGsB) for upcoming CPD opportunities which may be of interest.


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News in briefNews and information

from around the College

Research and quality improvementData collection is now complete for the Health Services Research Centre’s 6th National Audit Project (NAP6) (http://bit.ly/2tZTYq2), examining perioperative anaphylaxis. We’d like to extend our thanks to the team of over 300 local co-ordinators who worked tirelessly throughout the more than year-long NAP6 data-collection period. Case analysis and report writing is now underway, with the final report due to be published in May 2018.

SNAP-2: EpiCCS (2nd Sprint National Anaesthesia Project: Epidemiology of Provision of Critical Care Services) (http://bit.ly/snap-2-epiccs) is now international! Colleagues in Australia and New Zealand ran the project between Wednesday 21 and Tuesday 27 June 2017. In the UK all patient data collection, including 60-day follow ups, is now completed. Follow @SNAP2EPICCS for more.

Sites participating in the Perioperative Quality Improvement Programme (PQIP) have now received their first round of quarterly reports. The reports are targeted at specific user groups (surgical, anaesthesia, managerial, and nursing) and designed to help drive local quality improvement. The PQIP Library (http://bit.ly/2tZTxw0) is open to all and aims to inform and educate users about the different processes and outcomes measures. Follow @PQIPNews for regular updates.

PQIP’s YouTube channel (http://bit.ly/pqip-youtube) is now updated with more how-to guides to help deliver local quality improvement, including guides on choosing measures and plotting run charts. The PQIP Podcast can be downloaded via iTunes (http://apple.co/2q1mS7G).

H S R CHealth Services Research Centre

NIAANational Institute of Academic

Anaesthesia

Why did you choose anaesthesia? Are you passionate about anaesthesia? Do you want to be a part of recruiting the next generation of anaesthetists?

Help us by sharing your story about why you chose a career as an anaesthetist.

Simply complete this form (http://bit.ly/2uM5oeE) before 15 September telling us what sparked your interest in anaesthetics, what were the first steps you took once you made your choice, and what a career in the specialty means to you. We’d love to hear your thoughts.

If you would also like to be part of shaping the future work and strategy of your College and your specialty, you are welcome to join our Membership Engagement Panel. More information about the Panel and how to join can be found on the College website (http://bit.ly/RCoAListening).


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Professor Dion Morton,Director of Clinical Research, Royal College of Surgeons of England

Professor Mike Grocott,National Specialty Lead, Anaesthesia, Perioperative Medicine and Pain, NIHR Clinical Research Network

Guest Editorial

Research in perioperative medicine: anaesthetists and surgeons working together

Perioperative medicine is by definition an interdisciplinary activity: we care for our patients more effectively when we work closely with fellow professionals, in particular our surgical colleagues. But it is notable that anaesthetic and surgical researchers have tended to exist in parallel universes until very recently.


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Recent collaborative developments between the National Institute of Academic Anaesthesia (NIAA) and the Royal College of Surgeons of England (RCSEng), along with the stunning success of the surgical and anaesthetic trainee research networks, are changing all of this, and an increasing number of novel and exciting interdisciplinary projects are thriving.

For the last three years, the NIAA and RCSEng, have been working together to build collaborative research in the perioperative space. The driver for this has been a shared recognition that we are stronger together, and that innovation in perioperative care has direct relevance for us all. This is in part driven by funders, who have little interest in demarcation disputes between professional groups, and much more interest in seeing questions of importance to patients answered in the most efficient and effective manner possible. This goal is almost always achieved through interdisciplinary (and usually inter-institutional) collaboration. Decisions about who to collaborate with for any project should be driven by what is best for the project, rather than what is best for any one individual professional or institution. In the long run, this approach is likely to have a positive influence on the quality and success of the project, and therefore to benefit individuals and institutions anyway. Funders are also interested in critical mass, and the combined support of the anaesthetic and surgical communities for a proposal is substantially more compelling than that of either community alone.

This joint surgical and anaesthetic working has taken a number of forms. Three well-attended national meetings have brought together surgical and anaesthetic researchers. The first two were run in April 2014 and March 2015, one at each of the two collaborating Royal Colleges in London. The third was a joint perioperative care meeting held on 19 January 2017 at the Royal

College of Surgeons of Ireland in Dublin between the Society of Academic Research in Surgery and the NIAA. This very successful meeting incorporated two abstract sessions, with plenty of examples of great collaborative projects presented, and a forum on upcoming collaborative clinical trials (including trainee trials) as well as an invited plenary lecture by celebrated Canadian prehabilitation expert (and anaesthetist) Professor Franco Carli.

We have previously partnered with the RCSEng and the NIAA to develop collaborative systematic reviews in perioperative care. This jointly funded initiative supported four systematic reviews of relevance to perioperative care, and required that every review team comprised consultants and trainees from both specialties. The ambition of this programme is to build inter-specialty teams that go on and secure successful grant funding for major clinical trials.

The links between the two organisations have been manifest in other ways: the RCSEng contributed expertise to the NIAA led James Lind Alliance Priority Setting Partnership in Anaesthetic and Perioperative Care,1 the RCSEng Clinical Effectiveness Unit is a key partner in the delivery of the RCoA-run National Emergency Laparotomy Audit (NELA), and the NIAA is represented on the RCSEng International Surgical Trials Initiative.

So is this flirtation translating into a sustainable and productive romance? The answer is a very clear yes, if the criterion of judgment is successful collaborative research. The recently completed NIHR funded EPOCH trial (20,000 patients) of a quality improvement initiative in emergency laparotomy care was a joint anaesthetic-surgical collaboration. From this has developed the ALPINE trainee network study of lung-protective ventilation in emergency laparotomy and the NIHR Health Technology

Assessment funded FLO-ELA trial (7,600 patients) of goal-directed fluid therapy in emergency laparotomy, which commences recruitment in summer 2017. FLO-ELA is another anaesthesia-surgery collaboration, with leads from trainee networks in both specialties as named co-applicants. Data from the Comprehensive moUthcare to reduce Postoperative Pneumonia (CUPPA), led by the South West Anaesthesia Research Matrix (SWARM), contributed to the funding application of the international multicentre COMMAS study run by the West Midlands Surgical Research Collaborative.

On the ground, surgical and anaesthetic trainee networks are commonly working in partnership to recruit into large observational studies, and are now beginning to dabble in interventional trials. A cluster of large effectiveness RCTs will be coming on line in the next 12 to 24 months, offering increased opportunity for collaborative working.

More and more studies are achieving funding and delivering high-quality research through effective and productive inter-specialty working and, through this, collaborative relationships are being built that will be sustained for many years. A generation of trainee surgeons and anaesthetists are coming of age as consultants in a professional environment where collaborative research has become the norm, rather than a rare activity.

Reference

1 Boney O et al. Identifying research priorities in anaesthesia and perioperative care: final report of the joint National Institute of Academic Anaesthesia/James Lind Alliance Research Priority Setting Partnership. BMJ Open 2015;5(12):e010006.


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http://www.ncbi.nlm.nih.gov/pubmed/26674506





Dr William Harrop-Griffiths, RCoA Member of Council

Anaesthesia Clinical Services Accreditation (ACSA)

Confessions of an ACSA virgin

I am old enough to remember ‘College Visits’ in their 1980s incarnation. I was a senior registrar when my department was visited by two august Professors from College Council. During a prolonged inquisition, they sought unsuccessfully to persuade us trainees that our consultants were workshy ne’er-do-wells. At the end of the ordeal, all members of the department felt rather bruised, and were puzzled as to who actually benefitted from the visitation. How things have changed! I was fortunate to accompany Dr Simon Fletcher (ACSA Lead on College Council) on a recent ACSA visit to a hospital that I will not name, but which I will simply identify as being Some Distance North of Watford. Over two days, the department’s compliance with the many ACSA standards was probed and pondered. It was a tiring experience for all concerned, but to my mind an overwhelmingly positive one. Those leading the process in the hospital had put in a huge amount of effort but, with the support of their managers and co-workers, had succeeded in raising the standards of care in the hospital from an already high level to one that satisfied almost all the ACSA standards. In the process, they had been able to identify in which areas their practice fell short of contemporary standards as set by the College, and were able to ‘up their game’. It was

probably no coincidence that, as we arrived, technicians were unpacking and installing brand new anaesthetic machines in their operating theatre suite.

I must admit that I had previously been an ACSA sceptic, but my scepticism was put to flight by the visit. I could see no losers: processes had been improved and documented, equipment had been updated, and all in the department had had an opportunity to reflect on their

practice. We brought the trainees into our presence and quizzed them about their work patterns and work environment. They were positive and supportive – not only of their consultants but also of the ACSA process. We left feeling that we and ACSA had done some good that would actually benefit patients. How different from 30 years ago!

For more information about ACSA please visit www.rcoa.ac.uk/acsa.


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Chris Kennedy, RCoA CPD and Revalidation Co-ordinator

Revalidation for anaesthetists

Planning for a new CPD Online Diary

The previous issue of the Bulletin included an update on the Technology Strategy Programme (TSP), the first phase of which is focusing on improving members’ learning tools. Work is now underway to develop a new e-Portfolio (see page 22) and core aspects of a new online logbook as part of a new Lifelong Learning platform, and an enhanced version of the current CPD Online Diary will follow next.The CPD Online Diary was launched in 2011 with the CPD web app version following in 2014, and we have been keeping a record of suggested enhancements to these systems in the years since. For example, one popular request is that it should be possible to add ‘real-time’ reflection during participation in an event or other CPD

activity, rather than only at its conclusion, and it has also been suggested that the systems should permit temporary ‘read-only’ access to allow their appraiser to look at a doctor’s CPD records.

Some suggestions have been received about improved customisation in the reporting functionality – for example, linking the programme to the section

for reflecting on an event’s learning outcomes – and in amending the information fields in using the system to set up a personal development plan,

Event providers have suggested that there should be a ‘save and return’ option when applying for CPD approval, and have also requested that there should be a more intuitive way to make applications for multiple, duplicate versions of events.

With work soon to commence on planning user journeys for the enhanced CPD Online Diary, we are very keen to hear your suggestions – what parts of the systems do you find particularly helpful, what improvements could be made to the current format, and are there any new features which you would like to see? Please send your comments to Chris Kennedy, Revalidation and CPD Co-ordinator, at [email protected].


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mailto:[email protected]

Medicine at its best is always a joint enterprise. All of our work is dependent on all those we work with, and aims at a seamless matching of skills for any given task. This is also essential at organisational levels, where it is important to work with parallel groups that work in the same field, but which have a different focus or membership. The British Pain Society (BPS) is the oldest organisation in the UK that reflects the concerns of those involved in the management of pain – a broad church both of opinion and membership, and inclusive of all those involved in the field, irrespective of their discipline. This is the Multidisciplinary Team approach at the organisational level. The FPM and the BPS have cross-membership of their Boards, and are linked with other groups, such as

the Pain Consortium. Their aim is to cross fertilise on ideas, to pool resources on common issues, and avoid duplication.

Pain treatment outcome measuresWe are currently running a joint project on outcome measures, led by Dr Baranidharan for the FPM, and Dr Cameron for the BPS. Pain is well recognised as a subjective experience, it

is within the core IASP definition, but it is still possible to devise ways to measure both the impact of the condition and the effect of treatments. The literature has many validated such tools and these can be used by services that are increasingly under pressure to show evidence outcomes for comparisons between units. The aim is to suggest where tools may best be focused to provide consistent and useful information. This initiative has involvement from NICE and the Clinical Reference Group for Chronic Pain.

Political interestThe two groups are holding a meeting later this year for members of both Houses of Parliament (any new elections not withstanding), to look at the state of education, of the workforce and of local and regional distribution of pain services. We have ongoing liaison with a number of interested parliamentarians, and it is important that we keep them informed of our work and thinking, and encourage their support.

Dr Barry Miller, Dean, Faculty of Pain Medicine

Faculty of Pain Medicine (FPM)

A melody is many notes


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Dr Daniele Bryden, Chair, Careers, Recruitment and Workforce Committee,Faculty of Intensive Care Medicine

Faculty of Intensive Care Medicine (FICM)

Recruitment to retirement

A reorganisation of the Faculty’s main working groups has created the Careers, Recruitment and Workforce (CRW) committee. From showcasing working in ICM, recruitment into training and the development of a lifelong career with planning for a healthy retirement from clinical practice, the remit of the CRW is wide. Underpinning it all is the knowledge that the ICM workforce needs to match the demands of the future service. So what about the workforce? ICM posts have grown steadily since the new CCT programme in 2011, and the biggest growth has been in the numbers of non-anaesthetic trainees entering ICM (current figures for 2017 show only 56% of entrants have an anaesthetic background), with an associated rise in consultant posts advertising ICM with flexibility for other sessions, meaning that posts for non anaesthetists trained in ICM are being created.

Workforce census returns indicate that many respondents want to stay in ICM for the duration of their career, and it’s the non clinical pressures (fatigue, revalidation requirements, the need to wear other professional ‘hats’) that impacts on their ability to see a way to do this. The undesirable manifestations of working in an acute specialty are generic, and so we are working with other groups and specialties to emphasise the importance of workforce wellbeing in a wide sense. Anaesthesia

is not the ‘fall back’ position for people wanting to come out of intensive care: both specialties are having to address the spectres of resident consultant on call, job planning and increasing demand for our resuscitative and planning skills across hospital services so both are under pressure.

The immediate future is unlikely to impact on the close working relationships that anaesthetists and their ICU colleagues have, but there are subtle changes occurring in workforce which means that the work of CRW has relevance for anaesthesia as well as ICM.


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Dr Kirstin May,RCoA SAS Member of Council

SAS AND SPECIALTY DOCTORS

SAS DEVELOPMENT

The RCoA welcomes the new guidance1 on the development of Specialty and Associate Specialist (SAS) doctors in the NHS in England. This jointly-developed document was published in February 2017, following the ‘SAS Charter’2 published in 2015.

The principles set out are not only aimed at SAS doctors, but can also be applied to other doctors not in formal training, for example, trust-grade doctors. This cross-specialty guidance is particularly relevant to our specialty, as we know from

the 2015 Census that SAS anaesthetists contribute 22% of the anaesthetic workforce (http://bit.ly/2eVoNkN).

The Academy of Medical Royal Colleges, the British Medical Association, Health Education England and NHS

Employers have worked together to produce this guidance to ensure that this important group of doctors is helped to remain fit to practice and to develop in their careers. Joint workshops were held by the four organisations in 2015, to identify needs, aspirations and barriers

‘Do not fear going forward slowly; fear only to stand still’Chinese proverb


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https://www.rcoa.ac.uk/sites/default/files/SAS%20doctor%20development%20guide%20FINAL.pdf

http://www.aomrc.org.uk/

http://www.aomrc.org.uk/

https://www.bma.org.uk/

https://hee.nhs.uk/

http://www.nhsemployers.org/

http://www.nhsemployers.org/

to development, and the information coming out of these workshops has formed the basis of the new guidance. The guidance advises SAS doctors on how to develop and extend their professional roles to best meet the need of patients, for example, by taking on educational, managerial and appraisal roles. It also provides links to other documents giving guidance on, for example, autonomous practice, routes to Certificate of Eligibility for Specialist Registration (CESR) and progression on the specialty doctor pay scale. There is also guidance for NHS Boards, medical directors and medical staffing and human resources departments, which suggests actions to best support their SAS workforce, and to ensure that best practice is followed in the development of SAS doctors.

Case studies are included as examples of SAS doctors performing in extended roles and of training programmes being developed specifically for SAS doctors. One interesting example is a development programme in Wessex for emergency department doctors, with focused training on the skills required to allow them to become senior decision makers during night shifts. This takes the form of a formal four-months programme with two focused, small-group educational sessions per fortnight, including simulation training. This benefits the professional and personal development of the doctors, but also benefits the employing hospital’s ability to maintain a safe rota and patient safety.

