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TRANSCRIPT
CONSULTANT JOB INTERVIEWHOW TO SUCCEED?
medicaljobinterview.org.uk
R. Sand MACommunication Consultant
D. Raj FRCS (Tr & Orth)FRCSI, MCH Orth, MS Orth, D Orth, MBBS
Consultant Orthopaedic Surgeon
Forth edition
May 2011
0845 6439597
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Contact: R Sand
Address: WestcottLittleport LaneSibseyLincolnshirePE22 0RS
Tel no. 0845 6439597Email: [email protected]
Website: medicaljobinterview.org.ukMedical-interview-book.co.uk
Medical-Course.co.uk
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CONTENTS
Introduction
Feedback
Chapter I: R Sand
Issues before the Interview
Curriculum Vitae
Seeking a Consultant job
How to choose the correct hospital for you?
The Post
A strategy to get your desired Consultant Appointment
Application Form
How to answer a question?
How to present yourself at the interview?
Formatting an answer
Chapter II: D Raj
Consultant Interview Questions
Chapter III: D Raj
Interview
Mantra
Interview Panel
Mock interview
Chapter IV: R Sand
Presentation
Role play
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Chapter V: D Raj
Personal and General issues
Introduce yourself
Teaching experience
Communication skills
Leadership skills
Good doctor
Conflict
Complaints
Stress
Criticism
Confronting angry patient or relative
Consent
How do you take consent from a patient?
Drunken colleague
Difficult nurse
Main weaknesses
Personal development plan
Assessment, appraisal
Licensing and revalidation
Team leadership
Training
Why did you apply this job?
How can you ensure that you are adequately trained to be a consultant when you gain
CCT?
Consultant contract
Outcome
Chapter V: D Raj
Management issues
Business plan
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Doctor – manager relationship
Negotiation
Time management
Coding
Chapter VII: D Raj
Modernising Medical Careers, Training, EWTD and Deanery
Modernizing Medical Career
Foundation Programs
Specialty and GP Training
Assessment of Training
European Working Time Directive
Hospital at night
Deanery
How will you contribute to the Deanery?
Tooke’s report
Chapter VIII: D Raj
Research, Audit, Ethics and Clinical Scenarios
Research
Research Framework
Research Governance
Level of Evidence for Primary Research Question
Audit
Ethical Issues
Clinical scenarios
Prioritize your job
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Chapter IX: D Raj
Clinical Governance, Multidisciplinary Team and National Health Service
Clinical Governance
Multidisciplinary Team
The Structure of NHS
White paper
Authorities and Trusts
Strategic Health Authorities
National Institute of Clinical Excellence
Foundation Hospital
Primary Care Trusts
NHS Litigation Agency
Risk Management
National Patient Safety Agency
National Tariff and payment by results (PbR)
Independent Sector Treatment Centre (ISTC)
National targets
Heath Care Commission (HCC)
Quality Care Commission (QCC)
Lord Darzi’s report
Chapter X: Alok Tekriwal
Summary
Chapter XI: R Sand
Standard Questions
Useful Links
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INTRODUCTION
Congratulations on completion of your training! You should have a date in your mind
when you are going to start applying for the post as it takes a few months to collect all
the information which you would like to put in your CV. The information below has
been collated from a number of sources, our own personal experience and also
experiences of our colleagues. It is, in the main, applicable to any medical job
interview but concentrates on that potentially most important one - The Consultant
Interview, hopefully, your last interview.
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FEEDBACK
We would really appreciate feedback from you about this book. Please send your
positive and negative experiences of the interview as well as any opinions, criticism,
and suggestions. If you have any queries, we will be happy to answer them. If you
find any factual error(s) in the book, please let us know.
Contact details:
E-mail: [email protected]
Website: medicaljobinterview.org.uk
medical-course.co.uk
medical-interview-book.co.uk
R Sand
D Raj
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CHAPTER I
R Sand
ISSUES BEFORE THE INTERVIEW
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CURRICULUM VITAE
While applying for the post of Consultant you will clear all the hurdles and your CV is of paramount importance. Nowadays, you have to fill the NHS job websites but the information comes from your CV. There are numerous websites providing tips and hints from where you should gather all the information. It is absolutely important to do spell check and make sure everything you write in your CV is accurate. The common errors made by the people in their CV are
• Poor formatting
• Incorrect or missing contact information
• Inaccurate dates or no dates
• Spelling errors (Topographical and grammatical)
• Long CVs with long paragraphs
• Personal information unrelated to job
It is difficult to do the proof reading on your own. You have spell checkers these days everywhere but the commonest mistake is misspelling words which are still spelt like other words. If English is not your first language it is imperative to get someone to check your sentence structure and general syntax.
It is essential to keep your CV updates on a regular basis. It is certainly a good practice to keep your CV updated regularly - sometimes it is needed at fairly short notice (research proposal, ethics committee, PYA).
At interview, you should be able to discuss each and every aspect of your curriculum
vitae (CV). Often your CV or job application will be in front of each panel member. I
recommend the following structure when writing your CV:
1. Summary: Have a one page summary of your CV. This is important as it
should cover your qualifications, current job, research, audit, presentations and
future plan (Short, Intermediate and Long term).
2. Current job
3. Previous jobs: In chronological order (starting from the immediate past). List
some of the consultants you have worked with.
4. Clinical experience: Try to personalise your CV. Your personal experience
should match the job you are applying for (as much as possible)
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5. Assessments and Learning agreements. In every job, try to have three learning
agreements (ocap.org.uk), one at the beginning, and one in the middle and the
last one at the end of the contract.
6. Research
7. Audit
8. Presentation (Local, Regional, National and International)
9. Courses attended
10. Communication skills
11. IT skills
12. References / Referees: Select your referees carefully. Talk to them and take
their consent before putting them down as your referee. Ask for advice in
preparing your CV.
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SEEKING A CONSULTANT POSTSome tips:
1. Choose the hospital carefully
2. Make sure that the hospital which you are going for needs a consultant with your expertise, experience and training
3. Be careful about an appointment to a hospital where you have been at the end of your specialist registrar training. It is very flattering to be asked to join the consultant staff but you may always be the specialist registrar in the eyes of your consultant colleagues with all that entails.
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HOW TO CHOOSE THE CORRECT HOSPITAL?As a Consultant, you are going to be very important for the trust. They will depend on your ability to earn their income and reputation. You should therefore to be counted to join the hospital. It is useful to look at the information that was sent with the application. Does it make you feel like I want to work there; if it does not make you think like that or the description is rather dull then that might reflect the attitude of the hospital. In this day and era, hospital should be selling them; they do it to a primary care so they should do it for the prospective consultants.
Find out about the hospital whatever you can, for an example: Grapevine at the surgical meetings or medical meetings. Look at the Healthcare commission website and there should be reports on the hospital as star ratings. Is the hospital having a foundation status? What are the future plans? How does the hospital do in terms of quality of care and also utilization of resources? Visit at a weekend and wander around to see what it feels like. Go to the postgraduate education centre to see what are teaching and training commitments in the hospital and specifically in the department. It is surprising how much you gain from first impressions. Were they really welcoming and helpful? If so, it is a good sign of happier staff and if not good, would you really want to work there?
Look around the geographical area with your partner; look at the facilities which are available in terms of recreation (work-life balance), schools, and connections to other parts of the country/cities / houses and their costs. Remember if you or your partner do not like things then you do not apply, you might get the job but be realistic though life is about compromise.
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THE POST
In the application pack, you go through very carefully which should contain the following:
1. Job Description which should include a model timetable
2. Information on the Trust
3. Teaching commitments
4. Person specification
5. Staffing and relevant Services
6. Terms and conditions of Service
If any information is missing ask for that. They might refer you to the Department of Health website for the terms and conditions which is acceptable.
All Consultant posts should be suitable for those wishing to work less than full time. If not then the Trust should clarify why not.
It should also outline how the post being advertised fits in with the department and thus any sub-specialty interest that may be needed.
If not ASK - the hospital may just be on a fishing trip to see who applies but this may lead to all kinds of problems.
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A STRATEGY TO GET YOUR DESIRED CONSULTANT APPOINTMENT
When I was looking for a Consultant Post my then chief advised me:
Choose the hospital more carefully possibly than your partner sadly it is easier to separate from a partner and establish another relationship than it is to leave a hospital post and get another one?.
Be very careful about an appointment to a hospital where you have been at the end of your SpR training. It is very flattering to be asked to join the Consultant staff but you may always be the SpR in the eyes of your consultant colleagues with all that that entails?
After many years of observing consultants and their progress I am sure these comments still hold true. Preparatory Work:
Visit the Hospital officially.
You should try and meet the following:
Possible Consultant Colleagues in the same specialtyPossible Consultant Colleagues in an allied specialty ex: Anaesthesia, Radiology, Nephrology, Gastroenterology etc to see what they feel about the new appointmentPossible colleagues in the support services ex: physiotherapyMedical Director- they may give you a slightly different view from potential colleaguesChief Executive - they should give you the same view as the Medical Director if not what is the relationship in management and where is the Trust heading
Questions to Ask:
What is expected of the new appointment?:Is it a replacement? Thus all that is expected is to maintain the status quo - could be boring if you are not allowed to developIs it to increase the capacity of the department? The department is busy good reputation etc and they want another pair of hands to complement everyone elseIs it to increase the capability of the department? Your chance to develop your sub- specialty interestIs it to increase the portfolio of the Trust? This is to develop a completely new specialty doubtful in this day when specialties are contracting that this will be the situation
These questions will give you a flavour of what will be expected of you in the post.
No matter what, you need to establish that the Trust has thought about the implications of the appointment especially around costs for:
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Equipment - especially if you are replacing a retiring consultant, they will not necessarily be using modern techniques ex minimally invasive kit. I doubt whether they will have thought about this.
Support Departments? Any special investigative procedures that are now needed for you to provide a modern service the hospital may not have.
Support Staff? If they are increasing the numbers are the support staff available ex junior medical staff, theatre sessions, anaesthetists, and physiotherapists to mention but a few.
Medications? Not so much possibly for surgeons but there may be new non-operative treatments that requires a substantial investment in drugs.
It is important to ASK about the above as if the Trust has not thought these matters through then you could spend the first few years of your consultant life fighting for what you consider the bare essentials of a modern service? Not good.
They may seem very receptive to new ideas but if you get the impression that there will be little support in the broadest sense for new ideas then is careful.
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APPLICATION FORM
Everyone has the CCT so you have to ensure that your application gets selected. Make it interesting, try and tailor it to what the hospital wants ex if they want a hand surgeon make sure that your training in hand surgery is well presented and stands out. If in your spare time you do something different ex sailing across the oceans again makes sure it stands out. All this looks as if you are the correct person for the post and also you are someone who has that little bit extra to offer.
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HOW TO ANSWER A QUESTION?