The role of SAS doctors in our specialtyThe RCoA Census of 2015 has confirmed the significant role within the specialty that SAS doctors play (http://bit.ly/2eVoNkN), and comparing this with previous census data, we know that numbers are increasing in this grade. SAS anaesthetists are represented across the whole age-range and across the whole range of experience.

We also have census evidence of a significant number of vacant posts, as well as anecdotal evidence from clinical directors of the difficulties in recruiting to this grade. Undoubtedly, competition between recruiting hospitals has opened up development opportunities for potential recruits.

A change in the landscapeHistorically, SAS grades were seen purely as service grades, with few training opportunities. SAS grades were often used to maintain service – for example, to free trainees for teaching sessions or consultants for clinical governance meetings. Since the introduction of a strengthened appraisal framework and revalidation, a duty of self-development has been placed on all medical practitioners. This duty on the part of the doctor must be matched with a willingness on the side of the employer to support and assist training and development for all.

Examples of good practiceSAS doctors have always played an important part – one that is not always acknowledged – in the training of junior

anaesthetists during clinical sessions, as well as in classroom teaching. The 2008 specialty doctor contract mandates a minimum of one SPA, with the expectation that this will increase over a doctor’s professional life. Many trusts have now opened managerial positions to SAS doctors. SAS doctors act as appraisers, not only for other SAS doctors, but also for consultants. SAS doctors with a suitable level of expertise take on lead roles in clinical services. At the RCoA, SAS doctors are involved in all areas of the College’s work.

SummaryThe new development guidance challenges outdated ideas and prejudices about SAS doctors, and emphasises the value of the skills they can offer. Our RCoA SAS committee regularly receives queries from doctors asking about professional development, and we hope that our replies to them are useful. Feedback is always welcome please email [email protected], especially share examples of good practice that we could present to a larger audience.

Since 2015, the SAS representatives on College Council have held engagement sessions during all major College events, and we plan to continue to do so. Please join the conversation on how we can strengthen the professional role, opportunities and standing of SAS anaesthetists, for the benefit of SAS anaesthetists themselves, but also for the benefit of the whole profession and – most importantly – that of patients.

References1 SAS doctor development: Summary

of resources and further work. NHS Confederation (http://bit.ly/2uMiU26).

2 SAS charters, BMA (http://bit.ly/SASCharters).

SAS doctor development can be downloaded at http://bit.ly/2uMiU26


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Paul Mincher, RCoA Lifelong Learning Project Manager

Technology Strategy Programme

Lifelong learning: Consulting the experts

Replacing and improving key information systems used by College members on a daily basis is never going to be less than challenging. The technical phase of work by the College project team on replacing the e-Portfolio and logbook systems with one online platform started in April 2017 with partner agency Nomensa (see Bulletin 104). One of the key early themes of the project has been ensuring the involvement of clinicians in the technical development process. Starting with the early gathering of system requirements and the appointment of Nomensa, we have sought to involve trainees and consultants as much as has been practically possible.

In May, we conducted a mini-consultation on how the Annual Review of Competence Progression (ARCP) and Multi-Source Feedback (MSF) processes can be implemented on the new platform. With nearly 300 responses, it was clear that these processes needed to be improved, with less dependency on calling the College to change an ARCP date or close an MSF early.

In June, working with Nomensa, we started testing an early prototype at the College Tutors’ Meeting in Belfast and with a group of trainees in Bristol. ‘Guerrilla testing’ – a rapid, low-cost method of quickly capturing user feedback – was used, involving a user-experience consultant asking

questions about specific areas of the new application. During the sessions, we showed the participants the following screens from the prototype: ‘Dashboard’, ‘Anaesthesia Clinical Evaluation Exercise’ (A-CEX) and ‘Completion of Unit of Training’ (CUT) forms, ‘Personal Development Plans’, and ‘Reflection’. The initial feedback was generally positive and also generated ideas that could be implemented in a future phase.

July has seen a series of face-to-face and remote (via web conferencing and discussion fora) testing events being planned with volunteers nationally, including meetings in Scotland, Birmingham and London.

If you are interested in getting involved, please email [email protected] and for more information please see http://bit.ly/2rM0QqA.

College Tutors testing the Lifelong Learning prototype in Belfast


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mailto:[email protected]

RCoA Research Department

Quarterly research reporting to drive quality improvement

The National Emergency Laparotomy Audit (NELA) and Perioperative Quality Improvement Programme (PQIP) have both launched systems of quarterly reporting, designed to give hospitals more regular feedback, allowing them to make use of their most recent data to facilitate local quality improvement and track their performance over time.The NELA reports include all cases taken to theatre regardless of whether they are locked or unlocked on the NELA webtool. For PQIP, reports have been produced only on patients with locked records.

All NELA reports are publicly available via https://data.nela.org.uk, under the ‘Reports’ tab. NELA reports do not currently include outcome measures such as unplanned return to theatre or postoperative length of stay, though we will consider including these in future if data quality allows meaningful reporting.

For PQIP, logged-in users can find their hospital reports at www.pqip.org.uk under the ‘Reports’ tab. Reports are targeted to specific users groups, such

as surgical, anaesthesia, managerial, and nursing. Please use this opportunity to improve local engagement with PQIP by disseminating as widely as possible.

We encourage all users to use their reports to drive local QI, focusing on areas of greatest local need and interest and including different members of the MDT in the process. The PQIP website contains a library of QI guidance and resources and NELA has a series of animations to help you get started (http://bit.ly/NELA-videos).

Thank you to everyone who is engaged with these projects. These reports have been created with you in mind; please give us your feedback.

Let us know your thoughts at [email protected] and [email protected]

Example layout of NELA and PQIP reports

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https://data.nela.org.uk

http://www.pqip.org.uk

http://bit.ly/NELA-videos

Our College has taken a bold step on the road to change with the publication of its five-year strategy, and is now taking an equally bold step with a structured review and implementation of a new governance structure that will align with the strategy.Other than writing two e-learning sessions, I have never been actively involved with the workings of the College. This changed in 2016 when I responded to an advert asking for ordinary Members to help in a review of the governance of the College. After an expression of interest, and a brief paragraph on why I ought to be invited to take part, I was appointed as one of two non-Council-Member anaesthetists on the group (the other being a former Member of Council who had already been appointed by a separate process). It proved to be one of the most rewarding roles I have undertaken.

Why did I volunteer? I hoped to represent the views of the ordinary membership in potentially the biggest restructuring of the College in 25 years.

I had long believed that there was no clear route to becoming involved in the governance of the College for those whose ‘bent’ lay in areas other than College’s core functions of professional standards. ‘Perhaps,’ I thought, ‘the Council did represent us professionally, but did not seek a broader skill base to help run its governance functions.’ This was an entirely personal view borne out of no knowledge other than a view from a distance. As a medical manager I felt I could bring a different view to the table.

My first meeting of the Governance Group was in May 2016. The outcome was five groups to review the following areas:

■ representation: charter, ordinances and regulations

■ scheme of delegation: currently financial regulations but with the need for clear annual-planning processes

■ reporting processes to Council and the wider College: currently nearly 70 boards, committees and working groups with many reporting to Council

■ aligning our Faculties with the College: each has its own regulations

■ aligning our devolved nations’ boards: each has its own regulations.

The Representation Group was the key. The group’s remit was to explore potential new structures for the College’s governance A key area for discussion was the College’s status as a charity. As a charity, the College requires oversight by trustees and all elected Council Members are

THE COLLEGE GOVERNANCE REVIEWA personal viewpoint

Dr Paul McAndrew, Deputy Medical Director,City Hospitals Sunderland NHS Foundation Trust

‘Outside in the distanceA wildcat did growlTwo riders were approachingThe wind began to howl’Bob Dylan, All Along the Watchtower


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trustees of the College. With that status comes responsibility for all aspects of governance.1 As the trustees of the Kids Company discovered, ignorance about responsibilities is no defence.2 Evidently, not all people have expertise in every area of the College’s charitable activities, so one of the fundamental questions was whether to establish a separate board of trustees, with trustees appointed from outside the membership for their expertise in areas such as finance and business acumen. We had expert help from Andy Friedman and his organisation, Professional Associations Research Networks.3 We were also able to call on expertise from other Royal Colleges, particularly the Royal College of Obstetricians and Gynaecologists, who have been through a similar process in the recent past. Several meetings and conference calls later we had a series of proposed recommendations for College Council to consider. They voted on 8 February 2017 to establish a more formal trustee role, including the introduction of lay trustees. Now the work really begins, and that work will be voted on by you, the Fellows, at the Annual General Meeting in 2018. The president has already written about this work in the Bulletin4 and in his

e-newsletter, but I think it is important that the membership and fellowship are aware that this work is being undertaken, and that in due course they will be asked to vote on the changes. I hope that you will find assurance in the Council actively seeking involvement of non-Council professionals, both peer and non-peer, to provide some balance and challenge.

What have I gained from this personally? First, a much broader understanding of how the College functions. The welcome I received was warm and inclusive, from all Council and staff alike. Attending College Council was an eye-opener, and I would recommend attending if the opportunity presents. Second, a renewed certainty that everyone within the College is working for us as Fellows and Members. There were difficult conversations, and no doubt there will be more of these in the months ahead, but there is a willingness to change – to improve the robustness of the College’s governance structures, and to seek the best talent to make that happen.

I think this is an opportunity for a broader range of Fellows and Members to become involved in the College, and potentially apply for membership of Council. It is not breaking a confidence

to write that some Council Members have indicated that they lack some of the skills required in certain areas of governance, and that they did not fully appreciate what the role of trustee involved when standing, particularly from a legal view point. The College is working hard to address this, and will benefit from the broadest range of skills in shaping and running its governance. It has certainly made me consider how I might contribute further.

The journey is only just beginning, but I am confident that we as Fellows and Members will have a strong, adaptive College that will serve us well for the years to come.

References1 The Charity Commission. Setting up and

running a charity: trustee role and board (http://bit.ly/2taTvxN)

2 The Collapse of Kids Company: lessons for charity trustees, professional firms, the Charity Commission, and Whitehall. House of Commons Public Administration and Constitutional Affairs Committee, The Stationery Office 2016 (http://bit.ly/2tlBTmM)

3 Professional Associations Research Networks website (www.parnglobal.com)

4 President’s View. RCoA Bulletin 2017;101:5–6

RCoA Council meeting, July 2017

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https://www.parnglobal.com/

SAFEGUARDINGPLUS:a new source of information for anaesthetists


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SAFEGUARDINGPLUS:a new source of information for anaesthetists

‘Safeguarding’ is the action taken to promote the welfare of children and vulnerable adults and protect them from harm. ‘Consent’ involves the principles on which good clinical decisions should be based. The new SafeguardingPlus pages1 on the RCoA website will provide a one-stop shop to support anaesthetists, wherever they work in the UK, in finding the right references and educational materials, as well as helping to stimulate discussions about best practice.

How do anaesthetists keep up to date in what often seems like a minefield of ever-changing information on Safeguarding and Consent issues? Whilst good guidance is provided by the GMC, BMA, and Department of Health, the speed and regularity at which this changes is at times confusing and often difficult to keep up with. Your hospital will aim to deliver the essentials as part of regular ‘generic’ in-house mandatory training. Whilst this will contribute to annual appraisal, the modules delivered can be a relatively unrewarding personal education option, and often seem to have little relevance to the needs of anaesthetists. As a

consequence, the RCoA has supported a small multidisciplinary project to assemble and develop a set of linked webpages called ‘SafeguardingPlus’.

Contents‘SafeguardingPlus’ contains four introductory pages – ‘Safeguarding Children’, ‘Safeguarding Adults’, ‘Consent and Ethics for Children and Young People’, and ‘Consent and Ethics for Adults’. These in turn link to shorter pieces on specific topic areas, including Confidentiality, Duty of Candour, Restraint, and DNACPR, with integral signposting to well-developed and up-to-date guidance. Many of these resources (such as, the AAGBI’s recent guidance on consent2) will be familiar to you, but almost certainly there will be some which you have not seen or explored (for example, the Social Care Institute of Excellence website, which contains excellent guidance on the Mental Capacity Act). We hope

Dr Kathy Wilkinson, Consultant Paediatric Anaesthetist, Norfolk and Norwich University Hospital NHS Foundation Trust

Natalie Bell, RCoA Business Co-ordinator


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that collecting all this relevant guidance together will facilitate quick reference and aid decision making in clinical settings.

In the ‘Resources’ section in each topic area there are links to free e-learning materials (some of which require separate online registration). There are also bespoke pieces in the form of virtual cases, expert reviews, and even a couple of short films. All of which might give you some ideas if you are organising local governance sessions with safeguarding leads.

Why do anaesthetists need to know more? SafeguardingPlus seeks to complement local mandatory training, hopefully providing you with a greater depth of knowledge, interest and understanding in these areas. In some sections we have also supplied links to sites that

highlight relevant research, to provide some evidence-based reasons why these ‘softer’ topics are important to both society and good patient care.

Anaesthetists work in all parts of acute secondary care and at all points in the perioperative pathway. They have leadership roles in critical care and pain medicine and play a major role in areas such as obstetrics, pre-hospital, and trauma care. See Table 1 for examples of cases where further knowledge regarding safeguarding and consent issues would be useful.

This project has been driven by anaesthetists for anaesthetists. However, we acknowledge that we are not generally the experts in most of the topics covered. Therefore, we also involved paediatricians, adult

safeguarding leads, a lay member and medico-legal experts, who have all provided invaluable help and advice.

The content has now been extensively peer reviewed, and we invite you to dip in and tell us what you think.

References1 SafeguardingPlus. RCoA

(www.rcoa.ac.uk/safeguardingplus)

2 Association of Anaesthetists of Great Britain and Ireland. AAGBI: Consent for anaesthesia 2017. Anaesthesia 2017; 72: 93-105. (http://bit.ly/2u9cYlG)

Table 1: Case scenarios where anaesthetists encounter safeguarding and/or consent issues

Domestic abuse An obstetric anaesthetist sees a woman in the high-risk pre-assessment clinic at 32 weeks. It seems that she is no longer in a stable relationship with the baby’s father, and when he examines the patient there are suspicious (recent) bruises on the abdomen and flank. She has two other small children.

Complex consent A 15-year-old girl that has been seen by another anaesthetist on the ward arrives in your anaesthetic room very upset. She no longer wants an operation to fix a complex upper-limb fracture, and is reluctant to let the team access her cannula. While waiting for surgery, she has googled the procedure on her phone, as the orthopaedic registrar mentioned a risk of nerve injury when he took consent. The registrar comes into the anaesthetic room and explains that the risk is low but concedes that she could end up with an ulnar nerve injury. She is now adamant that she doesn’t want an operation. Her parents are equally adamant that it should go ahead.

Duty of candour A young man of 22 is rushed to theatre with a haemothorax, secondary to a traumatic chest-drain insertion during the previous night for a spontaneous pneumothorax. At the end of a successful emergency thoracotomy during which he needs a six-unit transfusion, the anaesthetist asks the surgeon whether anyone has told the young man about the cause of this (avoidable) complication. The surgeon says he does not feel this is needed, as bleeding is a recognised complication of chest-drain insertion.

Tell us what you think at www.rcoa.ac.uk/

safeguarding/feedback

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Perioperative Journal Watch is written by TRIPOM (Trainees with an Interest in Perioperative Medicine – www.tripom.squarespace.com), and is a brief distillation of recent important papers and articles on perioperative medicine from across the spectrum of medical publications.

PERIOPERATIVE JOURNAL WATCHDr Lena Al-Shammari, Dr Deborah Douglas, Dr Geetha GunaratnamPerioperative Medicine Fellows, University College London HospitalsDr John Whittle, Consultant, Royal Free Hospital

The RCoA is committed to developing a collaborative

programme for the delivery of perioperative care across the UK

www.rcoa.ac.uk/perioperativemedicine

Enhanced recovery after surgery program implementation in two surgical populations in an integrated healthcare delivery system

This pre-post difference-in-differences study evaluated the impact of enhanced recovery after surgery (ERAS) implementation on two target patient populations. Patients undergoing elective colorectal resection (n=3,768) and emergency hip fractures (n=5,002) were compared with patients undergoing elective gastrointestinal surgery and emergency orthopaedic surgery respectively.

The authors report an improvement in process and outcome measures, including hospital length of stay and postoperative complication rates. Furthermore, there was a reduction in the hospital mortality rate in colorectal ERAS patients, and an increase in home-discharge rates among hip fracture ERAS patients.

Liu et al. JAMA Surgery 2017; published online doi:10.1001/jamasurg.2017.1032

Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing non-cardiac surgery

Myocardial injury after non-cardiac surgery is independently associated with an increase in 30-day mortality. The VISION study was a large international prospective cohort study of 21,842 patients (aged ≥45 years) undergoing non-cardiac surgery between 2008 and 2013. Postoperative high-sensitivity troponin T (TnT) measurements were taken at 6–12 hours and then daily for three days.

Death occurred in approximately 1.2% of the cohort. There was a significant association between high-sensitivity peak postoperative TnT measurement and 30-day mortality, independent of eGFR and sex of the patient. An absolute TnT change of ≥5 ng/L was associated with an increase in 30-day mortality, even in the absence of chest pain or ECG changes.

These findings highlight the potential scale of undiagnosed postoperative cardiac morbidity and mortality, and the potential role for secondary prevention.

Devereaux et al. JAMA 2017;317(16):1642–1651

Predictors, prognosis, and management of new clinically important atrial fibrillation after non-cardiac surgery: a prospective cohort study

The authors of the Perioperative Ischemic Evaluation (POISE) trial present this observational analysis of its participants. They defined clinically important atrial fibrillation (AF) as occurring in patients who were symptomatic or required treatment. They sought to:

■ determine the association of new clinically important AF with 30-day outcomes

■ assess the management of these patients

■ derive a clinical prediction rule for new AF in patients after non-cardiac surgery.

AF occurred in 2.5% of patients, and was independently associated with an increased length of hospital stay and vascular complications (stroke and congestive cardiac failure). Only a minority of patients with new AF and high CHADSVASC scores were discharged on an oral anticoagulant or anti-platelet agent. Older age and type of surgery were independent predictors of new AF, forming the basis of the authors’ prediction rule. This now requires external validation.

Alonso-Coello et al. Anesthesia and Analgesia 2017; 125(1):162–169


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http://www.tripom.squarespace.com

Dr Emma James,Locum Consultant Anaesthetist,Imperial College Healthcare NHS Trust

Dr Helgi Jóhannsson,Consultant Anaesthetist,Imperial College Healthcare NHS Trust

PREPARE for surgery: a paradigm shift

developed a hub of peer-to-peer support through a community where patients train together in the gym, and support and compete with each other.

In addition, the rate of surgical complications has decreased, as has the severity of these complications. Preoperative measurements in METS and self-efficacy scores have also improved. The median length of stay in hospital has also significantly reduced

Venetia Wynter-Blyth,PREPARE Clinical Nurse Specialist, Imperial College Healthcare NHS Trust

What is it?The PREPARE for Surgery programme consists of key elements for the implementation of a shifting paradigm surrounding the surgical-patient journey. It targets the phases of prehabilitation, enhanced recovery, and postoperative rehabilitation. Our view of what the PREPARE programme should look like was changed completely by involving our patients, not only in the implementation, but also in the design of the programme. Our patients have very different needs, and wanted a personalised programme that was multidisciplinary, local to them, and made full use of modern technology.

The programme looks at the whole picture, ‘training’ patients for surgery by targeting physical activity, nutrition, psychological wellbeing, stopping smoking, excessive alcohol intake, medication management, and education for enhanced recovery goals.

‘Our patients are better prepared on their day of surgery; they are motivated, fit, well nourished, and have a glint in their eye and a determination to get through the operation’.

The outcomesOne of the key benefits of the programme is patient engagement, through which patients have felt empowered to take charge of their health throughout the whole pathway. It has also

‘You wouldn’t run a marathon without training for it, would you? So why do we expect our patients to undergo major surgery with just a bit of pre-assessment and a pat on the back?’

PREPARE for Surgery programme


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as patients recover more quickly, and this has been paralleled by a dramatic decrease in the incidence of postoperative pneumonia.

Costs and sustainabilitySince 2015, the programme has been running with grants from the Imperial Health Charity and the NIHR CLAHRC, (The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care – West) with 80 patients scheduled for major upper gastro-intestinal surgery having completed the programme to date.

The supplemental team consists of a core clinical nurse specialist, dietician and exercise therapist, supported by the hospital team of surgeons, anaesthetists, nurses, physiotherapists and clinical psychologists, alongside Macmillan Cancer Support, Maggie’s Centres, and the Lynda Jackson Cancer Centre. The core team costs £20,900 per year, and provides an estimated cost saving of £265,000 per year, based on reduced rate and severity of complications and length of stay. Further costs have been incurred in creation of an interactive ‘app’ and provision of perioperative remote monitoring of patients (PROMPT). The programme is still fully charity funded at the moment, but as we are planning to roll this out to other specialities and hospitals, and the cost benefits of the programme become clear, we envisage full incorporation into the NHS.

The patient experienceOnce listed for oesophago-gastric surgery, patients are invited to the PREPARE clinic, where baseline measurements are taken to provide a benchmark to improve on over the four-to-six-week programme.

Patients are reviewed by the clinical nurse specialist, who conducts a psychological assessment, gives patients information on the procedure, and answers any questions

they may have. Providing good quality personalised information to patients and their relatives and carers has been shown to improve outcomes, reduce anxiety and improve the patient experience. The nurse specialist continues to meet the patient at key intervals to discuss progress and guide information to specific needs. They support patients through decision making, provide advice on side effects and symptom management, and provide emotional and psychological support throughout the surgical journey and recovery.

A personal trainer assesses each patient, and prescribes a personalised exercise programme. Patients have access to the hospital gym free of charge. or are given a home-based fitness programme. Physical activity aims to increase aerobic capacity and increase muscle and core strength. Respiratory exercises are taught and practised daily before the operation and every one to two hours after the operation as a preventive measure against postoperative pneumonia. A collaborative, tailored plan is then made with the patient, with daily or weekly goals which are then adjusted as the patient progresses.

The dietician assesses nutritional status, and reviews blood results, diet, lifestyle and the surgical treatment plan, and also

provides a diet plan, supplements, and referral for prescription of vitamins and minerals as required.

Medications are also reviewed, and a perioperative plan made for medications that may need to be stopped or bridged with alternatives around surgery. Lifestyle modification is a central part of the programme – being given a cancer diagnosis is a shock, but provides an opportunity for our patients to reassess their lives and a motive to be healthier. The programme has an excellent record for smoking cessation (nearing 100%) and our patients also manage to cut down their alcohol consumption. The importance of the patient knowing what they can expect cannot be emphasised enough. Our patients are not only more motivated, but also motivate our staff, for instance by reminding us that they are due to have their afternoon physiotherapy. They are central to their care and take ownership of it.

PREPARE for Surgery won two awards at the recent BMJ Awards.

Learn more about the PREPARE for Surgery programme and watch their video at https://vimeo.com/160850030 to hear from patients.

Aerobic training and muscle strengthening exercises in the gym with our exercise therapist


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After 19 years as a consultant anaesthetist, I am now a Guardian of Safe Working at an acute trust in London. I have been a British Medical Association (BMA) activist for several years so was quite familiar with the 2016 contract and how it came into being – with both the BMA and NHS England wanting Guardians in post regardless of whether or not the contract was imposed, but with nobody being quite sure how it would work in practice.

Colonel Glynn Evans, Guardian of Safe Working, London North West

Healthcare NHS Trust

The 2016 contract and exception reporting

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I answer directly to the trust board, and report upon the compliance of junior doctors with the hours regulations: are they working safely, being overworked, working more than their allocated hours, etc.? This whole process hinges on the submission of Exception Reports (ERs).

My first part in the process is to assist in the design of rota templates. Whilst it is the responsibility of each department to define service needs, I work with them and ensure that rota templates are compliant with the new regulations. A major challenge in this is that many of the traditional work patterns are no longer permitted, and yet a number of senior consultants seem unable to think beyond these. I have also noticed attempts to make a rota compliant by claiming that trainees work only from 9.00am to 5.00pm.

In every case that I have seen thus far, the new rota template offers trainees more time off; meaning less training time or less time delivering service commitments. As the service commitments won’t go away, this leads to short-staffing and rota gaps. Consultants are now worried as they are increasingly being asked to act down and do the trainees’ work, which may not be within their current competencies.

Having populated the rota, ERs now become important. If a trainee works other than their rostered hours, an ER should be submitted. The 2016 contract states that trainees “will” submit an exception report1 and both the GMC and Health Education England (HEE) have issued guidance on so doing.

The ER isn’t about blame, it’s about noting how much we are working our doctors. Nobody complains when we ask pilots or Heavy Goods Vehicle drivers to keep track of their hours, so why is there such resistance amongst doctors?

When an ER is submitted, the Educational Supervisor (ES) should agree or disagree with it, and award pay or time off in lieu. There are two electronic systems currently in use within the NHS for this – neither is perfect and there is wasted time and frustration aplenty.

After the ES, the ERs are passed to the Guardian to monitor trends. In particular, I look for consistent overworking within a particular rota, or when a particular firm is on duty, and feed this back to the clinical director and general manager. If significant breaches of working hours regulations occur, I fine the department concerned. The purpose of this feedback is to attempt to ensure that the departments acknowledge the trainees’ workload and move towards compliance. The purpose of fines is to deter departments from the more significant breaches.

Unfortunately, there is a lot of resistance from some longer-serving consultants: “I worked those hours, so my juniors will”, “There’s nobody else, you will just have to stay on”, “If you don’t stay late, it’s the patients who will suffer”.

I find this incredulous. If I reflect on other professions with hours regulations, I ask myself who would wish to fly with a pilot who had already flown maximum hours but had been told to keep flying, as there was no other pilot and the passengers would suffer?

Under the 2016 contract, the evidence on which I can act is the ERs and the statements within them. Every quarter, I summarise the evidence from the ERs and present a paper to the trust board on whether the working hours regulations are being breached and why. These reports would normally be in the board’s public papers and can be found on the internet; some make interesting reading. The reports are copied far and wide, including the GMC, HEE and NHS England. In my reports I can also compare departments, and any attempt to escape the attention of the board by persuading trainees not to submit ERs is misguided, as the absence of reports from any department for three consecutive months attracts attention.

I recall that the reason why the contract was imposed by the then Secretary of State was to increase the number of doctors working at weekends. Has it achieved this? Yes and no, depending on how you view the statistics. In absolute terms, the number of junior doctors working at weekends has not increased in any rota of which I am aware. What has happened is that the number of juniors working on weekdays has decreased. There are therefore proportionally more doctors working at weekends. Sir Humphrey Appleby would be delighted!

References1 Terms and Conditions of Service for NHS

Doctors and Dentists in Training (England) 2016 Version 3, Schedule 5, Paragraph 5. (21 April 2017).

There is no exception to the rule that every rule has an exception


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Embedding shared decision making into the heart of perioperative practice is a key aim of the Perioperative Medicine Programme. A previous article described the concept of shared decision making and its evidence base.1 A survey we carried out2 suggested that anaesthetists want more information and training on delivering shared decision-making consultations. This series of articles aims to demonstrate how anaesthetists can use shared decision making in their daily practice, from high-risk consultations to minor cases. In the light of the Montgomery judgement,3 learning how to conduct these consultations, is even more important.

Consider this possible scenario and the professional perspectives: John is 73 and has severe peripheral vascular disease. He has been offered a bilateral axillofemoral grafting procedure following failed peripheral revascularisation procedures. He attends the high-risk anaesthetic clinic to evaluate his fitness for surgery. He has limiting chronic airways disease, with multiple hospital admissions over the winter months. He lives with his wife.

Dr Chris Snowden and Dr Mike Swart, RCoA Perioperative Medicine National Clinical Leads

Listen to the patient, he is telling you the diagnosis...William Osler

The surgeonIn this case, the surgeon has the technical skill and expertise to carry out the surgery, and realistically this procedure offers the only hope of limb salvage. The surgical consultation is therefore framed by the possibility of an operation. It is likely that the surgeon has concerns about whether it is the right thing to do, and indeed may not want to undertake surgery. However, as the clinician managing the disease, it may be difficult on a personal and professional level not to offer limb-saving surgery at all.

Dr Anne-Marie Bougeard, RCoA Perioperative Medicine Fellow

SHARED DECISION MAKING IN PRACTICE (Part one)


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This case is an example of the types of scenarios we see increasingly frequently. To many readers it may be obvious what the solution is, but from whose perspective? Patients will feel very differently in this situation. We would argue that the anaesthetist in this case is ideally placed to conduct a consultation, which would support a decision right for John, his medical team and his family. The anaesthetist has an independence from the surgeon–patient relationship described, and, with experience in risk assessment and access to objective assessments of fitness, can guide John through the decision-making process.

Why the anaesthetist?Grocott and Pearse4 have previously argued the case for anaesthetists as perioperative physicians. Shared decision-making consultations represent part of that role. They are an opportunity to make positive interventions to ensure that the right

patient is having the right surgery, and can be considered as a ‘time out’ to check patients’ understanding of their personal risks and that their expectations match reality. It is arguably part of the consent process. There is evidence that conducting shared decision-making consultations5 in a dedicated clinic can reduce the number of procedures performed, reduce the complexity of procedures and have positive effects on the relationship between clinician and patients, with lower levels of decisional regret.6 We should be doing what we can to make sure we are not undertaking risky, costly, and often futile surgery that patients do not want. On an economic level, investing in dedicated clinic time to have these consultations can be offset by reduced numbers of patients having inappropriate surgery.

In the next of this series we will illustrate how a shared decision-making consultation could be conducted, and show how we already possess many

of the basic skills to do it. We will also show how all anaesthetists can adapt these techniques to their everyday consultations outside of the high-risk clinic.

References1 Crossingham G. An overview of shared

decision making. RCoA Bulletin 2013;81:19-21.

2 Bougeard AM et al. A survey of UK perioperative medicine: preoperative care. Anaesthesia 2017.

3 Montgomery vs Lanarkshire Health Board. Supreme Court 2015. (http://bit.ly/2tU8ZFT).

4 Grocott MPW, Pearse RM. Perioperative Medicine: the future of anaesthesia? British Journal of Anaesthesia 2012.108(5): 723-726.

5 Coulter A, Collins A. Making shared decision-making a reality. No decision about me, without me. The Kings Fund 2011. ISBN 9781857176247.

6 Measuring Shared Decision Making – NHS England (http://bit.ly/2gPiGEi) accessed 24/6/17.

The patientJohn is fed up. He hasn’t been able to have a shower for a year because of the dressings on his legs. He hardly leaves the house. He would really like to use his caravan again. He knows he is dying. He says that each time he is discharged from hospital he is ‘ ”better” but overall a bit worse’, never getting back to baseline. He has the insight to take this to its logical conclusion. He doesn’t want heroic surgery, and knows it would be complicated and not guaranteed to work. He has a good relationship with the surgeon and great respect for him, but he doesn’t feel he can decline surgery as he has been told it is his only option.

The anaesthetistTraditionally, the anaesthetist in preassessment clinic would be in information-gathering mode: evaluating co-morbid disease, organising referrals, optimising medication and focusing on how to anaesthetise the patient for the listed procedure. There would have been little discussion of the suitability of the operation for the patient. He or she would conduct a risk assessment for the perioperative period, and advise John, make a plan for postoperative care and perhaps speak to the colleague giving the anaesthetic.