When you are asked a question it could be an open-ended question, (e.g. tell me about
Yourself) or it could be a closed one (e.g. what is the role of genetics in rheumatoid
arthritis?). When you are asked an open-ended question you have the opportunity to
sell yourself. Your answer should be structured. I usually follow a rule of 2 minutes
and 40 seconds. If you are asked an open-ended question, format and try to complete
your answer within two minutes. Watch the panel carefully- if they seem to be bored
then you should be in a position where you can finish off the answer within the next
ten to fifteen seconds, i.e. within forty seconds in total.
When you are answering a question, it is important to avoid using jargon. You should
try to use words used in day to day practice. If you are asked a question about a topic
you should not give an answer taken from a text book. You need to use simple words.
This gives a better impression and the panel will have a notion that this person thinks
and his/her answers are practical.
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HOW TO PRESENT YOURSELF AT THE
INTERVIEW?
• Make eye contact with the interviewer before speaking
• Adopt a relaxed posture sitting squarely in the chair
• Facial expressions and gestures should be natural
• Do not fidget or appear restless
• Keep to the point
• Aim to be precise
• Give a full answer and do not waffle
• Structure your answer; it should be logical and clearly understood
• Avoid using jargon
• Speak confidently so that you can he heard
• Do not speak too quickly or slowly
• Use your voice to reflect the meaning of what you are saying
• Do not argue with the interviewer.
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FORMATING AN ANSWER
There are so many different ways of formatting an answer; I follow the rule of three.
When I am asked a question I will think about it quickly but logically and pick out
three important points. If I have the opportunity and time I will discuss each point in
further three sub points and so on. This structure has the benefit that you know what
you are talking about and your answers are organised. At the same time, if you find
that during your answer the panel seem bored, at any time you can simply finish off
with some other major heading.
Question
Answer 1
Answer 2
Answer 3
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CHAPTER II
R Sand
INTERVIEW QUESTIONS
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Most commonly asked
Take me through your CV – highlight strong points
Tell us about yourself
Why do you want this job?
Why should we choose you?
What are your strengths?
Your hobbies
What do you think of 360 assessments?
What are your views on specialist care in the community?
Has the modernization programme worked?
What is the importance of research – personal and professional benefit?
Importance of clinical governance
What do you understand about audit cycle?
Challenge to the NHS for providing antiVEGF service
Administrative Do you have any changes to make to your CV?When are you available from?Do you have any courses booked?How many jobs have you previously applied for?Do you have any other job applications in at present?Why didn’t you apply for our previous post?Do you have a driving license?Have you looked around?Have you met any of the panel members?Do you have any questions?
Personal Why should we give you this job?Why do you want this job?What makes you good for this job? Where do you see yourself in 10 years time?Why did you become a doctor?When did you decide to become a geriatrician?Why did you want to concentrate on stroke medicine?Do you want mainly to be a geriatrician?What qualities make a good consultant geriatrician?
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What would you see as your role in this department?What is your special interest in this department?What can you offer this Trust?How would you develop the stroke service?What would you bring to this unit?How would your appointment raise the profile of this Trust? What are your strengths/weaknesses?What is your biggest fault?What makes you angry? What do you think of moving area?How do you feel about living in?What do you do in your free time?Tell us of a recent triumph/disappointment?
Training How does your previous training fit you for this job?What training do you think you should have to become a consultant geriatrician?Take me through your training so far?Why did you do a BSc, MSc?
How has it helped you in your working life?Do you see any deficiencies in your training?Is there any post you regret not doing as an SHO? What courses have you attended recently?Was it useful?What courses would you like to attend?Should hospital consultants have spent some time as GPs?Who should provide management training?In what way was the management course that you attended useful?What do you think of SpR training with respect to general medicine/geriatric medicine?How would you improve the training of SpRs?How do we attract the best junior doctors to this trust given the advent of MMC?
Politics What is clinical governance?What is NICE?Was the NSF for Older People a helpful document? How?What is your opinion of our last Health Care Commission report?What do you know about the recent NHS White Paper?What do you think of payment by results in geriatric medicine?What is your opinion of the recent GMC publication?What have we learnt from the Bristol heart cases?How has the Alder Hey scandal changed practice?
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Do you think the increased spending on the NHS has been put to good use?How does foundation status help patients?Why is acute medicine busier these days?How should we measure consultant productivity?What do you feel about the burden of proof shifting to that of civil courts for doctors? What do you think of the mission statement of our trust?How will the NHS reforms affect you in your daily practice?How would you ration healthcare?Is there any limit to the demand for health care?What is the future for geriatric medicine? How can we ensure patients from ethnic minorities receive proper access to health care? Are junior doctors’ hours now too short?How will MMC impact upon geriatric medicine?What do you think of the new consultant contract?What is your opinion of the GMS contract for GPs? What do you think about the super-specialization of geriatrics?What is the role of NHS consultants in teaching hospitals?Does general medicine exist anymore? What do you think about private practice?How involved should doctors be in management?What do you think about the CEA awards system?
Management What are the main roles of a multidisciplinary team leader?What is the role of a consultant geriatrician as a manager?What do you know about resource management?How should intermediate care services be organized?Are Day Hospitals an expensive luxury?What are the advantages of Day Hospitals?What is the biggest area of waste in the NHS? How would you deal with a 10% cut in your budget?How would you pay for a new piece of equipment if no new money was obviously available?How would you spend a £20000 one off grant? What are the components of a complaints procedure?How would you assess user satisfaction with your service?How would you define quality in geriatrics? What do you know of clinical governance?What is the difference between audit and governance?
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What clinical audits have you done?Who should appraise you?How should revalidation be undertaken? How would you reduce the number of acute admissions?How might you cut waiting times in your clinic?If you could change one thing in the NHS what would it be? What is your management style?How would you persuade the PCT to continue to purchase your service? How would you deal with an underperforming colleague?How would you deal with a colleague who turned up for work drunk?What would you do if you strongly disagreed with a colleague’s decision?
Teaching What did you last teach to nurses?What’s wrong with undergraduate education?What in geriatrics are the three main take home messages you would want to pass onto undergraduates?How would you make clinical meetings more appealing?What will you present on your first grand round?What is the purpose of a College Tutor?What makes a good educational supervisor? How should continuing education for consultants be arranged?What is the role of a supervisor for an MD/PhD?How do you see your teaching role with respect to SHOs and SpRs?Do you find the presence of undergraduates in your clinic a hindrance?
Research Do you have any current research interests?How is research relevant to clinical medicine?Why did you do an MSc?Explain your MSc in a few short sentences for the interview panel.What have you presented at an external meeting recently? What journals do you read?Tell us about a recent article that caught your eye?What is the most important advance in geriatric medicine in the last 10 years? How would you pursue your research interests in this job?Have you been allocated enough sessions for research in your job plan?If you haven’t got any research to show after a year should we reduce your salary by 2.5 SPAs? Do you feel it is important to have published research as a clinician?
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Why are you not the 1st author on more research? Explain how research differs from audit?
Clinical Topics Can you give an example of where you have encouraged good team working? What are the current controversies in your field?What are the main recent developments? What constitutes an acceptable delay in diagnosis?Should ‘geriatric’ patients be for resuscitation?What is the place of palliative care in geriatric medicine? In which areas do you need more experience? Who should manage a patient with a stroke? Closing Questions Do you have any questions for us?If this job is offered, would you accept this job?
Ophthalmology
• Explain what is diabetic retinopathy to a patient – diabetes affects small
blood vessels of the eye. Retina is the film…
• Explain cataract surgery to a patient
• Role as clinical lead – interface between department and management and
other department, teamwork, leadership, motivational skills, morale boosters,
negotiation skills, clarity of thought
• Take me through your CV – highlight strong points
• Tell us about yourself
• Why do you want this job
• Why should we choose you
• What are your strengths
• Your hobbies
• What do you think of 360 assessment
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• What are your views on specialist care in the community
• Has the modernisation programme worked
• What is the importance of research – personal and professional benefit
• Importance of clinical governance
• What do you understand about audit cycle
• Challenge to the NHS for providing antiVEGF service
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CHAPTER III
R Sand
Mantras
Interview Panel
Mock interview
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MANTRAS
Patient safetyPatient care
These two aspects are very important
Buzz words
Care pathwayTeam workMultidisciplinary approachConsensus approachPatient carePatient choice
Bring them during your answers. Practice in your day to day work
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INTERVIEW PANEL
Interview:
Congratulations you have been selected for the interview. As you have not done one for a few years ask your chief if he would mind giving you a mock interview to see if you have any bad habits which might make the panel not want you and to give you some feedback as to how you come over. You have one chance to impress the panel do not waste it!
You may be asked to give a presentation to staff. You will be informed of this in advance and how long the presentation should be. Find out the audience to whom you will be presenting to and tailor it to that audience. Keep it clear and succinct.
There will always be the standard interview at which all the panel members will have the chance to ask questions. Before the interview starts the questions that will be asked and by whom are agreed so that all candidates are asked the same questions.
A few tips in general:Short answers? Do not meanderTry and look as if you want the postKeep panel interestedTry and engage all panel members and watch their body language? If one is yawning or looking away then you have lost it!Watch your own body language
Questions:
The questioning usually follows a set pattern and in the following order:College RepresentativeUniversity RepresentativeHospital Consultants (usually 2)Medical DirectorChief ExecutiveLay Chair
College Representative:
There to see if you are appointable you should be as you have CCST so they could ask about your specific training for the post for which you are applying. Your chance to tell the panel you are just what they are looking for as your training in what they want is more than adequate and in addition you have done other related things e.g. know how to give chemotherapy for cancer and have been involved in trials.
University Representative:
Only present if there is a major teaching commitment so you will be asked about teaching and your experience and ways in which you know you are a good teacher ex feedback from students, pass rates at exams etc Tell the panel all this before they ask
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you and it has to be dragged out!
Hospital Consultants:
They usually want to know what you have done and why you want to join their department.
This is your chance to tell them why they should select you how your training fits into their department to strengthen it and make it a department to be proud of. Be positive it is surprising how few people can sell themselves.
The Rest:
This is where the question can be difficult to forecast but in general the Medical Director will want to know how you interact and the Chief Exec will want to be convinced that you want to come to his hospital and that it is not just the next in line. The lay chair will want to know a bit about you outside medicine. So these following questions could be asked:
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What are your strengths and weaknesses?
Any management course or book can explain what this is about and what answers are expected. Do NOT say I have none when it comes to weaknesses. Do not say another does not want to do your paperwork? might be true but not the best thing to say.
How do you deal with a difficult colleague?
Not an uncommon problem try to think how you dealt with a junior who was a problem and tell them how you dealt with it good practical stuff.
How do you deal with a failing colleague?
Obviously trying to prevent cover ups you must deal with it positively by involving more senior people you are too inexperienced in these matters. If they cover it up then go higher and higher in the organization. Remember if you know about something and do nothing you are in just as much trouble if an enquiry takes place.