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Strengthening the College’s AAC roleThe appointment of consultants is a high-stakes decision. Good decisions are safe for patients, help to develop service, training, research, and enhance the reputation of the organisation. Conversely, the direct and indirect costs of poor decisions can run into millions when lost productivity through poor performance, salary costs of suspensions, investigations and medico-legal costs alone are taken into account.

Dr Andy Norris,RCoA Lead AAC Assessor

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Despite the importance of these decisions, those readers involved in Advisory Appointment Committees (AACs) around the country will be familiar with the often weak processes and variable rigour in the conduct of consultant appointments. These weaknesses range from the quality of job descriptions and person specifications, to advertising, shortlisting, and the interview process itself. The whole process typically compares unfavourably with even the most junior appointments in large firms in other sectors of the economy. Typically, panels are poorly prepared, little consideration is given to what areas are to be assessed, questions are weak, and little or no effort is made to define in advance what would constitute strong and weak responses to questions. Arguably these weaknesses are mitigated in medicine because applicants have high levels of clinical expertise which has been frequently assessed over many years en route to the AAC. Furthermore this expertise is the central part of the consultant role. This contrasts with senior appointments in other areas. In many sectors competition for roles may be considerable, but this is relatively rare in consultant appointments where finding someone qualified may be the main problem; so sophisticated interviews and assessment, designed to rank many candidates, would be

inappropriate. These arguments may explain the fact that, despite the poor processes that typify many AACs, most appointments are successful. Only a small minority of consultants run into major difficulties. We should also acknowledge that future problems may or may not have been predictable at the time of appointment. However, there is a wealth of information now collated during training including ARCP performance, targeted training, extended training time and MSF responses, which can and should be informing the appointment process.

The College, through its job description approval process and involvement of its network of AAC assessors, can make an important contribution to strengthening consultant appointments. Foundation Trusts, of course are not obliged to engage a College assessor, though many do. However, we believe that the best way to maintain and improve engagement is to demonstrate the added value that a College assessor can bring. The AAC assessor can provide an external reference, benchmarking the post and the candidates against the national picture. They can also provide a degree of impartiality and objectivity. Therefore, while wholesale improvement would be welcome, and the College is keen to work with employers and other Colleges on

pre-interview aspects, our initial focus is on recruiting, supporting, educating and training our cohort of AAC assessors.

The College holds an annual training day targeted at both new and established assessors. This provides an opportunity to address questions and common misconceptions, and work through typical problems that may arise, as well as work on interview skills and pitfalls around unconscious bias and equality legislation. Questions that arose recently included: “Do I have to ask everyone the same question?” (No! But you should explore the same area(s)), and “Can I ask other questions in addition to exploring the CV?” (Yes). “Do I have equal voting rights to other panel members?” (Definitely Yes). Scenarios included applicants with non-standard training, on-the-day changes to the post being offered, biased or ineffective panel members and Chairs, and other thorny problems.

The College always welcomes enquiries and applications from experienced consultants who have been involved in leadership roles. The role is interesting, and challenging as well as rewarding.

For further information please visit www.rcoa.ac.uk/aac. Or contact [email protected] or 0207 092 1571.

The AAC assessor can provide an external reference, benchmarking the post and the candidates against the national picture.

For further information about AACs please visit www.rcoa.ac.uk/aac


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‘CROSSING THE RUBICON’Musings of a jobbing anaesthetist

on the RCoA Council

How time flies! It is already over a year since I was ushered into the ‘hallowed’ premises of our Royal College as a Council Member. I still vividly remember the phone call from the President on that fateful Friday in early December,

when he congratulated me on my success in the elections to Council. Initial euphoria gave way to trepidation, as the anointing day drew closer.


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Dr Krish RamachandranRCoA Council Member and Chair of the Equivalence Committee

You will understand my anxiety, as I am drawn from a jobbing background, with limited experience of high office. ‘Watch your back, you are about to enter the lion’s den’, were the words of a trusted senior colleague who is experienced in such matters. But I need not have feared, as the atmosphere is quite congenial (mostly), and I am made to feel very welcome. So after the first few months spent finding my feet, my confidence began to grow steadily. Undoubtedly, the learning curve has been a very steep one.

A year on, and I have moved on, and the gibbering novice I used to be is miles behind. I have been tasked with chairing the Equivalence Committee, and I also act as College advisor on the NCEPOD and SHOT (Serious Hazards of Transfusion) steering groups. The past year hasn’t been without its share of challenges, and I have had to make some sacrifices (no prizes for guessing which). I still remain on a 10-PA contract, working more flexibly and participating in the on-call roster. But, I am also conscious of the fact that challenges are likely to get even tougher over the next few years. For the time being at least, I am comfortably nestled between two esteemed, AAA-rated (Approachability, positive Attitude, extraordinary Accomplishments) colleagues in the Council chamber, hoping that their magic will rub off on me. There is time yet for that to happen. And that brings me to the subject I really want to talk about.

Perioperative medicineA few years ago, when the concept of perioperative physicians was first floated, I strongly identified myself with that

vociferous group of colleagues who were trenchant critics of the idea. I had similar misgivings to those of some of my fellow critics, and it is not difficult to imagine what they were. However, over the last year or so, and after discussions about this ‘sore’ subject with many colleagues, both on the Council and in the wider anaesthetic community, I can sense that my belligerent stance has yielded – a lot. As it has done so, I have made that mental leap across the chasm that divides those that have followed the College’s lead and those that haven’t.

Our specialty has evolved over the last 150 years, and has probably become unrecognisable to early pioneers in the field. The growth has been incremental; there have been lengthy spans of very little progress or of stagnation, punctuated by spikes of clever innovation that has accelerated understanding and progress by the specialty. So at this crucial juncture, when our specialty is at a crossroads, why should I stand in the way of the ‘innovation’ that will further enhance the safety of patients and, in my view, the job security of its practitioners? The vision of anaesthetists as perioperative physicians is beginning to grow on me, and grow fast. Although the contours of the perioperative physician role are not yet clearly defined and there are still many unanswered questions,

I believe that the College was correct in setting this ball in motion. Since its incorporation into the training curriculum, perioperative medicine has moved from being an abstract concept to being one of the shop floor. As it continues to embed and develop, future generations of trainees will not know any different view of the specialty, and I believe perioperative medicine will become the norm. The debate therefore has moved on from whether we should become perioperative physicians at all, to what the new role should look like. It is up to all of us to pick up that gauntlet, before colleagues in other specialties such as geriatrics fill the void.

But perceptions are hard to shift, and understandably so. There is still scepticism about perioperative medicine, and the College will have its work cut out to shift that. ‘Isn’t it odd how he has switched camps since joining the Council?’ I hear you cry! Some weeks ago, I was chatting with a senior colleague in my department about my work with the College. I was describing how the College has shaken off its old image, and is reaching out to its Members. He shot back at me, saying ‘it is you that has changed, not the College’. Maybe so, but I hope to prove him wrong...some day.

Interested in running for Council? See page 8.

Perioperative medicine is no longer an abstract concept


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Dr Shakeel MoideenConsultant in AnaesthesiaPrincess of Wales Hospital, BridgendABMU Health Board

STEALTH ANAESTHESIA

The ”Soothing Patients’ Anxiety” (SPA) experience recently won the ‘Anaesthesia Team of the Year’ award at the BMJ Awards 2017. This is how it began.Improving patient care need not involve new knowledge: it can be achieved by working differently. Small changes in the way we work can make huge differences to patient experience.

When we started a new day-care service for patients with learning difficulties receiving restorative dentistry procedures, nobody in the team had any prior experience of working with this cohort of patients. They ranged from children of two years to patients in their 70s who had difficulties understanding or communicating. Cerebral palsy, autistic spectrum disorders, patients with various syndromes, mental health disorders and dementia were some of the conditions that were encountered. Apart from having to face challenges associated with the various co-morbidities that presented often, we soon realised how vulnerable this group of patients were. A good number of them had previously

had very bad experiences in hospitals that made their behaviour even more challenging to manage. We soon learned from the patients’ carers how seemingly small events in environments outside the patients’ comfort zones had a huge negative impact on behaviour. There were too many potential trigger points at hospitals that set off difficult behaviour and distress in these patients.

We learned from the carers that the usual techniques had all been tried in the past – distraction, premedication, coercion and restraint – with varying degrees of success.

We needed to do something different. Our aim was to be able to get these patients into hospital, anaesthetise them without any delays, wake them up immediately after, and send them home as quickly as possible. Knowing that these patients may need to visit

the hospital in the future, we also had to make sure that it was a pleasant experience for them.

There isn’t a ‘one size fits all’ solution. We realised how apt Stephen Shore’s words were when he famously said ‘If you’ve met one person with autism, you’ve met one person with autism’. We had to treat each patient as the unique individual they were. This meant knowing the patient. We devised carers’ questionnaires, patient passports, and traffic-light documents to get to know each patient. When possible, we got them into hospital for a pre-assessment to desensitise them to a certain extent, and to familiarise them with the environment and with our faces. We combined the surgical clinic with the anaesthetic pre-assessment to avoid multiple trips to the hospital. We held multidisciplinary meetings for difficult patients who could not come

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Working in a dark room while the patient experiences sensory lights on the ceiling

Modified catheter mounts for a ‘Frozen’ experience

into hospital, and often needed to make domiciliary visits to understand the risks they may pose on the day, including airway assessments. We had to find their comfort zone. We would then tailor the environment and the anaesthetic management accordingly for that particular patient, knowing that we had one good chance at getting it right.

The SPA experience is a unique approach to co-production. Each patient has a personalised plan that can turn a

potentially frightening and unpleasant treatment process into something that can be safe, enjoyable and as memorable as a trip to the cinema, for the patient and also the staff.

So, what is Stealth Anaesthesia then? We try and communicate the need for the procedure, and the fact that we would make sure they would be asleep for it, to these patients. We try not to get them too involved with the induction process. They are usually either listening to their

favourite music, watching their favourite video (on a big screen on the wall), watching sensory lights on the ceiling in an otherwise dark and empty room (except for an anaesthetic machine), or are playing with their favourite toys. They need not be on the trolley if they don’t want to be – we can anaesthetise them on chairs or on the floor (with hoist slings behind them). It could mean a quick Venflon into a hand that has

been prepared with Ametop, followed immediately by propofol, or a slow sevoflurane induction with no mask. We rarely need to give premedication, and only very rarely needed to give intramuscular Ketamine in the car. We don’t use restraint, but have sometimes planned and asked the patient’s Positive Behaviour Management (PBM) team to provide safe holding. Patients usually get discharged very quickly from recovery, and often we go from theatre straight to the car for recovery.

Feedback from carers has been excellent. This approach has led to decreased anxiety and distress, and a decrease in difficult to manage behaviour and failure to treat. The need for heavy sedation, clinical hold, or even a hospital bed, has been rare. The staff feel valued and enjoy the day too, since this is a real team effort and it requires the anaesthetist, ODP, nurse and carers to all work to a pre-set plan which involves a lot of fun.

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RCoA 25TH ANNIVERSARY ESSAY PRIZES

What will anaesthesia look like in the next 25 years?42 |


The essay prizes were specifically developed to celebrate the College’s 25th Anniversary. A total of 47 entries were submitted – 21 from Foundation Year doctors, 18 from anaesthetists in training and eight from medical students. The winners and runners-up were announced at the RCoA’s Summer Symposium. Dr Jeremy Langton (RCoA Vice-President and 25th Anniversary Organising Committee Chair) chaired the judging panel. Elspeth Evans is on the RCoA Lay Committee and was a judge for the competition. Here, she gives an introductory overview:

Elspeth Evans RCoA Lay Committee Member

Dr Jeremy Langton RCoA Vice President

Medical students and Foundation Year doctors were invited to submit an essay in response to the title ‘What will anaesthesia look like in the next 25 years?’ Anaesthetists in training were also invited to submit an essay, but on the theme ‘A day in the life of an anaesthetic trainee in 2042’. As judges, we found many of the topics included in the essays pertinent and imaginative.

What might 2042 and the intervening years look like? Themes and ideas varied widely, from highlighting the political and economic issues of the NHS today, to a brave new world of virtual reality, genetic profiling and the use of drones in delivering medical care.

Obesity was cited as a major health challenge, with double-width hospital beds becoming a reality. In this healthier

new era, hospitals are barred from selling sweets and crisps, and a celebrity chef is the Minister of Health. Perioperative medicine has become the norm, and home visits can be carried out using video conferencing.

Drones deliver medical supplies and pre-mixed syringes are normal. Patients wear electronic tags so that their data is easily uploadable to an anaesthetic logbook app. Biosensors in the bathroom mirror, sink and toilet analyse molecules in breath, saliva and urine. Neo-organs are generated by 3-D printing following the introduction of the routine harvesting of stem cells at birth.

Operating theatres have become far more technologically advanced. Virtual reality means that patients are able to be transported to a tranquil environment

such as a beach, while being operated on. Wireless monitoring in theatre means an end to trailing cables, and robots assist with the delivery and monitoring of anaesthesia. A theatre black-box recorder provides a complete audio-visual record in case of future litigation.

The essays of the winners and the runners-up all displayed great imagination, creativity and were well written. Extracts from these essays are published on the next page, and the full essays can be viewed at http://bit.ly/rcoaessayprizes.

I hope you enjoy reading them as much as I did. A last thought: I didn’t realise anaesthetists drank so much coffee!

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‘I once met a patient who when confronted with going under general anaesthesia became a nervous wreck and a 14 gauge cannula’s breadth from punching the consultant and running. Uncertainty is unnerving. Our best weapon for combatting patients’ worries is evidence-based medicine. We may not have all the answers, but we have the best ones available. When approaching the future it would be hypocritical not to place that same trust into evidence-based prediction techniques. Clouds of uncertainty also hover above the future of anaesthesia. When asking what it will “look like” we are not merely asking whether the protocols will be different or the drugs new. We are asking whether anaesthesia will be demonstrably distinct from what it looks like now. Different factions predict shifts towards perioperative physicians inundated with clinics or mere technicians who intubate. There are also questions about how academic and global anaesthesia will fit into the picture. This essay will therefore draw upon the findings of leading psychologists, economists, and statisticians, whilst exploring how other sectors have coped with similar

challenges that anaesthesia may face. It will use evidence-based strategies to evaluate potential changes to the role of anaesthesia, showing trends away from academia but towards becoming safer for patients at home and abroad. Ultimately it will suggest that we embrace new technologies, support research, and lean towards perioperative medicine over the next 25 years.’

Tom Sanderson, Newcastle UniversityRunner-up‘Looking back upon the Age of Enlightenment and its discovery of nitrous oxide, we can see the beginning of a discipline that resembles anaesthesia today.1 However, since this origin, anaesthesia’s course has been far from unwavering. Despite William Morton’s demonstration of ether for the painless operation in 1846,2 public perception of the discipline was still tentative. It took the royal seal of approval from Queen Victoria when she used anaesthesia during labour in 1853 and 1857 to finally quash lingering hesitancies over this new era of medicine.3

Winner Ariella Midgen,

University College London

What will anaesthesia look like in the next 25 years?

RCoA 25TH ANNIVERSARY ESSAY PRIZES

MEDICAL STUDENT ESSAY PRIZE‘Patients and their families are often fearful about the future. Will the pain ever go away? Will resuscitation work? Will they wake up after general anaesthetic?’


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‘Jump forwards to 2017 and the calculated, exact, safety-centred specialty of anaesthesia may be unrecognisable to its early pioneers. The question is, will we be able to recognise it over the next 25 years?

The Role of the Anaesthetist‘We all take differently to the various epoch-defining buzzwords that circulate through the medical profession: ‘reflection’ and ‘resilience’ are just two from current trends. Even from my position outside the profession, I have become aware of such a phenomenon occurring within anaesthetics that has the potential for significant change.