Why this Hospital?
You must think of good reasons ex joining a good department and tell them how you know it is a good one, a hospital with a good reputation say how you know. What they need to know is that you have positively looked at the hospital and said? Yes? This is where I would want to be. Makes the CEO etc feel good about their hospital.
How do you relax?
Its amazing what I have heard reading medical a text is not the best answer how that relaxes you. Watching television - what Coronation Street!! Try and be a bit more specific. If you play a sport for example tell them who you play for or how often there are numerous ways in which to relax so be specific about whatever you do.
Where do you think your Specialty will be in 5 Years?
There have been so many changes in the last few years have you got any forward vision as to how things may change and how you are going to adapt.
How would you get to know the GPs?
Under the new payments system you will have to be able to sell yourself to the GPs preferably you do this by presentations, audit meetings etc. Arranging dinner parties? is not the correct answer.
What would you want from the Hospital?
Your chance to tell them what you would need to build up the department and for you to develop they should not want someone who thinks great I have my Consultant Post
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so that is it until I retire. Try and think what you would like to do to develop yourself.
Are you a Team Player?
More and more we work in teams so the answer should be? Yes? But give examples as to how you know e.g. feedback from your boss at appraisal.
What Audits have you been involved with and did they change practice?
Tell them what you have done.
What is your most favourite paper you have written and why?
Again tell them what you have done.
If I was to phone your Junior Staff and say what are you really like what would they say?
Try and get in a bit about team player, approachable etc remember your references may say different.
Why this area of the country?
Apart from the hospital and how great it is you can say that you have looked around the area and like what you see. Try and give examples of good points even if it is good connections with major centres or good schools etc.
If there is a recent article that affect the NHS then try and get a feel for its implications to you e.g. Bristol Enquiry, Shipman Enquiry. It may also be worth visiting the Department of Health website to see what is hot on the agenda www.doh.gov.uk
There may be numerous others but these are those that come up often. Do NOT try and crack jokes they can go horribly wrong. There seemed to be a vogue a little while ago to start your answer by saying. That was a good question? The panel knows it was a good question that is why we are asking it. We do NOT wish to be complimented on our question just answer it!!!
End of Interview:
You will be asked if you have any questions. You may want to clarify some points a bout funding of the post etc or you can say? No Thank You, I have had the chance to talk to everyone I wanted to. No one will be offended.
You will be asked if you were offered the post would you accept. Could I suggest you answer in the affirmative saying no thanks is not a good move wasting everyone’s
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time. Remember if you do not want the post do not come for the interview. The panel do talk to others in the specialty and such an answer soon gets around.
Successful Candidate:
Congratulations you have been called back and told you will be offered the job. Do NOT sign any contract most hospitals will not ask you to do this but some will. It should be a standard contract but go away and read it to make sure.
Post Interview Negotiations:
The job should lay down the number of PAs and there is nothing that you can do to increase these you may be able to negotiate them down if you wish to go less than full-time. What you could ask for is a pay increase above the minimum but I doubt if you will be successful unless you are in a shortage specialty.
References:
Remember there is a duty for your referees to tell the truth no longer can they give a good reference to? Get rid of you? Ask them what they are going to say about you it may come as a shock and if there is a problem then you need to try and correct it. I have seen references which say that a person is less that adequate for many reasons; not much of a chance of getting a consultant post with that reference. Ask your referees for an idea of what they are going to say about you The RITA assessments should give you an idea.
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MOCK INTERVIEW(Orthopaedic post)
Why should we give the job to you?
I would like to talk about my clinical work, teaching, training, clinical effectiveness and governance.
Clinical work- I would like to bring my experience and expertise in the lower limb service, specifically soft tissue knee reconstruction and uni- compartment arthroplasty. In the trauma side, I feel that I can compliment the services in the field of soft tissue knee injury, complex trauma around the knee, external fixator and frames (Reconstructive surgery).
Teaching and training- I would like to involve in undergraduate teaching, teaching ancillary team and post graduate trainees.
Clinical effectiveness- In the modern NHS, we not only need to do high volume of work but also need to show that the work we do is of highest standard. We need to set up audits involving outcome measures. It is essential that the he tools we use are simple, user-friendly, and reproducible. The data of the audit we get should be widely publicized so that we can learn from it. I think that all these measures will help us in improving the profile of the Department.
We need to have care pathways for most common trauma and elective orthopaedics cases.
Revalidation-Who is responsible, you or the trust?
I think that it is my responsibility because I am the one who would like to be revalidated. I have to take the responsibility and I think this is the right way.
Why did you apply to this hospital?
Department of Orthopaedics in this hospital is growing. My interest is lower limb arthroplasty, soft tissue knee reconstruction, anterior cruciate ligament work sports injury and uni-compartment arthroplastic surgery. There is a great demand of this work in the Trust. I have met all the Consultants in the department. There is a great mix of youth and experience. There is a great scope of developing soft tissue knee work. In trauma side, I would like to develop interest in the circular frame. The trust has modern theatres and friendly staff. I am really enthusiastic about this.Orthopaedics, especially sports knee injury / surgery is my passion. I would like to put all my efforts to set up a sports knee service in the hospital.
What do you think about 2.5 Supporting Professional Activities in the
Consultant contract?
This is very interesting and I think that as a Consultant it is not only just about doing the clinical work and going out. Supporting professional activities are very important
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for teaching, training, audit and also clinical outcome. Clinical outcome is something very close to my heart and I want to develop it further.
What do you do to make sure that your clinical outcomes are good?
Use most commonly used outcome measuresGeneral health QuestionnaireDisease specific questionnaireJoint specific questionnaireQuality of life measuresAdministrative supportOutcome assessmentImplementation
Have you got any deficiency in your training?
General trauma and orthopaedicsSpecial interestFellowshipResearch and audit
Need helpPelvic trauma – definitive managementSpinal trauma – definitive managementComplex hand trauma – definitive management
Why should we appoint you and what are the personal qualities you bring to the trust?
I think that I am an easy-going person. I like to go with the flow and do not create any confusion in the department and most importantly, as a Consultant when I work in a team I want to see that my team is very happy and I think by doing this we can get the best outcome.
What your patients think about you?
I would like to think that my patients feel that I am a highly skilled surgeon; have a caring attitude and above all a good human being.
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CHAPTER IV
R Sand
PRSENTATION
ROLE PLAY
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PRESENTATION
Usually you will be asked to give a presentation during the interview. This would be mentioned in your interview letter. A topic will be given.
Usually the topic will be related to your job. You need to know all about the hospital and the department prior to prepare your presentation. The information can be acquired from
1. Hospital /. Trust website: Annual report, future plan, HCC/QCC report, Chief executive report, Hospital news letter
2. Pre hospital visit3. Clinical Director / Lead: Ask direct questions. Know what the need is. Assess
how you can fit in.
Methods of presentation:
1. You might be asked to do a 5 minutes oral presentation. 2. You might be asked to do a 5 – 10 minutes presentation with the help of slides.
Sometimes you will be given a laptop where you can do a power point presentation. On other occasion, they will give you a projector where you can do a presentation on acetate papers. It is important to keep your presentations in a flash drive in a power point presentation mode. It’s a good idea to have a CD copy of your presentation and additionally have it stored in your e-mail. The idea is that when you are asked to do your presentation at the time of interview, if one method of system fails on that computer another method can be used to perform your presentation.
How to prepare for the presentation?
Plan your presentation. Usually the presentation will be related to your job or the department. Gather as much information as possible about the job, the department and the hospital.
You need to know the duration of your presentation and how many minutes you are going to leave for the discussion at the end.
• I prefer the following format:o Introductiono Aims and objectiveso Materials and methodso Discussiono Summary and conclusion
• Try to highlight only one or two ideas. • Prepare handouts of your presentation and distribute it to the panel prior to
starting the presentation. • At the end of a presentation you can ask the panel whether there are any
questions that they would like to discuss.
Power point presentations:
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o Font size: 24o Use bullet points, not more than 3 lines in one power point
presentation.o Don’t over do it.o Don’t make the presentation make very flashy.
Whenever you are doing a presentation • Keep notes ready with you. • Do lots of practice prior to the interview. It always helps.
Ultimately, the presentation is about:
• Your communication skills.• Your presentation skills.• Your confidence and body language.• How well you are able to get your message across
Remember, practice makes perfect.
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ROLE PLAY
Here it is about looking at your approach rather than knowledge. The scenarios you are going to do are straightforward. Try to keep it simple. Before you start think and try to work out what it is you need to get across. Have a structure in your mind.
Examples: complaint/error, difficult colleagues, taking bad news, taking consent
Positive signs1. You have a clear structure in your mind and are able to demonstrate it.2. Actions are natural and not rehearsed.3. Are able to communicate well, show empathy, honesty and are clear.4. You show that you understand the problem.5. You have a follow-up arrangement and information etc.6. You summarise at the end.
Negative signs1. Arrogant2. Dismissive3. Candidate does not understand the problem4. Keeping things vague5. Not summarising and making a follow-up plan
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CHAPTER V
D Raj
PERSONAL AND
GENERAL ISSUES
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INTRODUCE YOURSELFTELL ME ABOUT YOUSELF
Please introduce yourself.
ABOUT YOURSELF
Introduction
Background- Experience - clinical, audit, research, teachingQualifications
Quality - Leadership skills, Communication skills
Family / Interests /Sports / others
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TEACHING EXPERIENCE
What is your teaching experience?
Teaching experience•Informal Formal Patient educationBedside Lectures LeafletsPBL Group discussions Consenting
openclosed
Important roleSelf improvementMotivationTeam spiritBetter patient care
simulators, use of robotic tech, hand eye co-ordination assessmentHeading to wards services into two categoriesTrainersNon-trainers providing servicesTraining the trainers courseMSc in medical education
Learner / Facilitator / TrainerLearner / Facilitator / Trainer
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COMMUNICATION SKILLSHow do you rate your communication skills?
COMMUNICATION SKILLS
• Rate yourself - Good• Patient and relatives – Complex issues in simple way
Gain patient trust
Empathy (a process of puttingyourself in others shoes)
Breaking bad news
• Colleagues Able to communicate at all levels ApproachableKeep others informed –Senior (precise information)Juniors (Involve them)
• Nursing and other health professionals – Liaise with nurse and GP. Good record
keeping and communicat ion
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LEADERSHIP SKILLS
What are the qualities of a leader? Have you got any leadership skills?
LEADERSHIP SKILLS
• Aim should be clear• Self motivation- self starter (i.e. Audit/research
project)• Good management skills- Time management
Money managementMan management
• Motivate others FeedbackIdentify need for trainingInvolve peopleDelegation
Good leader is a good manager and a motivator.
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TEAM LEADERSHIP
If you lead a team, you must ensure that:
• Medical team members meet the standards of conduct and care set in the
guidelines
• Any problems that might prevent colleagues from other professions following
guidance from their own regulatory bodies are brought to your attention and
addressed
• All team members understand their personal and collective responsibilities for
the safety of patients, and for openly and honestly recording and discussing
problems
• Each patient’s care is properly coordinated and managed and that patients
know who to contact if they have questions and concerns
• Arrangements are in place to provide cover at all times
• Regular reviews and audit of the standards and performance of the team are
undertaken and any deficiencies are addressed
• Systems are in place for dealing supportively with problems in the
performance, conduct or health of team members
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GOOD DOCTOR
Are you a good doctor?
GOOD DOCTOR
• Main strengths
• Good clinical care
• Good medical practice
• Teaching, training, appraisal and assessing
• Relationship with patients• Probity (information, reports, documents,
research)
• Health
• Good clinical care Providing a good standard of practice, decision making,
Treatment in emergencies
• Maintaining good medical practice up to date, performance
• Teaching and training, appraising and assessing
• Relationship with patients Obtaining consent, Respecting confidentiality,
Maintaining trust, good communication, Ending professional relationship with
patients
• Dealing with problems in professional practice- conduct/ performance of
colleagues, Complaints and formal enquiries
• Working with colleagues Treating colleagues fairly, working in a team,
Leading teams, Arranging cover, sharing information from colleagues,
Delegation and referrals
• Probity Providing info about your services, Writing reports, giving evidence,
signing documents, Research, Conflict of interest
• Health
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CONFLICT
If there is a conflict, how do you resolve it?
Give an example of a conflict you were involved in.
Conflict is difference of opinion
It goes back to the who, what and why sort of questions. Once an issue has
been raised we need to get to the bottom of it and define what the problem is? When
you know the problem the next question is how are we to resolve it? Can we resolve
it at a local level? Or do we need to involve the management, the hospital? In a rare
situation you might need to involve the Medical Defence Union (MDU) or General
Medical Council (GMC). Most of the issues arise because of the lack of
communication and poor information to the patients.
Once the issue has been resolved, we will look back and see how this could
have been prevented?
What did I learn from the conflict I had with someone or some organization?
How did I implement that experience into my practice and what benefits did it yield?
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COMPLAINT
How will you deal with a complaint against you?
COMPLAINT
• Prompt, open, constructive and honest response
• Should co-operate
• How? When? Why?
• PALS
• Apology• Patient care should not be prejudiced
Prompt, open, constructive and an honest response is mandatory by a doctor when
there is a complaint against him. Please read GMC guideline for complaint. It is the
responsibility of the doctor to co-operate.
How, when and what should be addressed. Once you know the issue you
need to resolve it. Involve everybody including the patient, relative, nursing staff and
other colleagues. If needed, involve the patient advisory liaison service (PALS).
One should not hesitate to apologise. Even if it is not your fault you can apologize for
the patient’s experience. If it is your fault, there is no harm in apologizing and trying
to resolve the issue. At the end of the day, patient care should not be compromised.
What did you learn from it? How are you going to change your practice if it was
your fault?
I will look back and do an audit to find out if the change of practice has made a
difference.
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There are many types of complaints.
• Bad food
• Rude staff
• Complication of treatment
• Negligence
The GMC requires doctors to give a patient who complains "a prompt, open,
constructive and honest response. This will include an explanation of what has
happened and where appropriate, an apology."
GENERAL PRINCIPLES:
Don't forget patient confidentiality. A competent adult must give a fully informed,
expressed consent before you can disclose clinical information to a third party who is
not involved in their clinical care. It can be a complex matter, so don't hesitate to seek
expert advice from the MDU on this issue. There is a 10 day time limit for providing a
response at the Local Resolution stage (the first stage) of the NHS patient complaints
procedure. The time limit is flexible provided you keep the complainant informed of
progress. Avoid the urge to give an instant reaction. Some complainants may be
distressed, but the tone of your response needs to be professional, measured and
sympathetic.
CHRONOLOGY OF EVENTS:
Give a factual description of the chronology of events as you saw them, using the
clinical notes as a framework. Refer to the clinical records whenever you can.
Describe each and every consultation or telephone contact in turn and this description
should include your working diagnosis or your differential diagnoses. State if you saw
the patient alone or accompanied by another person. Give the name and status of the
other person, e.g. spouse, mother etc.
Move on to respond to each and every concern raised by the complainant as far as
you can, including your opinion on what happened. Sometimes you can combine this
with the chronology of events, but often it is better to deal with one and then the
other. Many complaints arise from a misunderstanding and a detailed description of
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the patho-physiology involved can be helpful, and in some cases this might include
references to journal articles or standard medical textbooks. The complaint may
involve more than one clinician. It is hardly ever appropriate to express an opinion on
the acts & omissions of a colleague, unless they are under your direct supervision,
even if it is with their consent.
On some occasions a joint response, for example by the complaints officer, may be
appropriate. However, it will usually give a better impression, and help speed
resolution, for each clinician to provide their own response. These may be sent with a
covering letter from the complaints officer. Many complaints arise because there has
been a breakdown in communication and perceived rudeness is common. If it is
appropriate, you may wish to apologise, and you are encouraged to do so. No doctor
can get it right every time. Medicine is a life-long learning experience and every
doctor can learn something from every complaint. Complainants often want an
assurance that what happened to them will not happen to anyone else. The practice
should consider analysing each complaint as part of its adverse incident reporting
procedure. In that way the practice can see what can be learned from the event and
take steps to prevent or reduce the risk of the problem happening again. For
complaints that are more complex, perhaps involving more than one member of the
practice team, for example you could hold a significant event meeting.
This will allow the practice to discuss the case in detail, analyse what went wrong, if
anything, and make necessary changes. Your response to the patient can then include
details of the action taken by the practice to remedy the situation and to ensure the
problem is not repeated. This process also encourages the practice as a whole to adopt
a positive approach if things go wrong.
CLINICAL NOTES:
It is usually helpful to enclose a photocopy of the contemporaneous clinical notes and
where appropriate it might even be necessary for you to provide a word-for-word,
line-by-line, typewritten transcript plus abbreviations written out in full.
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Style of writing
Avoid the use of any medical abbreviations in your response. Many lay people
understand something like "BP", but few will know "SOB" (shortness of breath), for
example, so all medical abbreviations are best written in full. If you mention a drug,
give an idea what type of drug it is (e.g. antidepressant, antihypertensive). Give the
full generic name, dosage and route of administration of it as well (e.g. capsules,
inhaler, intra-muscular injection, suppository etc.). This will provide any independent
medical adviser who may read your response with a complete picture.
Write in the first person. It is very tempting to write in the passive tense because that
is the accepted format in a clinical report. The reader should have a good idea who did
what, why, when, to whom, and how you know this occurred. In other words, rather
than, "The patient was examined again later in the day....", it is far more helpful to
say, "I remember asking my registrar, Dr. Jim Brown, to examine the patient again
later on the same day, and according to the notes, he did so."
CLEAR DESCRIPTIONS:
Your description of both the history and the examination should enable a medically-
qualified third person to put themselves in your shoes. It is important to say not only
what you found, but also what you looked for, but failed to find. In the course of a
clinical report, the positive findings alone may be sufficient. It may be reasonable to
assume that where important symptoms and signs are not mentioned, they were
looked for, but found to be negative. In a medico-legal response this assumption
cannot be relied upon. If your evidence is to be challenged, it may be on the basis that
you failed to put yourself in a position to make an adequate assessment.
If your response at the outset clearly describes the full extent of the patient's history &
your examination, the patient is likely to be satisfied with the thoroughness of your
approach and is less likely to pursue the matter to an Independent Review, for
example. Your notes are not likely, in many cases, to contain the "negative"
information described above. No one expects you to make copious clinical notes of
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every last detail, nor will you be expected to remember every detail of a consultation
which at the time appeared to be routine, and which may have been one of several
thousand similar cases you have dealt with during the intervening time. It is perfectly
acceptable to quote from memory, but if you cannot recall the details of a case, then it
is acceptable to state what you’re "usual" or "normal" practice would have been in the
circumstances of the case.
In your response you should specify which details are based on:
1. Your memory
2. The contemporaneous notes and
3. Your "usual" or "normal" practice.
Complainants sometimes say, "The doctor never examined me". This normally means
the doctor did not touch the patient, but that is not the same thing. If you saw the
patient, then you will have seen or been aware of many features without the need to
touch him. Examples include emotional distress, breathlessness, cyanosis, jaundice,
sweating and many other things, which if present, you as a doctor would have noticed.
CONCLUSION:
A good Local Resolution response takes time and careful thought. It is worth the
effort. Remember, over 97% are successful. The prime purpose of the NHS
complaints procedure is to address the concerns of the complainant and to help you
identify changes that may be needed to improve your practice. It is not a disciplinary
process.
A thorough and detailed first response should help to minimise the risk of:
1. Further correspondence from the complainant asking for clarification and
2. Further medico-legal complications.
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STRESS
How do you manage stress?
HOW DO YOU MANAGE STRESS
• Recognition/Involvement of team/Feedback/management/prevention/family
• Prevention• Proactive organization of time and demands• Service configuration• Recognition• Identify the stress. Is the stress good or bad?• Manage the cause of the stress• Identify the cause of the stress and then try to recognize which components of the
cause you can manage on your own and which need help from colleagues/management
• Manage the symptoms of the stress• Discuss with colleagues, spouse, friends• Have quality time away from work to recharge your batteries• Have hobbies and interests which are important to you• Exercise
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CRITICISM
How will you deal with a criticism?
CRITICISM
• To be taken positively towards making patient care better
• Listen
• Identify
• Take on board
• Any change
• Importance of feedback
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CONFRONTING AN ANGRY PATIENT OR A RELATIVE
How to confront an angry patient or a relative?
Confronting an angry patient or a relative
•Good communication •Problem addressed•Action•Results•Summary
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CONSENT
The NHS Plan promised a review of consent procedures to ensure that good practice
in seeking consent for both treatment and research is in place throughout the NHS.
This work is being taken forward through the "Good practice in consent initiative",
supported by an Advisory Group made up of representatives of patients and carers,
clinicians, academics and NHS managers. The Plan recognised that a change of
culture would be required to ensure that patients become informed partners in their
own care. Legally, the same principles apply to consent in research practice as in
clinical practice.