‘The era of the Perioperative Physician may be dawning, and, if so, this could have major implications for the specialty. The role of the anaesthetist could

be changing dramatically, bringing responsibility for more general aspects of patient care before, during and after the operation. There are concerns from within the profession about what this will look like, what the definition of the perioperative physician is and even where the perioperative period starts and ends.4 However, others advocate that this new role could see the specialty grow into a new light, where our clinical scope expands to strive for better patient care and surgical outcomes.5

‘The design and implementation of a new perioperative medicine pathway will influence anaesthetics training in the UK,6 and it looks set for the role of the anaesthetist to change. In the next 25 years we could therefore see the ‘unmet needs’ of variation in surgical morbidity

and mortality greatly reduced,4 partially by the growth and development of anaesthesia for enhancing patient care.’

References1 Smith W. A History of Nitrous Oxide and

Oxygen Anaesthesia; Part I: Joseph Priestley to Humphry Davy. BJA 1965; 37(10):790–798.

2 Adams A. Tarnished Idol: William Thomas Green Morton and the Introduction of Surgical Anesthesia. Journal of the Royal Society of Medicine 2002; 95(5):266–267.

3 The History of Anaesthesia. RCoA 2017; www.rcoa.ac.uk/college-heritage/the-history-of-anaesthesia

4 Webster N. The anaesthetist as the peri-operative physician. Anaesthesia 2000. 55(9):839–840.

5 Grocott M. Pearse R. Perioperative medicine: the future of anaesthesia? BJA 2012. 108(5):723–726.

6 Royal College of Anaesthetists. Perioperative Medicine: The Pathway to Better Surgical Care. RCoA 2014.

They also thought pain would help the patient rebound. When they finally decided pain was a bad thing, they used ether.’

However, nearly half a century before that a young chemist known as Humphry Davy had discovered an anaesthetic before the word “anaesthetic” even existed.

‘I digressed and told them my favourite story. I told them about this 21-year-old chemist who was looking for a possible cure for tuberculosis. He started by inhaling carbon monoxide, dropped to his knees with agonising chest pain, became unconscious then recovered. A few days later he would try again.1

‘He then discovered nitrous oxide. It made him laugh, it made him tingle and it made him happy. Yet it did not cure tuberculosis. What he noticed however was that it temporarily relieved his toothache.1 He wondered if it could be used as an anaesthetic. This was a time that the idea of pain-free surgery was radical. Little attention was paid to Davy’s proposal until 40 years later, when surgeons decided that pain was a bad thing. When they made this discovery, they used ether and not laughing gas.

‘I could sense the rapt attention as I recounted this story. I told them that it was my favourite story because it is a

Winner Dr Dairshini

Sithambaram, Aberdeen Royal

Infirmary

FOUNDATION YEAR DOCTOR ESSAY PRIZE‘I told the class that pain was once thought to be a favourable thing. Back in the day, surgeons thought pain (with associated screaming) prompted them to cut faster and accurately.‘


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story about perseverance, discovery and creativity. While I had their attention, it was time for the climax and to finally conclude. It was time to tell them about one of the most important discoveries of our time that had changed our practice.

‘I described it as one of our best discoveries. I described this drug as a revolution to our practice – a game changer!’

Reference1 Perioperative Medicine: The Pathway to

Better Surgical Care. RCoA. 2014.

Dr Laura Marsland, Dartford and Gravesham NHS Trust Runner-up‘When reporting on their notable study of deaths associated with anaesthesia and surgery, Beecher and Todd commented on the ‘great changes’ that they had observed in anaesthetic techniques during

the five-year period of data collection between 1948 and 1952. They concluded at the time ‘the practice of anaesthesia is far, as yet, from achieving stability.’1

‘But while drug development and advancement of intraoperative clinical monitoring may have characterised the last twenty-five years, what changes do the next twenty-five years hold for the anaesthetic profession? It is reasonable to expect that with a National Health Service facing unprecedented and increasing demand, the profession may face quite different challenges in the future. Older patients and those with more complex physiology are undergoing operations and requiring intensive care. The nature of operations themselves is changing, with newer surgical techniques being associated with ‘new’ physiological responses, and an increase in endoscopic and laparoscopic procedures necessitating the requirement for safe ‘outpatient

anaesthesia’. Patients are expecting, quite rightly, a higher degree of input into and control over their planned interventions, and the medical profession as a whole is becoming more accountable. How will the profession and the RCoA adapt and progress to meet these challenges and to support the maintenance of the NHS as a world-class service?

‘Perhaps expansion of the role of the anaesthetist will characterise change over the next twenty-five years. The concept of ‘perioperative medicine’ and the role of the anaesthetist as a perioperative physician, according to some, will define the future of anaesthesia and may even be fundamental to the longevity of the profession.’

Reference1 Beecher HK, Todd DP. A study of the deaths

associated with anesthesia and surgery: based on a study of 599, 548 anesthesia in ten institutions 1948–1952, inclusive. Annals of Surgery. 1954; 140(1): 2–35.

‘Jim wakes up naturally, feeling refreshed from a quality night of uninterrupted sleep. This isn’t unusual for Jim, a final year chief resident in anaesthesia.’ ‘The term ‘trainee’ was finally abandoned in 2031 after years of collective misunderstanding of what a ‘trainee’ actually meant. Although the College resisted, the Americanisation was all but inevitable. Since the abolition of training programmes run by geographical areas or (Local Education and Training Boards (LETBs), as they were once known), and the move to a system in which doctors in anaesthesia are trained in one institution, the role of “chief resident” has been embraced.

‘Jim is refreshed because for the last two years of his training he has enjoyed working a 32-hour week. Anaesthetists are strictly forbidden to work in excess of 40 hours in a week and this should only occur under ‘extreme and exceptional circumstances’. Rules brought into UK law in 2035 reduced the maximum working week from 48 to 40 hours, and in 2040 all rosters within the UK adopted a 32-hour working week pattern. Experience in the early 2000s, led in part by the ‘up starters’ and

Winner Dr James Plumb,

Southampton University Hospital

ANAESTHETISTS IN TRAINING ESSAY PRIZE

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‘dotcom boomers’ in Silicon Valley; reignited the realisation that productivity actually increases when people work fewer hours.1,2,3 This had the knock-on effect of a reduction in the risk of stroke and heart disease.1,4 Problems identified by a national survey of anaesthetists in training in 2016-17 identified that 85% of anaesthetists in training were at risk of burnout. This led to widespread reform in working patterns and hours, which culminated in the GMC helping to build this into UK constitutional law.3

‘He saunters downstairs to enjoy his usual breakfast of scrambled eggs and avocado before heading out to cycle the 15 km journey into work. He gets a message via the screen in his kitchen at 6:30am to let him know that his daily calorie count for yesterday was sufficient and that his current levels of HDL/LDL and plumbolactin5 are within range, his blood pressure and heart rate are perfect and his BMI is 22; he is allowed to make the journey into work.’

References1 Why working fewer hours would make us

more productive. The Guardian (http://bit.ly/2uxNwXW) (Accessed 16/02/2017)

2 UK needs four-day week to combat stress, says top doctor. The Guardian (http://bit.ly/2uHttXl) (Accessed 22/02/2017)

3 Pencavel J. The Productivity of Working Hours. The Economic Journal 2015; 125: 2052–2076. doi: 10.1111/ecoj.12166

4 Get a life. The Economist (http://econ.st/2tFqZ6M) (Accessed 16/02/2017)

5 Plumbolactin was discovered in 2026 by researchers in Bristol. It is a sensitive biomarker of stress, and levels greater than 25 mol/ml are directly correlated with myocardial infarction and stroke.

Dr Naomi Ward, Chesterfield Royal Hospital Runner-up ‘The sun rises at six, waking me up at quarter past and after a quick breakfast, I hop onto the monorail for the short journey to the hospital. We have a four-hospital complex with paediatrics, maternity services, general medicine/surgery and public health/psychiatry all in one big area. I get in just before seven and quickly see the patients before we brief just after seven-thirty. I’ve already spoken to most of them via the internet link we have to the community preoperative assessment clinics; I’ve also managed to discuss several of them with my boss too. This service is invaluable to me as, unless something has changed relatively recently, I already have my anaesthetic plan in mind.

We get through the team brief with minimal joking about the state of hospital parking (non-existent – I don’t even know why anyone drives anymore with the cost of petrol and the gridlocked roads…) and this provides us with the chance to clarify with the surgeon about positioning, antibiotics etc. All patients are skin-swabbed in the community, and risk-assessed for the likelihood of postoperative surgical site infection; because we have such high antibiotic resistance, we only use prophylaxis if necessary.

My next task of the day is to get my drugs out of the cabinet. They’re all in premade syringes and need to be checked before being mounted onto the drugs module; I can then administer anything I need to give to my patient from my control panel. I always spend some time checking my machine and other equipment, but I usually manage to squeeze in a quick cup of coffee – a much needed energy boost!’

Read all the winners’ full abstracts at

http://bit.ly/ rcoaessayprizes

2ND ANNUAL POMCTN AUTUMN MEETINGWednesday 2 November 2017, Crowne Plaza, Manchester£45 (25% discount for medical students and AHPs)

Lectures and workshops with distinguished healthcare leaders and the opportunity for delegates to provide and receive constructive feedback on future studies and network with fellow researchers across the UK. POMCTN is open to new members and encourages trial submissions for presentation at the meeting!

■ Surviving the approval process ■ How can the CRN help you?

■ Qualitative data – more than just numbers ■ Working together with surgeons to deliver

perioperative studies ■ Who is the Chief Investigator?

Places are limited so please apply early. For more information or to make a submission visit www.pomctn.org.uk and follow @pomctn

5 CPD POINTS

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In 2003, as an anaesthetist and half-time secondee to the Department of Health, I received a proposal to develop e-learning to revolutionise radiology training. At that time, the internet was in its infancy, e-learning rudimentary, and national IT projects regularly mired in controversy. Nothing daunted, we turned it into the ‘most promising educational development for 20 years’ (Chief Medical Officer) and persuaded the government to invest in an NHS-wide e-learning programme: e-Learning for Healthcare (e-LfH).

Established in 2007, e-LfH started with eight flagship programmes, including e-Learning Anaesthesia (e-LA). We had to ‘rewrite the book’ on how to map e-learning to a curriculum, devise content that was bite-sized and interactive, blend teams of IT specialists and clinical authors, and build platforms and search engines that would deliver what clinicians need in a busy NHS setting, using anything from the oldest NHS computers to modern technology. Led by Ed Hammond and Andrew

McIndoe, e-LA has been at the forefront of these developments and won multiple awards. Now, e-LfH has over 120 programmes which are available free of charge to healthcare professionals in the NHS and beyond, transforming education, training and patient care in the NHS.

Launched in September 2007, e-LA has grown to be the largest e-LfH programme thanks to the efforts and commitment of over 30 editors and over 400 authors from the anaesthetic, intensive care and pain medicine communities. It contains over 2,000 e-learning sessions, CPD articles and interactive multiple-choice-question tests structured to support Core/Specialty training, exam preparation and Specialist revalidation. There are also learning paths for medical students and others that support postgraduate courses.

e-LA also led the way in the development of the new e-LfH Hub, its search engine and many of the other tools that are used across e-LfH, and continues to explore innovative ways of delivering medical education in the digital age. The numbers speak for themselves:

■ 46,400 registered users

■ 2.22 million sessions launched

■ 999,600 hours of learning completed.

So, congratulations e-LA on your first decade – roll on the teenage years!

People overestimate what they can accomplish in a year – and underestimate what they can achieve in a decade Tony Robbins

Dr Julia MooreNational Director, e-Learning for Healthcare (2007–2016)

A DECADE OF CHANGE

e-Learning Anaesthesia2007–2017

YEAR

S

Visit the e-LA website at www.e-lfh.org.uk/programmes/anaesthesia

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SENIOR FELLOWS CLUBMEETING AT THE ROYAL COLLEGE OF ANAESTHETISTS

Our ever-cheerful president, Dr Liam Brennan, struggled to find us good news – these are difficult times. But when David Wilkinson, the past-president of the World Federation of Societies of Anaesthesiologists, described the work of the Federation, we realised that we still have a great deal to be thankful for. The Club was delighted to see that the College now uses a sketch by our member John Mathias as the screen saver in the lecture theatre.

Our invited speaker was Harriet Tuckey, who told us about her brilliant but difficult father, Griffith Pugh. Pugh analysed the reasons for the repeated failures of British attempts to climb Everest, formulated the policies for oxygen usage, acclimatisation, hydration, diet and hygiene, and designed the clothing, tents, and high-altitude cookers used in the successful 1953 ascent. Harriet realised that Pugh’s role had been deliberately obscured in the official

account by John Hunt – admiration for amateurism was entrenched in the 1950s, and sharing glory is a hard thing to do. Pugh continued his work on high-altitude physiology by setting up the Silver Hut laboratory at 6,000 metres in Nepal, recruiting now legendary young scientists such as John West and Jim Milledge. He was fascinated by temperature control, and studied athletes, swimmers and walkers. After four children perished in one weekend on a walk in Yorkshire, Pugh

dressed volunteers in the dead youths’ largely cotton clothing, sprayed them with cold water in a wind tunnel, and showed that they were effectively naked. Griffith became a pioneer of sports medicine. He was sought out by athletes, but again his work was resented by the sporting establishment as ‘professionalism’. John West described Harriet’s biography of her father as ‘superb’. He was right.

Dr Ian Calder Chairman, Senior Fellows Club

Guest speaker: Harriet Tuckey

The next meeting will be on 2 November 2017 at the College. The invited speaker is Emeritus Professor Edzard Ernst


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Bulletin | Issue 105 | September 2017Bulletin | Issue 105 | September 2017

The talks will be available on our YouTube channel:

www.youtube.com/c/RcoaAcUk

Watching them can be recorded as a personal CPD activity attracting two ‘internal’ CPD credits when

accompanied by reflection.

ARIES TALK:FATIGUE

ANAESTHESIA RESEARCH INNOVATION EDUCATION SCIENTIFIC

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<Title>

Anaesthetists are experts in physiology, skilled in recognising subtle signs of patient’s bodies not working as they should and are trained to intervene to preserve and restore function. Proficient in early recognition and intervention, anaesthetists can prevent problems escalating to potential catastrophe.

Anaesthetists also understand fatigue and its impact. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published guidelines on Fatigue and Anaesthetists in 20041 and the RCoA joined the Royal College of Physicians to produce Working the Night Shift in 2006.

Despite this, working practices still cause serious concern. With an NHS workforce under increasing pressure, consequences are increasingly evident.

Ability depends on physiology. Clinicians rise to meet the demands of the NHS by pushing ourselves to our limits. While we may cope in the short-term, sustained pressure brings stress, impaired competence, plummeting morale, burnout – even death.

McClelland et al.’s national survey of the effects of fatigue3 demonstrates the high prevalence of fatigue amongst trainees.

Sleep deprivation and fatigue insidiously undermine every aspect of physical and mental health, increasing risks to personal and patient safety. Staff regularly report feeling dangerously unsafe driving home after work. For some, work-related fatigue results in death.4

In July 2017, the RCoA and the AAGBI took a major step forward in their collaborative approach to tackling this issue, by highlighting new evidence showing that, as a result of severe tiredness, more than half of trainee doctors have had an accident or near miss driving home after a night shift.

Fatigue lies at the heart of these issues, silently registered but ignored. We must change the culture that expects individuals to cope while ignoring the consequences. The AAGBI recommends immediate, essential measures to tackle fatigue.5 We must provide universal mandatory sleep and fatigue teaching early in careers.6 Employers must put in place measures to support staff to deliver care safely, effectively and efficiently.7

The alarms on our monitors are sounding louder. Under intense pressure, the system is reaching a tipping point. The RCoA and AAGBI continue their important collaborative work to address

the culture and causes surrounding doctor fatigue in hospitals. We must act before it is too late.8

References1 Ferguson K et al. Fatigue and Anaesthetists,

AAGBI, October 2014.