Types of consent form:
• Consent form 1 - Patient agreement to investigation or treatment• Consent form 2 - Parental agreement to investigation or treatment for a child
or young person• Consent form 3 - Patient/parental agreement to investigation or treatment
(procedures where consciousness not impaired)• Consent form 4- Form for adults who are unable to consent to investigation
or treatment• Consent form 5 - Consent to surgical treatment by patients who refuse to
have a blood transfusion ('Jehovah’s witness form').
http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Consent/index.htm
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http://www.nhs.uk/conditions/Consent-to-treatment/Pages/Introduction.aspx
Consent is the principle that a person must give their permission before they receive any type of medical treatment. Consent is required from a patient regardless of the type of treatment being undertaken, from a blood test to an organ donation.The principle of consent is one of the cornerstones of medical ethics. It is also enshrined (held sacred) in international human rights law.What constitutes consent?For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision. These terms are explained below.Voluntary: the decision to consent or not consent to treatment must be made alone, and must not be due to pressure by medical staff, friends or family.Informed: the person must be given full information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead.Capacity: the person must be capable of giving consent, which means that they understand the information given to them, and they can use it to make an informed decision.There are a few exceptions when treatment can go ahead without consent (see Consent to treatment - how it works).One main exception is if a person does not have the mental capacity (the ability to understand and use information) to make a decision about their treatment. In this case, the healthcare professionals can go ahead and give treatment if they believe that it is in the person’s best interests.Legal termsThis article mentions several legal terms and acts of parliament, which are explained below.The Mental Health Act (1983) sets out various legal rights that apply to people with severe mental health problems. The act also contains the powers which, in extreme cases, enable some people with mental health problems to be compulsorily detained in hospital.The Mental Capacity Act (2005) is designed to protect people who cannot make decisions for themselves. The act explains when a person is considered to be lacking capacity, and how decisions should be made in their best interests. The Court of Protection is the legal body that oversees the operation of the Mental Capacity Act (2005).An advance decision (previously called an advance directive) is a legally binding document that sets out in advance the treatments and procedures that someone does or does not consent to.How consenting to treatment works http://www.nhs.uk/Conditions/Consent-to-treatment/Pages/How-does-it-work.aspx
The seeking and giving of consent should not be a one-off event. It should be a continual process of communication between yourself and your healthcare providers.If you are going to have major medical intervention, such as an operation, your consent should be obtained well in advance so that you have plenty of time to study any information about the procedure. You should also have the chance to ask as many questions as you want.Additional procedures
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There may be some circumstances when, during an operation, it becomes obvious that you would benefit from an additional procedure that was not included in your original consent.For example, you may be having abdominal surgery when your surgeon notices that your appendix is infected, dangerously close to bursting and needs to be removed.If is felt that it would be too dangerous to delay the additional procedure and wake you up to get your consent, the additional procedure can go ahead if it is considered to be in your best interest.However, extra procedures cannot be done just because it would be convenient for the healthcare professionals treating you. There has to be a clear medical reason why it would be unsafe to wait to obtain your consent.Emergency treatmentIf you require emergency treatment to save your life, and you are unable to give consent as a result of being physically or mentally incapacitated (for example, you are unconscious), treatment will be carried out. Once you have recovered, the reasons why treatment was necessary will be fully explained to you.Giving consentConsent should be obtained from the healthcare professional who is directly responsible for your current treatment. This could be:a nurse who is arranging a blood testa GP who is prescribing new medication for youa surgeon who is planning your operationConsent can be given:verballynon-verbally – for example, you may raise your hand to indicate that you are happy for a nurse to take a blood samplein writing – by signing a consent formA signed consent form by itself does not constitute consent; it simply serves as evidence of consent. The consent form will not be valid if your consent is:not voluntarynot informed, oryou do not have enough mental capacity (the ability to use and understand information to make a decision) to give consentSee Consent to treatment - capacity for more information about capacity and situations that can affect your capacity. Refusing treatmentIf you have enough capacity and make a voluntary and informed decision to refuse a particular treatment, your decision must be respected. This is still true even if your decision would result in your death, or the death of your unborn child.You are still entitled to receive any other appropriate medical treatment and care that is felt would be in your best interest. However, if you ask for a course of treatment that healthcare professionals believe would not be in your best interest, they have no obligation to provide it.Children and teenagersTeenagers who are 16 and 17 years old are entitled to consent to their own treatment, and this consent cannot be overruled by their parents.Children who are under 16 years old can consent to their own treatment if it is thought that they have enough intelligence, competence and understanding to fully appreciate what is involved in their treatment.If a child who is under 16, or a teenager who is 16 or 17 years old, refuses treatment and by doing so this may lead to their death or a severe permanent injury, their
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decision can be overruled by the courts. The court used is the Court of Protection, which is the legal body that oversees the operation of the Mental Capacity Act (2005).In some cases, the parents of a child who has refused treatment have been allowed to consent for them. However, it may be best to go through the courts in such situations.Parental responsibilityIf a child who is under 16 does not have the capacity to consent, someone with parental responsibility can consent for them. See the box (left) for a list of people who can hold parental responsibility. The person with parental responsibility must have the capacity to give consent.If a parent refuses to give consent to a particular treatment, this decision can be overruled by the courts if treatment is thought to be in the best interests of the child.If one person with parental responsibility gives consent and another does not, the healthcare professionals can accept the consent and perform the treatment. If the people with parental responsibility disagree about what is in the child’s best interests, the courts can make a decision. In an emergency, where treatment is vital and waiting to obtain parental consent would place the child at risk, treatment can proceed without consent.ExceptionsThere are a number of exceptions where a capable person can be treated without first obtaining their consent. These exceptions are listed below.Under the Public Health (Control of Disease) Act (1984), a magistrate can order that a person is detained in hospital if they have an infectious disease that presents a risk to public health – such as rabies, cholera and anthrax.Under the National Assistance Act (1948), a person who is severely ill or infirm and is living in unsanitary (unclean) conditions can be taken to a place of care without their consent.Under the Mental Health Act (1983), people with certain mental health conditions, such as schizophrenia, bipolar disorder or dementia can be compulsorily detained at a hospital or psychiatric clinic without their consent.PrisonersThe legal rights of prisoners are unaffected when it comes to the issue of consent. No capable prisoner can be treated without consent even if that means their life will be at risk. This includes a prisoner who is refusing to eat food.
Parental responsibilityA person with parental responsibility for a child who is under 16 years of age could be:the child’s motherthe child’s father if he was married to the mother when the child was bornfor children born before December 1, 2003: the child’s father, if he marries the mother, obtains a parental responsibility order from the court or registers a parental responsibility agreement with the courtfor children born on or after December 1, 2003: the child’s father, if he registered the child’s birth with the mother at the time of the birth, or if he re-registers the birth (if he is the natural father), marries the mother, obtains a parental responsibility order from the court, or registers a parental responsibility agreement with the courtthe child’s legally appointed guardiana person with a residence order concerning the childa local authority that is designated to care for the child a local authority or person with an emergency protection order for the child
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HOW DO YOU GET CONSENT FROM A
PATIENT?
The process starts in the out patient department. Once a diagnosis has been made and
the treatment options have been explained, a decision can be made between the
patient and the surgeon on the best way forward for that individual. At this point the
patient would have a full description of the intended procedure, possible
complications that may occur, and the likely time spent in hospital and the length of
the recovery.
The patient would then have an information sheet/leaflet which would have all this
information down into the plain language. The patient is advised to discuss the
prospective treatment with family and friends, and to write down any questions that
arise, and ask these when they next see the team.
When the patient attends for surgery the whole process is repeated, to ensure that the
patient fully understands what is going to happen. This would be done by the
operating surgeon, or someone who is capable of performing the operation. Clearly
check and mark the limb with a permanent marker.
e.g. for THR risks stated would include dislocation, infection, Deep Venous
Thrombosis (DVT) or Pulmonary Embolism (PE), stiffness, leg length discrepancy
and wear (aseptic loosening)
http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Consent/inde
x.htm
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INCOMPETENT COLLEAGUE
How are you going to deal with an incompetent colleague?
HOW ARE YOU GOING TO DEAL WITH AN INCOMPETENT COLLEGUE?
• Patient/Colleague/Public safety• Hear/say/confirm• Direct communication• Next chain of command• Hospital protocol• Local/Regional bodies- BMA,MDU• Management• Prevention• Counselling
Firstly, "Act quickly to protect patients from risk if you have good reason to believe
you or a colleague my not be fit to practice". This places a clear professional
responsibility on each individual to take action where they have serious concerns.
A first step would be to discuss concerns informally with a senior colleague such as
the consultant, the Clinical Director, Medical Director, Chairman of the Medical Staff
Committee, or a colleague in the specialty from another hospital. In doing so, it may
be helpful to consider whether the use of locally available informal procedures
(counselling services, "Three Wise Men" or equivalent) would be appropriate. The
local BMA office is a possible source of advice on the range of informal procedures
in the locality. Discuss it with MDU.
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DRUNKEN COLLEAGUE
How will you deal with a drunken colleague?
It is a very sensitive situation. Acknowledge it.
A difficult doctor is the doctor in difficulty.
Patient safety comes first. Try to communicate with the doctor directly. If you are a
junior doctor, you can discuss the matter with your anaesthetist or other colleague i.e.
a senior sister in charge or a senior manager. If you are still unable to handle it, you
can ring another consultant colleague or the Clinical Director (CD) if it is possible.
Whatever happens, he/she should not be allowed to go and deal with the patient.
Doctor’s safety is important. How will he/she go home? Will he/she drive on his/her
own? If this is the case, you should find out a taxi or some other alternative measure
should be taken so that he/she goes home safely as the doctor’s and public safety is at
stake.
CHAIN OF COMMANDS:
A senior person who is in charge of the team should be informed. Now, “was it a one
off incident or is it a regular happening?” Do you need to record it? There is hospital
policy and guidelines for each trust and this should be followed. Involvement of the
Drunken colleague
Patient safetyDoctor’s safetyDirect communication- inform that CD will be informed Chain of commands – whistle blowingHospital policy /guidelinesBMA/ MDU
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British medical association (BMA) and Medical Defence Union (MDU) may also be
needed.
Remember, if it is a clinical governance issue or a criminal issue you have to take
appropriate action.
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DIFFICULT NURSE
If you are a new consultant / ST and the nurse keeps on saying in the Operating
Theatre that you are useless and is constantly criticising you, how are you going to
deal with him or her?
You have to go to the basic questions; when, where, what and whom? Discuss the
situation with him or her when the theatre is over. If needed, you should involve the
in-charge nurse and explain to the nurse that there are different ways to do the same
thing. That you are fully trained and you are competent in doing this. If the situation is
not resolved by direct conversation, you might need to involve the clinical director. If
the criticiser is correct, there is no harm in apologizing and thus resolving the issue. If
he or she is wrong, appropriate action has to be taken after discussing the situation
with the clinical and the Medical Director. You might need to take advice from the
MDU.
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MAIN WEAKNESS
What is your main weakness? Have you got any weaknesses?
Main weakness
Too serious about clinical commitmentsTry to do too much, must keep a realistic goalAffects family life Time management - course
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PERSONAL DEVELOPMENT PLANWhat is your personal development plan?
How do you want to develop yourself?