2 Horrocks N, Pounder R. Working the night shift: preparation, survival and recovery—a guide for junior doctors. RCP Working Group. Clin Med 2006 Jan-Feb;6:61–7.

3 McClelland L et al. A national survey of the effects of fatigue on trainees in anaesthesia in the United Kingdom. Anaesthesia 2017; 72: doi: 10.1111/anae.13965.

4 BBC News. Dr Ronak Patel ‘had been singing to stay awake’ before fatal crash. 12 July 2016.(http://bbcin/2tTSp9a) (accessed 17/07/2017).

5 Fatigue Education Resources, AAGBI website. (http://bit.ly/2lWyMem) (accessed 17 July 2017).

6 Farquhar M. Fifteen minute consultation: problems in the healthy paediatrician – managing the effects of shift work on your health. Archives of Disease in Childhood: Education and Practice 2017; 102: 3.

7 Guy’s and St Thomas’ NHS Foundation Trust. Guy’s and St Thomas’ staff encouraged to take regular breaks in new HALT campaign. GSTT website 17 March 2017. (http://bit.ly/2vSpF1O) (accessed 17 July 2017)

8 Farquhar M. For nature cannot be fooled: why we need to talk about fatigue. Anaesthesia 2017; 72: doi: 10.1111/anae.13982.

YEARS

Dr Michael Farquhar,Consultant in Sleep Medicine,Evelina London Children’s Hospital,Guy’s and St Thomas’ NHS Foundation Trust

The College and the AAGBI are working together to raise awareness of the dangers of fatigue. Dr Mike Farquhar recently delivered an ARIES talk on how fatigue affects our bodies and below he expands on these issues.


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http://dx.doi.org/10.1111/anae.13965

College Tutors Meeting 2017 Poster competition winnersAt the recent College Tutors Meeting in Belfast, the submissions for the annual Poster Competition were judged. The three highest-scored abstracts were selected for oral presentation at the meeting. Dr Ruth Greer was awarded first place, with Dr Rhys Rhidian in second place, and the Research and Audit Federation of Trainees (RAFT) in third. The presentations were all very professional, and enjoyed by the audience. The abstracts are printed below:

Does research and audit make you SQuiRM? Swindon Quality Improvement and Research ManagerDr Ruth Greer (ST5) and Dr Edward Bick (Consultant), Great Western Hospital, Swindon

Recent Care Quality Commission (CQC) reports for the Great Western Hospital highlighted the finding that clinical governance effectiveness was not always evident.1 The reports found that audit results were not always reported, that there was a lack of learning and instigation of change from audits carried out, with action plans either not being made or carried out. They also stressed that evidence-based practice should be ensured.

Within the anaesthetic department, there are currently monthly Journal Club and clinical governance meetings. However, due to irregular shift patterns, many trainees and consultants are unable to attend these meetings on a regular basis, and as a result Journal Club meetings are frequently cancelled or postponed. On questioning trainees and consultants, the department seems very proactive in carrying out quality improvement projects and audit; however there is little intra-departmental awareness of what other members are doing.

To address these issues, we created the ‘SQuiRM’ (Swindon Quality Improvement and Research Manager). A large notice board in the anaesthetic meeting room was used for the initiative. Half of the board is dedicated to an ‘Article of the Week’. Each week, a different trainee puts up a summary of a recent journal article that they have found interesting or that has altered their practice. The other half of the board is dedicated to Quality Improvement and Audit. Details of projects that are currently underway are displayed to raise intra-departmental awareness of all the work being undertaken, as well as ‘adverts’ from consultants who have ideas for new projects that would benefit from trainee input, or from trainees who are leaving the department but have unfinished projects that need taking over.

In addition, ‘The Weekly SQuiRM’ email is sent out to all anaesthetists within the department, to raise awareness of the most recent article put on the board and of any new project adverts that have been added.

‘SQuiRM’ is a simple, yet effective method of delivering anaesthesia education to the whole department. Having a physical board in a largely online world increases accessibility for all. Verbal feedback has been positive, and many ongoing and potential projects are now advertised on the board. There is a rota allocating each trainee a week to put up an article of their choice, and involvement in this has been very good. This initiative has successfully increased intra-departmental awareness of current audit and quality improvement work and evidence-based practice. Formal trainee and consultant feedback after three months will allow us to further improve this project. This initiative requires a lead, and will be handed to another trainee to ensure continuity in ensuring up-to-date articles, adverts and emails.

Reference1 CQC Report – Great Western Hospital,

Swindon www.cqc.org.uk/location/RN325/reports

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http://www.cqc.org.uk/location/RN325/reports

Prevalence of stress, depression and burnout syndrome in anaesthetic trainees – a systematic review of the literatureDr Rhys Rhidian, Dr Alex Looseley, Dr Ronelle Mouton, Southmead Hospital, North Bristol NHS Trust, UK

Anaesthesia has unique stressors compared to other specialties, and there is evidence that stress and burnout have a high prevalence in trainee anaesthetists.1,2The recent industrial action, and introduction of a new contract has again highlighted the wellbeing of junior doctors, including trainee anaesthetists. There has been no comprehensive systematic review addressing this issue. The aim of this study was to assess the prevalence of stress, depression, and burnout syndrome in anaesthetic trainees through a systematic review of the literature.

Review methods were according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The study was registered with PROSPERO. Four electronic databases were searched from inception to December 2016 – Medline, EMBASE, the Cochrane library and PsycInfo. Search terms included, ‘stress’, ‘fatigue’, ‘depression’, ‘burnout syndrome’, ‘suicide’, and ‘job

satisfaction and substance abuse in anaesthesia trainees’. The full search strategy is available.

There were 622 papers initially identified. After screening and selection by two independent reviewers, 74 studies were identified for qualitative synthesis. The majority of studies were level 2, observational studies. Data was extracted on predefined data fields, including the population that was assessed, the assessment tools used and the main outcome findings. Mean prevalence of burnout was 44.5% (range 6.3%–85%) in nine studies. Four studies investigated depression, and prevalence ranged from 4.9%–22%. The reporting of stress was variable, with both outcomes reported and assessment tools used being very heterogeneous. The wide ranges reported are likely to reflect the use of different assessment tools, the heterogeneity of the populations studied and variable quality of studies.

According to this systematic review of the literature, the prevalence of stress, depression and burnout in anaesthetic trainees is variable, but is high in many of the populations studied. The absence of more in-depth analysis constitutes the main barrier when interpreting data from these surveys. Larger, more in-depth studies using validated assessment tools are needed to investigate this further, and particularly to investigate the causes and consequences of stress, depression and burnout.

This study is part of the SWeAT (Satisfaction and Wellbeing in Anaesthetic Training) project, which is funded by an NIAA/AAGBI grant.

References1 RCoA: President’s News, RCoA, February

2017. (www.rcoa.ac.uk/rcoa-presidents-news-february-2017) (accessed March 2017)

2 Vaughan RS, Baird LM, Morgan M. Stress in anaesthetists. AAGBI, 1997. (www.aagbi.org/sites/default/files/stress97.pdf)


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http://www.rcoa.ac.uk/rcoa-presidents-news-february-2017

http://www.rcoa.ac.uk/rcoa-presidents-news-february-2017

Research and Audit Federation of Trainees National Survey 2016The RAFT executive committee (Dr Caroline Thomas, Dr Sam Clark, Dr Harriet Kemp, Dr Jaimin Patel) on behalf of RAFT

The Research and Audit Federation of Trainees (RAFT), is an organisation that supports and promotes collaboration between Anaesthetic and ICM trainees via nineteen trainee research networks (TRNs). The TRNs are regionally based, and have an excellent record of developing and running regional projects and contributing to NIHR portfolio studies. However, sustainability of our network remains a challenge despite support from NIAA, NIHR and other national bodies.

The RAFT executive committee conduct an annual survey of activity for all TRNs. Additionally, the November 2016 survey focused on barriers and enablers to project development

and to the inclusive participation of anaesthetic trainees. The survey was distributed via ‘Basecamp’ to the TRN RAFT representatives, who were asked to complete the survey on their group’s behalf.

Fifteen of the nineteen groups responded. Four new groups emerged in 2016: MAGIQ (Mersey), MERCAT (East Midlands), NEACTAR (Eastern) and SEQuoIA (North and East Scotland). All except two groups either planned or ran at least one locally devised project in 2016. Eighteen of the nineteen TRNs took part in one or more NIHR portfolio project. Twelve agreed that they are part of a motivated group of trainees with access to advice

when needed. Ten agreed that their deanery is supportive of their work, e.g. recognising TRN work at ARCP. Nine felt that their groups were adequately resourced. Funding is an ongoing issue. Many groups are funded by their trainee members, whilst some have secured deanery contributions. All agreed that RAFT should represent them at a national level.

The survey highlighted several issues around infra-structure, funding and interaction with the wider anaesthetic community. Engagement with the work of TRNs can provide trainees with locally available access to high-quality projects, and enable them to fulfil aspects of the Annexe G curriculum. Support of the TRNs, and of trainee involvement in their projects, is essential for long-term sustainability of the network. Access to available funding streams can be practically challenging. Recognition of involvement in TRN work at ARCP promotes trainee involvement in local research and audit work. RAFT would like to thank you for your help and your ongoing support.

Dr Sam Clark collected the award on behalf of RAFT

RAFT (Research & Audit Federation of Trainees)

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John Walmsley WarrickProfessor Tony Wildsmith, Editor, Lives of the Fellows Project

Dr John Warrick was elected as the 600th Fellow of the Faculty of Anaesthetists of the Royal College of Surgeons of England in December 1953. He is, as far as has been ascertained, our oldest living fellow, and he has some fascinating stories to tell. This short article has been produced from John’s reminiscences and recorded with the help of his partner, Renee (known as ‘Tim’) Fleury, also a retired anaesthetist. John was born in the London suburb of Blackheath on 2 August 1915. His grandfather changed his surname to Warrick because of a business inheritance, but it was originally Day Lewis and, in fact, John is directly related to the Anglo-Irish poet, Cecil Day Lewis, and his actor son, Daniel. John went to schools in Blackheath and Sevenoaks, and to a ‘crammer’ school in London, before attending Chelsea Polytechnic to take the 1st MB examination. He then studied medicine at King’s College, London, choosing this school because its senior surgeon, Cecil Wakely, was married to his next-door neighbour. For three years, he played rugby for the hospital, and returning home from a match on 30 November 1936 he saw the Crystal Palace burning down. He also played cricket for the ‘Wednesday Eleven’ who, on one occasion, were somewhat discomfited when Sir Jack Hobbs strode out to open the batting for the opposition – to their relief, rain stopped play!

After qualification in 1938, his first appointments (aided by the Wakely connection) were at King’s College Hospital: six months as House Anaesthetist, followed by another six

months as House Surgeon. He then continued to work as an anaesthetist, first in London and, from 1940, with the Royal Navy: Ceylon for three years; the Isle of Man for two years (passing the DA while there in 1944); Scapa Flow for six months, serving on His Majesty’s Hospital Ship ‘Isle of Jersey’ which, being the only duty-free ship, was very popular! Later he served on HMHS Barrow Gurney near Bristol, and was demobilised in 1946, returning to King’s College Hospital for a year, and then working for three years as SHMO in anaesthetics at St Alfege’s London County Council Hospital in Greenwich. The surgeon there, Marcelli Shaw, recommended John for the FFARCS to Ivan Magill (a founder member of the Board of Faculty) who supported his election.

In 1950, John was appointed consultant anaesthetist to West Dorset where he worked for 27 years until his retirement in 1977 at the age of 62. His colleagues describe him as a well-liked and respected colleague, and as a good all-round anaesthetist in a busy practice with frequent on-call, who kept well up-to-date in the specialty throughout his career. He had particular interests in

chronic pain, the use of stellate ganglion block for the management of Menière’s disease and tinnitus, and anaesthesia for peptic ulcer surgery, and published on all of these topics.

He married a nurse, Betty Cooke, on 23 March 1940, and together they had three children: Peter (born in Ceylon), who was to become a chartered accountant; Elizabeth (born under the care of Sir John Peel at King’s College Hospital) who became a nurse and was more recently an international dragon-boat paddler for Canada; and Gillian, also born at King’s College. After Betty’s death in 2009, John reconnected with a colleague, Renee Fleury, and together they are happily sharing their remaining years. A particular passion of John’s throughout his life has been playing the guitar, both classical and jazz, a passion ignited at the age of 15 by hearing Django Reinhardt. He has also enjoyed watercolour painting, carpentry, embroidery, gardening and gardening design. He has lived in the same house in west Dorset since 1955, where he turned a field into a place of beauty.

Dr John Warrick on his 100th birthday, 2 August 2015


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Dr Janice Fazackerley,Consultant Anaesthetist,

Warrington and Halton NHS Trust,RCoA Heritage Committee Member,

RCoA Council Member

AS WE WERE...This year the College celebrates the 25th Anniversary of gaining its Royal Charter, so it is fitting to reflect on life in 1992. February 1992 saw the Queen grant our Charter, and celebrate 40 years on the throne. More importantly, 12 member states signed the Treaty on European Union in Maastricht. I was a Fellow of nine years’ standing and a consultant in the north of England, and I confess to being underwhelmed by the reasons to have our own College. European unification inspired me more, and I spent 1992 working in a University Hospital in Paris.

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France was discontent, and only 51 per cent voted for the Maastricht Treaty – ‘un petit oui’! I arrived there, shortly before Eurodisneyland and the Renault Twingo, not to welcome banners, but to strike banners, in hospitals and elsewhere. It was reminiscent of Britain in the 1970s, and sadly, 25 years later, strikes have returned to English hospitals. French doctors worked longer hours and for more years, for less remuneration and with little hope of good pensions. The French anaesthesia workforce was fully trained, with trainees entirely supernumerary. Out-of-hours work was remunerated separately, and was covered on a voluntary basis. The effect was that younger doctors, needing money, experience and excitement, did most, and the more mature doctor, needing none of the above, did less. This contrasted with home, where as rotamaster, I struggled and begged ‘trainees’ (mostly overseas graduates) and locums to cover rotas. We have witnessed upheavals in training and recruitment over 25 years, yet the anaesthesia workforce crisis continues.

French anaesthetists worked in teams, sharing pre-, intra- and postoperative care, using standardised techniques. The professor advised on high-risk cases. My impression then, was of dictatorship and unprofessionalism, and I disliked having to conform and share cases. I appreciate today, in this era of Quality Improvement, that variability is the enemy of quality, and that maverick anaesthetists do not always improve outcomes. I worked in the orthopaedic anaesthesia group, and shared duties in four theatres, twice-weekly preoperative clinics, and daily pre- and postoperative ward

rounds. This work pattern supplied a huge, standardised, specialist caseload, and provided a platform for large studies and research. Perioperative medicine was being practised by French anaesthetists years before the RCoA highlighted its merits. My main contribution was to perform the first use of a laryngeal mask in the hospital.

Paris employed nurse anaesthetists who were qualified to deliver simple anaesthesia. They preferentially chose jobs which offered unaccompanied work, so the ‘Assistance Publique’ proved unattractive. We had, on average, one nurse anaesthetist per four theatres, I frequently worked unaccompanied, and anaesthetists also ran the cell saver, group-tested blood for transfusion, and manned the theatre-phone single-handedly. As we, in 2017, employ anaesthetic practitioners, we must accommodate their need to have interesting and rewarding work, and to be well managed. And we must retain well-trained anaesthetic assistants.

French patients seemed more interested in their health, many of them keeping records from childhood of all medical interventions. Every hospital episode produced an invoice, which most patients settled from social security and employment insurance. The resulting paper mountain had a positive effect – that of patients seeing the cost of interventions. They were generally less willing to have repeat investigations or consultations, unlike the British public, whose growing expectations of the NHS threaten its existence. In 1992 laparoscopic surgery and minimally invasive techniques were just starting out, and have since

developed to improve patient outcomes. General anaesthesia drugs and techniques have changed little since 1992, but use of regional anaesthesia, improved analgesia, and better patient education and organisation of care have been at the forefront of our specialty’s advance.

Nothing challenges one’s beliefs more, or teaches one more, than exposure to another way of life and work. On leaving Paris, I missed the lifestyle, but was relieved to slip back into English work. Reflection now makes me realise that France was ahead of the game. Maturity also leads me to value the courage and wisdom of my predecessors, who established a College for anaesthetists.

In the history of a Royal College, 25 years is a short time, but ours has grown to be the third-largest Medical Royal College by UK membership, promoting quality and standards with as much enthusiasm as training and exams. Our improved communications strategy allows engagement with Fellows, Members, government and the media. The Queen, after her ‘Annus Horribilis’ in 1992 has become Britain’s longest-serving monarch. Alas for Europe, Britain has delivered ‘un petit non’, reversing the union of 1992. We remain obsessed with rigid adherence to every sentence about misshapen tomatoes and constituents of crisp-flavourings, while France interprets EU rules with pragmatism, and moves on. It is still a troubled world, but there must be wider hope when a French president speaks publicly in English for the first time, to emphasise our shared responsibility to ‘make our planet great again’.


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Professor Monty Mythen, Editor

Dear Editor,I wondered if Bulletin readers would be interested in a follow up to the September 2016 article.

After our article1 appeared in the Bulletin I discovered that Dr Peter John Horsey (1924-2015, RCoA Lives of the Fellows), formerly a neuro anaesthetist in Southampton and RCoA examiner, had been one of 96 London medical students flown to help in Belsen in May 1945, before the European war ended. Each student was allocated a hut with about 500 inmates to care for with virtually no other medical aid. He, and eight others, independently detailed their remarkable Belsen experiences in recordings made by the Imperial War Museum (http://bit.ly/2tQ4LlP).

I first met another of the 96 students, Dr Eirian (Bill) Williams, in 1974. I had returned from California to a consultant post with John Nunn in the new MRC centre at Northwick Park in London. This was modestly remunerated, private practice was verboten but holiday locums were permitted. The travelling expenses exceeded the consultant fee if the locum was located far from London, for example at Haverfordwest. It was the first of several locums there. The hospital at Withybush was eleven huts built in 1942 to house a medical/

surgical unit for 6,000 RAF personnel stationed in Pembrokeshire during the Battle of the Atlantic. Together with the small Haverfordwest County Hospital it was absorbed into the NHS. The first consultant anaesthetist, Philip Robinson (1925-2016), arrived from Birmingham where, with John Nunn, he had been a Senior Registrar. He was continuously on call from 1955 to 1974 when a second consultant was appointed. He adapted a farm milking machine to provided theatre and recovery room suction; one of his three GP clinical assistants was lost at sea when on call, his body was never found. I became a periodic holidays locum consultant physician for Bill Williams (1925-91). Until a few years before he had been the sole physician for medical, geriatric and paediatric patients. He was flown out to Belsen on 30 April 1945, the day that Hitler shot himself. His 20th birthday in Belsen camp was the day the Germans surrendered. He was reticent about his experience but years later his widow showed me his Belsen diary. I wondered about the effects of this experience. The Withybush huts were similar to those at Belsen and for years Bill Williams fought a relentless battle, ultimately successful, for these to be replaced by a new hospital. This was a metaphor of Belsen where the surviving inmates were eventually transferred from the huts, which were

destroyed, to an adjacent purpose built hospital where Bill Williams also worked. His retirement lecture on the web was devoted entirely to his battle to establish the new Withybush hospital (http://bit.ly/2uqbB34). His Belsen experience was not mentioned.

Reference1 Jones JG, Winterbottom OC. An Anaesthetist at

Belsen. RCoA Bulletin 99: 53-55 (Sept 2016).

Professor Gareth Jones

Dear Editor,I read with interest the proposed Alphabetical code of Conduct on the letters page of the July 2017 Bulletin. I strongly endorse it; many medicolegal cases I have advised in would have been avoided if these principles had been followed. However it does not address the important issue of awareness and is also missing the letter Z. May I propose the addition of: Zzz – ensure all paralysed patients actually are asleep.

Dr Bernard Norman

Letters to the EditorIf you would like to submit a letter to the editor please email [email protected]

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REPORT OF MEETINGS OF COUNCILAt a meeting of Council held on Wednesday 21 June 2017 the following appointments/re-appointments were approved (re-appointments marked with an asterisk):

Regional AdvisersThere were no appointments this month.

Deputy Regional AdvisersThere were no appointments this month.

College TutorsNorthern IrelandDr C Turkington (Altnagelvin Hospital) in succession to Dr R Laird

KSSDr A Barakat (Frimley Park Hospital) In succession to Dr G Sridhar

Dr M Sange (Darent Valley Hospital) in succession to Dr Darshinder Sethi

Mersey*Dr S Swaraj (Royal Liverpool University Hospital)

North West*Dr K Beresford (East Lancashire Hospital)

East & North YorkshireDr S Price (Hull Royal Infirmary) in succession to Dr M Mallick

West Yorkshire*Dr K Melarkode (Pinderfields Hospital)

Certificate of Completion of TrainingTo note recommendations made to the GMC for approval, that CCTs/CESR (CPs be awarded to those set out below, who have satisfactorily completed the full period of higher specialist training in Anaesthesia, or Anaesthesia with Intensive Care Medicine or Pre-Hospital Emergency Medicine where highlighted.

North Central LondonDr Judith Cheong-Leen

Bart’s & The LondonDr Anna Malik

South EastDr Caroline Pocknall

NorthernDr Mark Worrall

West of ScotlandDr Andrew Grant

Dr Mark Patek

Dr Rajib Ahmed

Dr Kim Flatman

Dr Stuart Hannah

Dr Alistair Maddock

Dr Jill Selfridge Joint ICM

Dr Iain Thomson

Dr Sriram Naithilath

South WestPeninsula

Dr Mark Pauling

WessexDr Lucy Marshall

Dr Timothy Martindale Joint ICM

West MidlandsStokeDr Mohan Vellalapalayam Sathyamoorthy

Dr Elizabeth Willetts

Dr Gurinder Malhi

Yorkshire & The HumberWest YorkshireDr Sheila Black

Dr Ossian Auckland-Child

Regretfully, due to an administrative error, details of the trainees listed below who had been awarded joint certificates in Anaesthesia and Intensive Care Medicine were not made available for publication in the Bulletin at an earlier date.

AngliaDr Najwan Abu Al-Saad

St George’sDr Manprit Waraich

LeicesterDr Sameer Hanna-Jumma

Barts and the LondonDr Jerry Lim

WessexDr James Keegan

WalesDr Ceri-Ann Lynch

Dr David West

Kent, Surrey & SussexDr Abhijoy Chakladar

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At a meeting of Council held on Wednesday 19 July 2017 the following appointments/re-appointments were approved (re-appointments marked with an asterisk):

Regional AdvisersThere were no appointments this month.

Deputy Regional AdvisersThere were no appointments this month.

College TutorsEast of England*Dr J Lermitte (Peterborough City Hospital)

LondonImperialDr A Sabharwal (Chelsea & Westminster Hospital) in succession to Dr S Galton

North Central LondonDr R Seneviratne (North Middlesex Hospital) in succession to Dr A F W Man

StokeDr S Shanbhag (Manor Hospital) in succession to Dr M K P Prasanna

Certificate of Completion of TrainingTo note recommendations made to the GMC for approval, that CCTs/CESR (CP)s be awarded to those set out below, who have satisfactorily completed the full period of higher specialist training in Anaesthesia, or Anaesthesia with Intensive Care Medicine or Pre-Hospital Emergency Medicine where highlighted.

East of EnglandDr Eleanor Carter

Dr Amy Gospel

Dr Lalani Induruwage

LondonNorth Central LondonDr Roxaan Jappie

Dr Vishal Nangalia

Dr John Whittle

South EastDr Kathy Shammas

MerseyDr Moiz Alibhai

Dr Matthew Gwinnutt

Dr David Mayhew

Dr Benjamin Murray

Dr Rachel Smith

Dr Woei Yap

North WestDr Claire Allen

Dr Michael Bassett

Dr James Brooker

Dr Andrew Deacon

Dr Alistair Duncan

Dr Daniel Hayley Joint ICM

Dr Joanne Mullender

Dr David Rawlinson

Dr William Rieley

Dr Ian Tyrrell-Marsh Joint ICM

OxfordDr Christopher Lockie Joint ICM

East of ScotlandDr Pauline Austin Joint ICM

North of ScotlandDr Faszillah Ismail

West of ScotlandDr Luay Kersan

Dr Peter Carachi

Dr Christina Niciu

SevernDr Emma Riley Joint ICM

WessexDr Renee Ford

Dr Nicholas Jenkins

West MidlandsStoke

Dr Bikina Sridhar

WarwickshireDr Anuja Patil

Yorkshire & The HumberDr Vanathy Karthikeyan

CERTIFICATE OF ELIGIBILITY FOR SPECIALIST REGISTRATION (CESR)To note recommendations approved by the General Medical Council, that a Certificate of Eligibility for Specialist Registration

be awarded to those set out below:

Dr Hariprasad Kuttambakam

Dr Petrus Fourie


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Council received and approved the list of Fellows by Examination from June 2017.

Abdel-Gadir DinaAchary CherylAfzal Safeena AkhtarAhmad Kirran AmnaAlexander Tamara ClairAllenAndrew JohnAllen Eireann Grainne KerrAnjilivelil Daniel ThomasAntill Philip JohnAshok VighneshAtkinson Philip AlanAtkinson Thomas Jeffery OwenAvann Felicity JayneBaban Nian SalaheddinBaker RoisinBaldwin Melissa JayBalfour Paul John PatrickBallantyne Thomas Alistair JamesBarnes Alice JoannaBarnes Shelley MarieBarraclough LaurenBatley Sian ElisabethBaxter Linden SharonBeardmore Matthew DavidBelford Iain SmithBentley RichardBeverly AnairBhudia NishaBiggart Stephen AlexanderBird Ruth HannahBlackburn Julia RoseBlair Alison JoanneBluhm SimonBouras Lisa AnnBowden Faye ElizabethBoyd Matthew ColinBrunnen Derek JohnBuchanan Fraser GordonBugo John MuzunguByott Tara JayaCahill NicolaCashell Catherine Ann

Challifour Catherine AnneChan Suet MayChannell AdamChapman Susan Jennifer FergusonChoo Yin YongCook Oliver ThomasCoulson Samantha ElizabethCouzens ChristopherCutler HughDavenport Garry MarkDavies LouiseDavy Bryony Victoria JennerDean Anna Claire JadwigaDensham Ian RobertDias Luke DanielDillon Diarmaid JosephDodds Nicholas LascellesDoherty Sean BernardDowning Lynsey JaynDryden Leon StephenDukoff-Gordon AmyDurrand James WilliamEaves Lai KarenEden Daniel JamesElgarf SarahEllis GeorgiaEllisy Khaled Osman Mohamed ElnadyEnglish Jennifer ClaireEusuf Danielle VictoriaEvans Matthew ThomasEvans Melissa LouiseFerguson CameronFirth-Gieben Jennifer AlexFitzGerald Simon JohnFleet DanielFleming NaomiFoggo Graeme RobertFrancis Christopher WilliamFreeman David Henry CliveFullbrook Aidan IanFurniss Timothy JamesGanegedara Kakusanda Mudiyanselage Harini KaushalyaGore David Geoffrey

Gosling Jennifer LouiseGott EmilyGovier Matthew RichardGreen Ruth ElizabethGreen Victoria LouiseGreenwood Edward LewisGrobler SophiaGrzelinski GrzegorzGunarathna Nanayakkara Wickramasekara Palliyaguruge Dilusha GayanHale Suzanne IlonaHardwick James AndrewHarper Kathryn LouiseHarrison Siew-ling CatherineHepple David JohnHigenbottam Caroline Verity JoyceHill Jeremy MorrisonHodgson Keith William LaughtonHolland Michael RichardHutchison Colin ElderIbrahim Ramez Iftikhar NaumanJames Arul Prakash PandianJayathillake Herath Mudiyanselage ThusithaJohnston Jessica Sophie Catharine WilleyJolliffe Nicolas StephenJones Claire NadineJones ElizabethJordan Anna JaneJundi OmarKadr MiranKarim Naveed AhmedKathuria PoojaKeating Sean James PatrickKelly Jemma MichelleKennedy Katharine LydiaKhan MariaKhpal MuskaKidd Lawrence RoryKingston Hazel ElaineKnowles Timothy CarltonKok Waisun


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Kopargaonkar SwatiKotwinski David PeterKua JustinLeighton Christopher JamesLiu Hon SumLivingstone Thomas JamesLloyd Catherine PatriciaLloyd James DavidLodwick GarethLoughnan Alice ElizabethLowe Richard HarryLowis Elizabeth AnnLoy Maria Frances CatherineMaguire Mark ChristopherMarshall Helen RachelMassouh Laura MarieMaughan Sharon StephanieMay RosieMcadam ColinMcCartney Robert LeeMcClelland Lucy Elizabeth MargaretMcCorkindale AlasdairMcGuckin Dermot GerardMerchant Ami HarshMeredith GarethMilne Gemma MaryMilne Lesley FionaMitchell AndrewMitchell Claire Marie HeratyMorgese CiroMorris Jonathan PhillipMudalige Anushka DilaniMulcahy Kathleen VeronicaMurley Jessica ClaireMurnin MaireadMurrell KarenNeal Robert JohnNeely JuliaNelson Sarah CarolineNevin Joseph OliverNyamaizi Brenda

Oakes Keith JonathanO’Carroll James EdwardO’Connell Martin AndrewO’Donnell Robert David WallaceOliver Nathan Desmond JosephOsborne FionaOwen Andrew PhilipOwolabi AdetokunboPatey Susannah JulietPaulich Skylar PhilipPernu Pawan KooteluPerring Roslyn RebeccaPhillips Harry JamesPhillips Stephen PricePisarczyk-Bathini AnnaPoonur Janarthana ReddyPotla Priyadarshan BhaskarPowell Robert James ArdernPrince MarkPuwackwaththa Arachchige Nimali LochanieQuin Andrew JamesQuinn Natalie ElizabethRadhakrishnan ArchchanaRamage Stephen NicholasRao RoshanRatnayake Gamunu Priyantha BandaraRay Andrew GordonRees DavidRiccio Francesca ChiaraRiddell Rory Niall JamesRobinson David PaulRobinson Susannah ClaireRuck Claire SuzanneRughooputh Naresh Rai ShumsherRussell Katie Victoria AliceSampson Paul JosephSangam Amy VeenaSarao Sarbpreet KaurScott Harriet RoseScott Liam Paul

Seaton Alister JohnSheikh Usaama QaiserSheils Mark AnthonyShelley Kathleen ClaireShevlin Sean PatrickSmith Emma-JaneSriram NishaStacey Lucy Alexandra MargaretStanworth HelenStevenson Sara AnnStewart Mark MichaelStolady Daniel GarethSutherland Angus JamesSwarbrick Claire JaneSykes Ryan DavidTabiner Nicholas StevenTan Cheng YeowThirsk Joanna FrancesThompson Elizabeth SuzanneThompson NatalieTopor BorysUnell Sophie CharlotteVadher MehulVenkat Raman VishalVowles Benjamin JamesWang Nancy QianWariyar RaviWelfare Emma LouiseWhite James David EdwardWigley James AlanWilkins Edward HuwWilkinson Brian RaymondWillder Jennifer MaryWilliams Anna Charlotte LouiseWilliams LucindaWilson Matthew GrantWimble Katie Louisa Worku Elliott TheodroseYap Christina


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FRCA Examinerships for academic year 2018–2019The College invites applications for vacancies to the Board of Examiners in the Fellowship of the Royal College of Anaesthetists, for the academic year 2018–2019. Examiners will be recruited to the Primary examination in the first instance. The number of Examiners required will reflect the number of retirements from the current Board of Examiners.