PERSONAL DEVELOPMENT PLAN
• Clinical
• Research/Audit
• Teaching
• CPD
• Management waiting list target/Day care center/Day surgery unit/Early discharge
• Personal
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ASSESSMENT AND APPRAISAL What do you think of an assessment and an appraisal? What difference is there between an assessment and appraisal?
DIFFERENCE BETWEEN ASSESSMENT AND APPRAISAL
• Assessment : Performance v/s Standard
• Appraisal: Assessment + setting target for further progression
• The difference between Assessment and Appraisal has been summarised thus:
• “Ticking boxes set by others” (Assessment)
• “Ticking boxes that I have helped to set myself” (Appraisal)
• The purpose behind appraisal for medical staff under training is to set goal is for training. In this context, it is inevitable that career options will be discussed.
ASSESSMENT AND APPRAISAL: An assessment is essentially performance versus
standard. An Appraisal is an assessment while additionally setting targets for others’
progress. The difference between an assessment and an appraisal has can be
summarised as ticking the boxes set by others, an assessment, and appraisal when
ticking boxes that I have helped to set for myself.
It is essential to enable both doctors and patients to see that there are mechanisms by
which good practice is acknowledged by peers and ultimately revalidation and bad
practice is identified and then addressed. The government is trying to develop a plan
for revalidation of doctors under the GMC.
http://www.appraisalsupport.nhs.uk/files2/UK_Appraisal_and_Revalidation_Support_Aug07.pdf
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Appraisal for GPs
http://www.pdptoolkit.co.uk/Files/appraisals/gp_appraisals_and_revalidation.ht
m
Appraisal for GPs was introduced in April 2002, following full and detailed
consultation with the General Practitioners' Committee of the BMA. Responsibility
for appraisals rests with PCTs. Updated guidance was published on 23 August 2004.
Appraisal for NHS clinical consultants
In 2001 clinical consultants became the first group of NHS doctors to undertake
annual appraisal. This was intended to support the learning and personal development
needs for consultants. It also developed models of best practice that featured in the
introduction of appraisal for other NHS doctors.
http://www.appraisalsupport.nhs.uk/
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LICENCING
http://www.gmc-uk.org/doctors/licensing.asp
To practise medicine in the UK all doctors are required by law to be both registered and hold a licence to practise.Doctors work in many different environments. Those who treat patients must be registered with a licence to practise. This applies to all doctors irrespective of whether they practise full time, part time, as a locum, privately or in the NHS, or whether they are employed or selfemployed.
Only doctors who are registered with a licence to practise can, for example:
• Work as a doctor in the NHS• Write prescriptions• Sign death or cremation certificates
Licensing is the first step towards the introduction of revalidation. This new approach to medical regulation will give patients and employers regular assurance that their doctors are up to date and fit to practise.Licences will require periodic renewal by revalidation. When revalidation begins licensed doctors will be required to demonstrate to the GMC that they are practising in accordance with the generic standards of practice set by the GMC (as described in Good Medical Practice).This section contains the following information:
• Regulations and guidance• Information for employers and other organisations• Information for patients
Overseas medical regulators can also download a briefing on licensing (PDF, 1MB), which explains the changes that were made to the registration arrangements for UK doctors on 16 November 2009.
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REVALIDATION
http://www.gmc-uk.org/doctors/revalidation.asp
Over the next few years, the General Medical Council will be changing the way doctors within the UK are regulated to practise medicine. Revalidation is the process by which licensed doctors will demonstrate to the GMC that they remain up to date and fit to practise.
Revalidation is expected to start from late 2012, according to a joint statement published in October 2010 by the General Medical Council and the health departments of England, Northern Ireland, Scotland and Wales. Revalidation: A Statement of Intent (pdf) sets out the key milestones that employers will need to meet before revalidation is introduced.
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WHY DID YOU APPLY FOR THIS JOB?
Department
Unit
Colleagues
Place
Family
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HOW CAN YOU ENSURE THAT YOU WILL
BE ADEQUATELY TRAINED TO BE A
CONSULTANT WHEN YOU GAIN YOUR
CCT?
A safe and competent consultant - Is able to manage his services well along with the training responsibilities in the defined
clinical team- understands his limitations- and knows when to ask for help and where?• Skill improvement : clinical/ Decision making/Operating/ Interpersonal/
Communication/ Leadership/Management/Teaching/ Research/Audit• Learning /Training agreement• Direct supervision• Assessment: Progress at each level of training
• RITA assessment 6months/ 1 year and annually thereafter• Log book• 360 degrees feedback
• Intercollegiate specialty examination• Last 2 years will be dedicated to developing subspecialty interest/ Fellowship• At this stage I will go through the process of CCST• Onus : myself At the end of the day I should feel that I have completed my training and
am ready for the job
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CONSULTANT CONTRACT
Consultant contractIn the year 2003 the current consultant contract came into effect in England, Scotland and Northern Ireland. The aims of the new contract
1. Reduce excessive working hours2. Strengthen job planning3. increase consultant productivity
It has introduced a number of principles that fundamentally change the way consultants work. Discussion points:
1. Performance related pay2. Increases management control of how consultants relate to their patients and
employers3. Imposes a strict working timetable
The key principles of the contract are • No consultant can be compelled to work more than 40 hours a week.• Consultants wishing to work in the private sector may be asked to
work an additional four hours a week or forfeit a pay progression if this request is declined.
• The working week is made up of program activities (PAs) four hours each. Typically 7.5 PAs (30 hours) are set aside for direct clinical activity including patient administration and 2.5 PAs (10 hours) set aside as for supporting activities.
• The allocation of time necessary to undertake supporting activities has been a contentious issue of the contract and is discussed further.
• In England, Scotland and Northern Ireland the annual increment has been replaced with entitlement to pay progression, subject to the trusts chief executive being satisfied that the consultant has achieved his or her objectives as identified in the agreed job plan.
• On-call work is recognised by the payment of a percentage of salary; depending on the frequency of the rota and the allowance in the job plan by the time typically spend returning to work whilst on-call.
• No consultant may be required to undertake non-emergency work in weekends between the hours of 7 PM and 7 AM.
• Additional PAs may be offered and accepted were additional capacity is needed.
• It reinforces the need for consultants to maintain an accurate diary of all the activities. If there is a conflict between one trust and the consultant any mediation or formal appeal will require evidence to be produced as opposed to the anecdotal considerations.
Job Planning• You should have a job plan that is well defined in the job description
when you apply for consultant post.• The consultants will be invited by their employers to undertake no
more than 10 PA contracts.
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• This is entirely consistent with contract at may mean a reduction in salary for those currently working in excess of 10 PAs.
• If the trust is proposing that you reduce your PAs you need to be satisfied that there is a reduction in activity so that any work your employer requires of you can be done within the 40 hours envelope.
• If there is any disagreement about whether this can be achieved you should post to this through the mediation and appeal process to reach a mutually acceptable agreement.
• You should establish clearly with your employer the scope of the role that is involved.
• You should raise any issue of ambiguity or uncertainty about responsibilities in a multidisciplinary team in order to clarify:
1. Lines of accountability for the care provided to individual patients.2. We should take on leadership roles or line management
responsibilities.3. Where does the responsibility lie for the quality and standard of care
provided by the team?
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CHAPTER VI
D Raj
MANAGEMENT ISSUES
BUSINESS PLAN
THE DOCTOR-MANAGER RELATIONSHIP
NEGOTIATION
TIME MANGEMENT
CODING
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BUSINESS PLAN
Introduction
It is essential to have a realistic, working business plan when you're starting up a business. A business plan is a written document that describes a business, its objectives, its strategies, the market it is in and its financial forecasts. It has many functions, from securing external funding to measuring success within your business.
The audience for your business plan
There are many benefits to creating and managing a realistic business plan. Even if you just use it in-house, it can:
• help you spot potential pitfalls before they happen• structure the financial side of your business efficiently• focus your development efforts• work as a measure of your success
Many people think of a business plan as a document used to secure external funding. This is important because potential investors, including banks, may invest in your idea, work with you or lend you money as a result of the strength of your plan.
The following people or institutions may request to see your business plan at some stage:
• Finance department• grant providers• anyone interested in buying your business• potential partners
You should also bear in mind that a business plan is a living document that will need updating and changing as your business grows. Regardless of whether you intend to use your plan internally, or as a document for external people, it should still take an objective and honest look at your business. Failing to do this could mean that you and others have unrealistic expectations of what can be achieved and when.
What the plan should include
Your business plan should provide details of how you are going to develop your business, when you are going to do it, who's going to play a part and how you will manage the money.
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Clarity on these issues is particularly important if you're looking for finance or investment. The process of building your plan will also focus your mind on how your new business will need to operate to give it the best chance of success.
Your plan should include:
• An executive summary - this is an overview of the business you want to start. It's vital. Many lenders and investors make judgments about your business based on this section of the plan alone.
• A short description of the business opportunity - who you are, what you plan to sell or offer, why and to whom.
• Your marketing and sales strategy - why you think people will buy what you want to sell and how you plan to sell to them.
• Your management team and personnel - your credentials and the people you plan to recruit to work with you.
• Your operations - your premises, production facilities, your management information systems and IT.
• Financial forecasts - this section translates everything you have said in the previous sections into numbers. The executive summary
The executive summary is often the most important part of your business plan. Positioned at the front of the document, it is the first part to be read. However, as a summary it makes sense to write it last.
It may be the only part that will be read. Faced with a large pile of funding requests, venture capitalists and banks have been known to separate business plans into 'worth considering' and 'discard' piles based on this section alone.
What is it?
The executive summary is a synopsis of the key points of your entire plan. It should include highlights from each section of the rest of the document - from the key features of the business opportunity through to the elements of the financial forecasts.
Its purpose is to explain the basics of your business in a way that both informs and interests the reader. If, after reading the executive summary, an investor or manager understands what the business is about and is keen to know more, it has done its job.
It should be concise - no longer than two pages at most - and interesting. It's advisable to write this section of your plan after you have completed the rest.
What is it not?
• A brief description of the business and its products. It's a synopsis of the entire plan.
• An extended table of contents. This makes for very dull reading. You should ensure it shows the highlights of the plan, rather than restating the details the plan contains.
• Hype. While the executive summary should excite the reader enough to read the entire plan, an experienced investor or businessperson will recognise hype and this will undermine the plan's credibility.
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Your business, its products and services
If you want other people to invest in your business or if you're writing your plan to focus your existing business activities, you must be able to clearly convey what your business does.
This part of the plan sets out your vision for your new business and includes who you are, what you do, what you have to offer and the market you want to address.
Start with an overview of your business:
• when you started or intend to start trading and the progress you have made to date
• the type of business and the sector it is in• any relevant history - for example, if you acquired the business, who owned it
originally and what they achieved with it• the current legal structure• your vision for the future
Then describe your products or services as simply as possible, defining:
• what makes it different• what benefits it offers• why customers would buy it• how you plan to develop your products or services• whether you hold any patents, trade marks or design rights• the key features of your industry or sector
Remember that the person reading the plan may not understand your business and its products, services or processes as well as you do, so try to avoid jargon. It's a good idea to get someone who isn't involved in the business - a friend or family member perhaps - to read this section of your plan and make sure they can understand it.