Applicants will be assessed against a comprehensive Person Specification which, along with the Job Description and applications forms for this role, can be downloaded from the examination pages of the College website: http://bit.ly/rcoa-examiner

An outline of the key essential requirements for the role of FRCA Examiner is set out below (although applicants must read the person specification and job description before applying).

Essential1 Fellow by Examination, a Fellow ad eundem, or a Fellow by Election of the Royal College of Anaesthetists.

2 In good standing with the College.

3 Holds full registration, without limitation, with the General Medical Council.

4 At least five years’ experience as a substantive Consultant/SAS grade.

5 Shall currently be active in clinical practice in the NHS.

6 On 1 September 2018 shall have the expectation of completing at least ten years as an FRCA examiner.

7 Can demonstrate active involvement in the training and assessment of trainees.

8 Within the past five years shall have visited a Primary or Final FRCA examination.

9 Good written and verbal communication skills.

10 Ability to work as part of a team.

11 Documentary evidence of satisfactory completion of Equal Opportunities training in the last three years and willingness to undertake further exam-specific E&D training on an annual basis.

12 Able to commit to long-term and active involvement in examiner duties including the ability to devote a minimum of 12 days per academic year to the role. This includes both the delivery and development of the examinations.

DesirableShall demonstrate a special interest(s) directly relevant to the balance of expertise required in the Board of Examiners.

Copies of the person specification, job description and application form can also be obtained by contacting:Mr Graham Clissett, Examinations Manager via Tel: 020 7092 1521 or Email: [email protected].

THE CLOSING DATE FOR RECEIPT OF COMPLETED APPLICATION FORMS IS: MONDAY 16 OCTOBER 2017.

APPOINTMENT OF MEMBERS, ASSOCIATE MEMBERS AND ASSOCIATE FELLOWSMembersDr Jennifer Charlotte AlldisDr Helena Margaret Elizabeth Wright

Associate MemberDr Mustafa Abduljabbar Shawkat Serri

Associate FellowsDr Antonella MeragliaDr Muhammad ShahbazDr Mahmood Reyaz


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CONSULTATIONSThe following is a list of consultations to which the College has responded in the last two months. Those published on the RCoA website via our Responses to Consultations area (http://bit.ly/rcoa-consultations) are marked with an asterisk.

Originator Consultation

National Institute for Health and Care Excellence

Trauma Quality Standard


Type 2 diabetes: prevention in people at high risk

Medicines and Healthcare Products Regulatory Agency

Post-implementation Review of the Human Medicines Regulations 2012


Hypertension in adults

Health Education England Accelerated Return to Training (ARTT)

Care Quality Commission Next phase of regulation: consultation 2


Emergency and acute medical care in over 16s

College of Operating Department Practitioners

BSc(Hons) in Operating Department Practice Curriculum

Nursing and Midwifery Council

Standards of proficiency for registered nurses

DEATHSWith regret, we record the death of those listed below.

Dr J-P van Besouw, Surrey

Dr Gordon Bush, Alder Hey

Dr Paul Charlton, Leeds

Dr Arthur Chow, Bury St Edmunds

Dr James Clarke, London

Dr Peter Coldrey, Gwent

Dr Edgar Cooper, Hexham

Dr William Hamilton, USA

Dr David Pearson, Cumbria

Dr Colin Pemberton, Anglesey

Dr Diana Gillian Rees, Essex

Please submit obituaries of no more than 500 words, with a photo if desired, of fellows, members or trainees to: [email protected].

All obituaries received will be published on the College website (www.rcoa.ac.uk/obituaries).

APPOINTMENT OF FELLOWS TO CONSULTANT AND SIMILAR POSTSThe College congratulates the following Fellows on their consultant appointments:

Dr Caroline Curry, Belfast Trust

Dr Navneet Sinha, Northampton General Hospital

Dr Caroline Pocknall, Ashford and St Peter’s Hospital, Chertsey

Dr Tauheedur Shaikh, Bucks Healthcare NHS Trust

Dr Pauline Austin, Ninewells Hospital, Dundee

Dr Cristina Niciu, Institute of Neurological Sciences, Glasgow

Dr Adele Babic, Royal Gwent Hospital

Dr Ruth Whiteman, Queen Elizabeth Hospital, Gateshead

Dr Mohan Sathyamoorth, Croydon University Hospital

Dr Tom Knight, Gloucester Hospitals

Dr Oliver Blightman, Maidstone & Tunbridge Wells NHS Trust


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mailto:website%40rcoa.ac.uk?subject=Obituary%20for%20the%20website

http://www.rcoa.ac.uk/obituaries


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THE MSA SAQ WRITERS CLUBThe Writers Club has seen more than 700+ trainees through the SAQ Papers with a successful pass rate for those who have kept to the

necessary disciplines. But many trainees apply far too close to the examination to derive anything like the full benefit from membership. That full benefit includes free admission to the SAQ Weekend Courses, the acquisition of a large and useful collection of answer sheets and a

valuable motivation towards sustained revision.

Membership fee: a single payment of £400

Members are entitled to all benefits until successful in the SAQ Paper

Attendance to the SAQ Weekend Courses – free of charge

Writers Club Motto: ‘Within the Discipline, Lies the Reward’

Candidates are urged to join before October 2017 for the Spring 2018 Examination to reap maximum benefit

Enquiries to: [email protected]

Courses for the Royal College of Anaesthetists Examinations

Courses Dates 2017/2018 Capacity

Primary SBA/MCQ 6–12 October February 2018 No Limit

Primary OSCE Weekend 13–15 October December 2017 48

Primary Viva Weekend 20–22 October January 2018 No Limit

Primary OSCE/Orals 27 October–3 November January 2018 48

Final Written ‘Booker’ 4–8 February August 2018 No Limit

Final SAQ Weekend 9–11 February August 2018 No Limit

Final SBA/MCQ 12–18 February August 2018 90

Final Viva Revision 4–9 November May 2018 No Limit

Final Viva Weekend 24–26 November June 2018 100

It is with great relief and a measure of delight that I can say I passed the Final FRCA on my first attempt – in no small thanks to the philosophy of the Mersey School and Dr Gray. I am very grateful to all at the MSA for the time and effort that you have invested in candidates, including myself, over the years. It’d have been a far steeper mountain to climb without your help. & To those who come after me – Trust Dr Gray – his methods work. The ‘Mersey Method’ for the Final Written might sound daft but it works and I’ve also had that fed-back to me from the College Examiners.- Final Written Candidate, March 2017

Thank you so much for the guidance and support - I did Mersey for primary MCQs/OSCE/VIVA and for the finals the Booker and the 2 viva courses… I passed them all first time and Mersey was the common theme! By the time I got to the final viva it was a no brainer for what course I should attend. Even though the viva courses were a nightmare for me to organise my rota round I had serious superstition about missing out on my pre exam trip up north! Despite the hard work, I enjoyed all the courses, have made some firm friends who I’m still in touch with even from the primary courses, and above all felt very well prepared for facing each of those exams after the time spent in Mersey, and of course after some necessary straight talking from DG!

Thanks again to all of you for having me, making me feel very welcome and looked after during those long and full on weeks. I’m sad to think i’ll never be back… but i’m blooming glad I don’t have to take any more exams!! – Final Viva Candidate, June 2017

To see details of all of our courses please visit: www.msoa.org.uk or contact us at: [email protected]

Find us on Facebook Badge CMYK / .ai


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CPD STUDY DAYS

#RCoACPD

CPD credits

10

CPD credits

5

Our CPD Days are designed for busy doctors, to efficiently maintain competence and aid with revalidation in anaesthetic and surgical practice. Our study days provide updates on new treatments and techniques, including top tips on improving your performance, from specialists in the clinical field. You will also have access to experts who will equip you with new skills to cope better with the demands of everyday working life.

CPD STUDY DAYS (TWO DAY EVENT)All days: £355 (£270 for trainees)* 1 day: £230 (£175 for trainees)*

■ 25–26 September 2017 – RCoA, London

■ 12–13 June 2018 – RCoA, London

CPD STUDY DAY (ONE DAY EVENT)£200 (£150 for trainees)*

■ 17 November 2017 – Royal Hotel Hull

■ 30 November 2017 – RCoA, London (Evidence Base in Anaesthetic Practice)

■ 1 February 2018 – RCoA, London (Paediatric Anaesthesia)

■ 28 February 2018 – RCoA, London (Perioperative Medicine)

■ 19 March 2018 – RCoA, London (Regional Anaesthesia)

■ 18 April 2018 – RCoA, London (Anaesthetic Emergency)

AIRWAY WORKSHOPS

The airway workshops provide an opportunity to learn core airway management techniques from experienced consultants. There is hands-on practical experience with commonplace airway equipment as well as plenty of discussion on airway management including current UK guidelines. Appropriate for all grades of anaesthetic trainees, specialty doctors and consultants.

£240 (£180 for trainees)*

Airway Workshops ■ 12 October 2017 – G&V Royal Mile Hotel, Edinburgh ■ 7 February 2018 – RCoA, London ■ 18 March 2018 – RCoA, London ■ 13 June 2018 – RCoA, London

Airway Leads Day ■ 15 March 2018 – RCoA, London

Airway Management Training the Trainer ■ 10 May 2018 – RCoA, London

ANAESTHETISTS AS EDUCATORS

The Anaesthetists as Educators series of events supports clinical educators in delivering high quality education and training in the workplace.

One day event£220 (£165 for trainees)*

Two day event£425 (£320 for trainees)*

Simulation Unplugged ■ 13 October 2017 – RCoA, London

Educational Supervision ■ 13 November 2017 – Park Inn, York City Centre

Anaesthetists’ Non-Technical Skills (ANTS) ■ 24 November 2017 – RCoA, London

Teaching and Training in the Workplace ■ 1–2 February 2018 – RCoA, London

An Introduction ■ 5 June 2018 – RCoA, London

CPD credits 5




SALG PATIENT SAFETY CONFERENCE22 NOVEMBER 2017

Manchester Conference Centre £215

The Safe Anaesthesia Liaison Group (SALG) Patient Safety Conference will be held in Manchester for a day of valuable insight and engaging lectures on important patient safety related topics.

The meeting will consist of lectures followed by ample time for discussion and networking opportunities for doctors engaged in clinical anaesthesia, pain management and intensive care medicine, and who have an interest in improving patient safety.

The event also features a trainee competition, including both oral presentations and a poster exhibition.

Lectures include:

■ standards and safety

■ the Quick Reference Handbook

■ resilience and safety

■ learning from adverse incidents

■ learning from excellence

■ what has happened to non-luer connectors?

■ simulation for maternal safety

■ patient safety in smaller obstetric units

■ the Healthcare Safety Investigation branch (HSIB)

■ clinical debriefing

■ stop or mock before you block?

Be sure to join us for this essential patient safety event.

#SALGPS

CPD credits 5

UK TRAINING IN EMERGENCY AIRWAY MANAGEMENT (TEAM) COURSEOur simulator-based course provides the knowledge, skills and attitudes required to safely manage the airway and post-intubation period in an emergency situation outside the operating theatre.

£450

Upcoming events ■ 19–20 October 2017 – RCoA, London

■ 19–20 October 2017 – Royal Infirmary of Edinburgh

LEADERSHIP AND MANAGEMENT COURSES

Our Leadership and Management series is designed to prepare anaesthetists for the leadership challenges they face in the workplace. Tailored to the needs of senior trainees and newly appointed consultants, the course presents the realities of working in the modern NHS through real life examples and provides opportunity for active participation in non-clinical skills development.

RCoA, London £220 (one day event) | £395 (two day event)

An Introduction ■ 25–26 September 2017 | 7–8 March 2018 (Novotel,

Sheffield) | 30–31 May 2018

Personal Effectiveness ■ 29 September 2017

Working Well in Teams and Making an Impact ■ 22 November 2017

Leading and Managing Change Success with Service Development

■ 16 March 2018

CPD credits 10



70 | Book your place at: www.rcoa.ac.uk/events

PRACTICAL WORKSHOP13 December 2017 RCoA, London Fee: £240 (£180 for trainees)*

SYMPOSIUM14 December 2017 RCoA, London Fee: £200 (£150 for trainees)*

Our regional anaesthesia events, run in partnership with LSORA, feature clinical scenarios, group discussion, hands-on skill practice and lectures.

These events cover a number of topics to improve knowledge and competencies in ultrasound-guided regional anaesthesia. Suitable for budding to experienced regional anaesthetists, supported by expert faculty and speakers.

REGIONAL ANAESTHESIA PRACTICAL WORKSHOP AND SYMPOSIUM

UPDATES IN ANAESTHESIA, CRITICAL CARE AND PAIN MANAGEMENT

EARLY BIRD PRICE

CPD credits 10

■ Informative lectures on: UK anaesthesia and our place on the international stage, global health and the NHS in 2018

■ Practical workshops on: Stress, shared decision making and management

■ Quick-fire updates on: Obstetric haemorrhage, paediatric airway, acute pain and head injuries

■ Controversial debates ■ Peer-to-peer discussion sessions

Early Bird PriceFirst 50 places 15% off

Full Price

All days 1 day All days 1 day

Standard£335£60 saving

£220£40 saving

£395 £260

Trainee*£250£45 saving

£165£30 saving

£295 £195

Standard Trainee*All Days £490 £3701 Day £195 £150

Book your place now and save up to £60 with our early bird price, limited to the first 50 places.

For more information and to book visit www.rcoa.ac.uk/anaesthesia

CPD credits 15

11–13 December 2017Royal Welsh College of Music & Drama, Cardiff

Update yourself on cutting edge research, topical issues and new procedures in:

■ perioperative blood management

■ cardiology ■ intensive care medicine ■ obstetric anaesthesia

■ what the papers said ■ paediatric anaesthesia ■ emergency care ■ regional anaesthesia


Book both the workshop and symposium and save £100 (£70 for trainees)

22–23 MayInternational Meeting of the Royal College of Anaesthetists

ANAESTHESIA 2018 British Museum, London



GLOBAL ANAESTHESIA: A PLATFORM FOR DEVELOPMENTMonday 16 October 2017RCoA, London£80

OverviewThe RCoA is delighted to host a special global anaesthesia event at the College on 16 October to mark World Anaesthesia Day.

The event will explore key themes affecting the delivery of safe anaesthesia on a global scale, including the findings of the Lancet Commission report into Global Surgery, the global anaesthetic workforce and how anaesthetists can take further steps to improve patient safety.

The programme will also feature the launch of the updated e-SAFE resource, which provides free access to e-learning content targeted at non-physician anaesthetists working in resource-limited areas.

This event is open to all individuals who have an interest in the provision and delivery of anaesthetic services and a wider interest in global health provision across the world.

Sessions on the day include: ■ anaesthesia provision globally ■ partnership working ■ global anaesthesia – wider issues ■ the next steps.

We are delighted to announce that the RCoA’s Royal Patron,

Her Royal Highness The Princess Royal, will be

attending this event

For more information and to book visit www.rcoa.ac.uk/globalanaesthesia

CPD credits 5

Recruit, retain and resolve · Recruit, retain and resolve ... Perioperative Journal Watch 29...

Documents

Transcript of Recruit, retain and resolve · Recruit, retain and resolve ... Perioperative Journal Watch 29...