Your markets and competitors
In this section you should define your market, your position in it and outline who your competitors are. In order to do this you should refer to any market research you have carried out. You need to demonstrate that you're fully aware of the marketplace you're planning to operate in and that you understand any important trends and drivers.
You should also be able to show that your business will be able to attract customers in a growing market despite the competition.
Key areas to cover include:
• your market - its size, historical data about its development and key current issues
• your target customer base - who they are and how you know they will be interested in your products or services
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• your competitors - who they are, how they work and the share of the market they hold
• the future - anticipated changes in the market and how you expect your business and your competitors to react to them
Marketing and sales
This section should describe the specific activities you intend to use to promote and sell your products and services. It's often the weak link in business plans so it's worth spending time on it to make sure it's both realistic and achievable.
A strong sales and marketing section means you have a clear idea of how you will get your products and services to market.
Your plan will need to provide answers to these questions:
• How do you plan to position your product or service in the market place? • Who are your customers? Include details of customers who have shown an
interest in your product or service and explain how you plan to go about attracting new customers.
• What is your pricing policy? How much will you charge for different customer segments, quantities, etc?
• How will you promote your product or service? Identify your sales methods, e.g. direct marketing, advertising, PR, email, e-sales.
• How will you reach your customers? What channels will you use? Which partners will be needed in your distribution channels?
• How will you do your selling? Do you have a sales plan? Have you considered which sales method will be the most effective and most appropriate for your market, such as selling by phone, over the internet, face-to-face or through retail outlets? Are your proposed sales methods consistent with your marketing plan? And do you have the right skills to secure the sales you need?
Your team's skills
Your business plan needs to set out your own background and skills and the structure and key skills of both your management team and your staff. It should identify the strengths in your team and your plans to deal with any obvious weaknesses.
The management team
If you're looking for external funding, your management team can be a decisive factor. Explain who is involved, their role and how it fits into the organisation. Include a CV or paragraph on each individual, outlining their background, relevant experience and qualifications. Include any advisers you might have such as accountants or lawyers.
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If you're looking to satisfy your bank manager or other investors, you need to demonstrate that your management team has the right balance of skills, drive and experience to enable your business to succeed. Key skills include sales, marketing and financial management as well as production, operational and market experience.
Your investors will also want to be convinced that you and your team are fully committed. Therefore it's a good idea to set out how much time and money each person will contribute to the business and the salaries and benefits you plan to draw.
Your operations
Your business plan also needs to outline your operational capabilities and any planned improvements. There are certain areas you should focus on.
Location
• Do you have any business property?• What are your long-term commitments to the property?• Do you own or rent it?• What are the advantages and disadvantages of your current location?
Production facilities
• Do you need your own production facilities or would it be cheaper to outsource any manufacturing processes?
• If you do have your own facilities, how modern are they?• What is the capacity compared with existing and forecasted demand?• Will any investment be needed?
Management-information systems
• Have you got established procedures for stock control, management accounts and quality control?
• Can they cope with any proposed expansion?
Information technology (IT)
• IT is a key factor in most businesses, so include your strengths and weaknesses in this area.
• Outline the reliability and the planned development of your systems.
Financial forecasts
As part of your plan you will need to provide a set of financial projections which translate what you have said about your business into numbers.
You will need to look carefully at:
• how much capital you need if you are seeking external funding
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• the security you can offer lenders• how you plan to repay any borrowings• sources of revenue and income
You may also want to include your personal finances as part of the plan at this stage.
Financial planning
Your forecasts should run for the next three (or even five) years and their level of sophistication should reflect the sophistication of your business. However, the first 12 months' forecasts should have the most detail associated with them.
Include the assumptions behind your projection with your figures, both in terms of costs and revenues so investors can clearly see the thinking behind the numbers.
Presenting your business plan
To make sure your business plan has maximum impact, there are a number of points to observe.
Keep the plan short - it's more likely to be read if it's a manageable length. Think about the presentation and keep it professional - even if you only intend to use the plan in-house. Remember, a well presented plan will reinforce the positive impression you want to create of your business.
Tips for presenting your plan
• Include a cover or binding and a contents page with page and section numbering.
• Start with the executive summary.• Ensure it's legible - make sure the type is ten point or above.• You may want to email it, so ensure you use email-friendly formatting.• Even if it's for internal use only, write the plan as if it's intended for an
external audience.• Edit the plan carefully - get at least two people to read it and check that it
makes sense.• Show the plan to expert advisers - such as your accountant - and ask for
feedback. Redraft sections they say are difficult to understand.• Avoid jargon and put detailed information - such as market research data or
balance sheets - in an appendix at the back.
Make sure your plan is realistic. Once you have prepared your plan, use it. If you update it regularly, it will help you keep track of your business' development.
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DOCTOR-MANAGER RELATIONSHIP
The Doctor The ManagerTrained to emphasise the scientific approach
Has to remember political factors and human motivation
Has face to face contact with patients and their families
Rarely meets patients or family
Will never be primarily concerned with costs
Focused on treatment efficiency delivered within the allocated resources
Focuses on individual patient Focused on population/group and government agenda
Expected to solve all presenting problems Must to choose which problem to tackleHas learnt to be independent and competitive
Expects to share responsibilities with others
Expects problems to have solutions Expects to tolerate many insoluble problems
Expects to stay with the same trust for whole career and has job security
Has to move to gain promotion or due to redundancy
High social status and professional freedom
Medium social status and public pressures
(From Garelicka and Faginl the Doctor manager relationship advances in psychiatric treatment 11) (2005)
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NEGOTIATION
Introduction Negotiation is something that we do all the time and is not only used for business purposes. For example, we use it in our social lives perhaps for deciding a time to meet, or where to go on a rainy day. Negotiation is usually considered as a compromise to settle an argument or issue to benefit ourselves as much as possible. Communication is always the link that will be used to negotiate the issue/argument whether it is face-to-face, on the telephone or in writing. Remember, negotiation is not always between two people: it can involve several members from two parties. There are many reasons why you may want to negotiate and there are several ways to approach it. The following is a few things that you may want to consider.
Why Negotiate?
If your reason for negotiation is seen as 'beating' the opposition, it is known as 'Distributive negotiation'. This way, you must be prepared to use persuasive tactics and you may not end up with maximum benefit. This is because your agreement is not being directed to a certain compromise and both parties are looking for a different outcome.
Should you feel your negotiation is much more 'friendly' with both parties aiming to reach agreement, it is known as 'Integrative negotiation'. This way usually brings an outcome where you will both benefit highly. Negotiation, in a business context, can be used for selling, purchasing, staff (e.g. contracts), borrowing (e.g. loans) and transactions, along with anything else that you feel are applicable for your business.
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TIME MANGEMENT
Central to good time management is the ability to prioritise tasks and there are different ways of going about this.
1. You should try to handle a piece of paper once. i.e. when you read you post you should aim to deal with each item in the same way. Deal it, delegate it or act upon it.
2. Make good use of your waste paper/ recycling bin. If you have a tendency to procrastinate on certain tasks doing them first to get them out of the way.
3. Delegate as much as you can.4. Keep a list of things to do.5. Let people know there are times you don’t want to be interrupted, unless there
is an emergency.6. Keep and use a diary or an electronic organiser.7. Enter all commitments as they are met.8. When planning time to carry out a project, estimate the time it will take you
and then double it. 9. Learn to say no. To request that you don’t have the time or inclination for.10. Try to keep your desk tidy.
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CODING
87
CHAPTER VII
MODERNISING MEDICAL CAREERS
TRAINING
EWTD
TOOKE REPORT
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MODERNIZING MEDICAL CAREERS
http://www.mmc.nhs.uk/
The Modernising Medical Careers team is working with colleagues around the
country to develop a better way of training doctors through the implementation of the
Foundation Programme and the reform of specialty and general practice training
programmes.
What is MMC?Modernizing Medical Careers (MMC) aims to improve patient care by delivering a modernized and focused career structure for doctors through a major reform of postgraduate medical education. It aims to develop demonstrably competent doctors who are skilled at communicating and working as effective members of a team. As training and education are central to the work of doctors and their role in delivering patient care, MMC will also bring about significant changes to career structures, providing qualified staffs that are able to meet the needs of patients.
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FOUNDATION PROGRAMS
http://www.foundationprogramme.nhs.uk/pages/home
The Foundation Programme is a two-year training programme that forms the bridge between medical school and specialty / general practice training.
All graduates of UK medical schools are required to complete the Foundation Programme before applying for specialty training.
During the Foundation Programme, trainees will have the opportunity to gain experience in a series of placements in a variety of specialties and healthcare settings.
Foundation Year 1 (F1)
The first year of the Foundation Programme builds upon the knowledge, skills and competences acquired in undergraduate training.
Foundation Year 2 (F2)
The second year Foundation Programme builds on the first year of training. In F2, the focus is on training in the assessment and management of the acutely ill patient. Training also encompasses the generic professional skills applicable to all areas of medicine – teamwork, time management, communication and IT skills.
http://www.foundationprogramme.nhs.uk/
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FOUNDATION PROGRAMS: Training and Assessment
http://www.foundationprogramme.nhs.uk/pages/home/training-and-assessment
Your training will be supported by the Foundation Programme Curriculum and you must gain all of the competences detailed in the curriculum before you can complete the Foundation Programme. This section explains more about your education and training, assessments and your Foundation Learning Portfolio.
Rough Guide to the Foundation Programme
The Rough Guide will give you an overview of the programme and tell you what to expect in your induction, placements, study leave, etc. The guide also contains case studies from foundation doctors which may help give you an insight into what actually happens during your first two years as a doctor. It is best if you can read this before you look at the curriculum or the portfolio.
Foundation Programme Curriculum
You will be assessed against the competences in the curriculum and you should keep all of your assessments (not just the good ones) in your Foundation Learning Portfolio.
Foundation Learning Portfolio
The portfolio may either be paper-based or electronic, depending on which version your foundation school has decided to use. The paper-based portfolio can be downloaded and printed off from this website.
If you are going to use the electronic portfolio, your foundation school will provide you with your login details and password, and the website address. (Scotland uses a different web address to the rest of the UK, but the portfolios have the same content).
Assessment and assessment tools
Workplace-based assessment and feedback are central to the philosophy of foundation training. Regular assessment ensures you are progressing, provides documentary evidence of your achievements and can be used to identify any problems you are having early on.
The goal is to help you provide better care to patients; and to help you strengthen any areas of weakness that are identified.
You will be assessed against the standard of competence that is expected of a doctor completing the F1 year. This means that, in your first days as a foundation doctor, you
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may not reach the standard required. Don’t worry, this is to be expected and is NOT a failure. The assessments are designed to measure your progress through the year. At the end of F1, you will be expected to have progressed to a satisfactory level.
There are three types of assessment commonly used:
• Multi-Source Feedback (MSF) provides an opportunity for a number of your colleagues to rate your abilities and offer comments. The three tools currently in use are:
o Mini Peer Assessment Tool (mini-PAT),o Team Assessment of Behaviours (TAB)o Multi-source feedback tool (used in Scotland).
With all of these tools, you will be asked to submit a list of colleagues (including non-clinical members of your healthcare team) as possible raters/assessors. An administrator will contact these raters and will compile the results once sufficient responses are received. The report is sent to your educational supervisor, who will discuss the results and comments with you.
• Direct observation of doctor/patient encounters are observed clinical interactions which provide the opportunity for immediate feedback to the junior doctor. The two most commonly used tools are:
o Direct Observation of Procedural Skills (DOPS)o Mini Clinical Evaluation Exercise (Mini-CEX).
During your placements, you should ask experienced colleagues (including SpRs, consultants, GP principals, plus experienced nurses and allied health professionals in the case of DOPS) to observe you performing a particular procedure (DOPS) or clinical consultation (mini-CEX), rate your level of competence and provide feedback. It is your responsibility to arrange the assessments and submit copies of the reports.
• Case-Based Discussion (CBD) – this is a structured review of cases you have been involved in. It allows you to discuss your decision-making and clinical reasoning in a safe, non-judgemental environment with a senior clinician.
The assessments may sound intimidating, but they all come with instructions and training material for you and the assessors.
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SPECIALTY TRAINING
http://www.mmc.nhs.uk/specialty_training_2010.aspx
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GP TRAINING
http://www.gprecruitment.org.uk/
The National Recruitment Office co-ordinates recruitment to general practice training schemes throughout England, Wales, Scotland and Northern Ireland.
This website is designed to help doctors who want to train for general practice identify the available opportunities, make informed judgments about where they wish to train and guide them through the application system.
Eligibility requirements, Deanery information plus the answers to your most frequently asked questions are available on this site which also serves as a gateway to individual deanery sites.
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EUROPEAN WORKING TIME DIRECTIVEEUROPEAN WORKING TIME DIRECTIVEhttp://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraini
ng/Modernisingworkforceplanninghome/Europeanworkingtimedirective/DH_41
5
This is a still a hot topic. Please go to the Department of health website to update
yourself.
What is the European Working Time Directive?
The EWTD is a directive from the Council of Europe (93/104/EC) to protect the health and safety of workers in the European Union. It lays down minimum requirements in relation to working hours, rest periods, annual leave and working arrangements for night workers.
The Directive was enacted into UK law as the Working Time Regulations, which took effect from 1October 1998. The Government negotiated an extension of up to twelve years to prepare for full implementation for doctors in training.
What is the situation at the moment?
Since 1991, doctors in training have been covered by the New Deal, a package of measures to improve the conditions under which they work. One of the key features of the New Deal is limits on the working hours of junior doctors. From August 2003 all junior doctors are limited by contract to 56 hours of active work.
The legal definition of working time
"Working time shall mean any period during which the worker is working, at the employer's disposal and carrying out his or her activity or duties, in accordance with national laws and/or practice."
The European Court made a judgement in October 2000, in answer to a claim by doctors in Spain, that time spent resident on call be defined as work:
• The SiMap ruling
What is the timetable for implementation of the WTD?
August 2007
Interim 56-hour maximum working week. (Rest break requirements became legally enforceable in 2004)
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August 2009
Deadline for 48-hour maximum working week. This may exceptionally be extended by another three years at 52 hours, with 48 hours then being implemented in 2012.
What are the rest and break requirements?
• A minimum daily consecutive rest period of 11 hours• A minimum rest break of 20 minutes when the working day exceeds six hours• A minimum rest period of 24 hours in each seven day period (or 48 hours in
14 days)• A minimum of four weeks' paid annual leave• A maximum of eight hours' work in any 24 hours for night workers in stressful
job
What flexibility will NHS employers have in giving rest entitlements?
A derogation is an agreement to introduce flexibility in some of the rest requirements, allowing doctors, for example, to take compensatory rest in lieu of the rest they should be getting while working. We have derogated from rest requirements for doctors in training (subject to immediate compensatory rest) under the Working Time Regulations 2003, thereby giving NHS employers some flexibility as to when rest is taken. This will help the NHS to plan services around patient needs.
.
Training and staff
Shorter hours will mean less training?
The WTD will indeed challenge us to look at the way we deliver training. That is why
the Government launched its Modernizing Medical Careers strategy in February this
year. This heralds a thoroughgoing review of training systems and methods as well as
looking at the end product of training. The better-managed, better structured and more
robust training arrangements we envisage will lead to more meaningful and focused
training. This is exactly what is required in addressing the WTD.
How are we going to get everything done – using other staff?
Changes to service delivery to bring doctors in training hours into compliance with
the WTD provide an opportunity for all members of the health care team (not just
nurses), to review their contribution to patient care, and to develop their roles. We are
investigating innovative ways to share work amongst all professions, and aim to
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develop other employees to take on work traditionally undertaken by doctors in
training. Innovations include the modeling of different working patterns (with live
pilots), skill mix solutions etc. Many nurses are extending their roles to run clinics,
perform minor surgery, admit and discharge patients, and request tests and
investigations.
Costs and finance
Where is the money for implementing the EWTD?
NHS funding is expected to increase by an average of 7.4 % in England over each of
the next five years. This includes provision for the impact of WTD.
Isn’t it too expensive to implement?
Changes to working practices need not cost more, and can actually lead to improved
care for patients. Solutions require more flexible use of new and existing staff, so
Trusts must assess what skills are needed, when they are needed and who has those
skills.
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HOSPITAL AT NIGHT
The Hospital at Night project aims to redefine how medical cover is provided in
hospitals during the out-of-hours period. The project requires a move from cover
requirements defined by professional demarcation and grade, to cover defined by
competency.
We believe the project provides the best possible care for patients given the changes
in permitted working hours of doctors in training. It offers the most efficient method
of preserving, and even enhancing, doctors’ training in the reduced hours available.
The Hospital at Night model consists of a multidisciplinary night team, which has the
competencies to cover a wide range of interventions but has the capacity to call in
specialist expertise when necessary. This contrasts the traditional model of junior
doctors working in relative isolation, and in specialty-based silos.
The project also advocates
• Supervised multi-specialty handover in the evenings
• Other staff taking on some of the work traditionally done by junior doctors
• Moving a significant proportion of non-urgent work from the night to the
evening or daytime
• Reducing the unnecessary duplication of work by better coordination and
reducing the multiple clerking and reviews.
The project has used the Joint Consultants Committee as its steering group and the
model is endorsed by them, as well as the Royal College of Nursing and the British
Medical Association.
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Evaluation published for 'Hospital at Night' project
Hospital at Night, a model of shift patterns and staffing mix for the NHS to use in response to the European Working Time Directive has delivered improvements to patient care, according to a new report published today.
The report details evaluations from four acute hospital sites across England that piloted the scheme in 2003.
The report concludes that Hospital at Night:
• Helped improve patient care during the night by prioritising acutely ill patients, and ensures that patients are treated more quickly and are seen by doctors who are more alert
• Had no negative impact on doctors training• Has not affected the achievement of national performance targets in the areas
of A&E waiting times, cancelled operations and inpatient waiting times.
The Hospital at Night project redefined how medical cover is provided in hospitals during the out-of-hours period. The project requires a move from cover requirements defined by professional demarcation and grade, to cover defined by competency.
Key elements of Hospital at Night include multi-disciplinary teams, multi-specialist handovers, bleep filtering, extended nursing roles, and moving non-urgent work from the nighttime.
The project is a partnership between the Department of Health, the NHS Modernisation Agency, the British Medical Association and the Royal Colleges.
Public Health Minister Caroline Flint said:
'Implementation of the Working Time Directive for doctors in training in August 2004 was not easy, but it is testament to the hard work and dedication of staff that we have managed to come this far.
'Hospital at Night played a key part role in helping trusts formulate new ways of working, achieve Working Time Directive compliance, improve patient care and encouraged a better work/life balance between doctors.
'As the report shows, the successful implementation of Hospital at Night prioritises acutely ill patients, and ensures that patients are treated more quickly and are seen by doctors who are more alert.
'The involvement and advice from professional organisations and colleagues in the wider NHS has been critical to the successful implementation of Hospital at Night.
'The Working Time Directive was a great opportunity for us to modernise the way we work to provide faster treatment for patients, a better patient experience and a better working environment for staff.
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'Hospital at Night was a key element of this strategy. We need to build on this success. We must keep up the momentum in reducing doctors' hours - the job is not fully done but the principles underpinning Hospital at Night will be a key solution to the 2009 48-hour European Working Time Directive.'
Patrick Chu, Clinical Director of Haematology at the Royal Liverpool NHS Trust, one of the pilot schemes, said:
"The Hospital at Night model is a very good working model to help pave the way for the full implementation of the European Working Time Directive in 2009. It also has much wider benefits including training more highly skilled nurses, ,improving communications, team building and time management. The hospital at night model can be improved further by applying the concept across the 24 hours of the working day."
The report also highlights:
Team working - At all Trusts for the pilots the multidisciplinary team comprised highly trained nurses and doctors from a range of specialties. Doctors felt that team working reduced the intensity of their workload and allowed them to concentrate on specific patients without interruption.
Handover - All staff felt that the more formal handover that is a key requirement of Hospital at Night guidance improved patient care. Doctors felt that they were picking up the most acutely ill patients and it was easier to get cross speciality referrals.
Night Coordinator role - The importance of the Night Coordinator role - a senior nurse at each of the pilot sites - was a critical part of the implementation and working of Hospital at Night teams. Nurses in particular reported that they felt more willing to bring problems to the attention of the Night Coordinator, which led to improvements in patient care.
Bleep filtering - The inappropriate bleeping of doctors helped doctors to see patients more quickly, carry out patient consultations without constant interruption. It also contributed to improving the work/life balance of doctors by helping them finish their shifts on time.
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TOOKE REPORThttp://www.mmcinquiry.org.uk/draft.htm
Why an inquiry?
The former Secretary of State for Health, Patricia Hewitt, invited Sir John Tooke to lead an Independent Inquiry into Modernising Medical Careers (MMC) in the wake of the debacle surrounding MTAS, the process used for selecting trainee doctors for specialist training. Seldom in my professional career has an issue provoked such an outcry from the profession and expressions of concern for the future of trainee doctors and the delivery of medical care and health service developments to which we hope they will contribute.
Summary
1. Management of Postgraduate Training in England
Lack of cohesion
Suboptimal relationships with service and academia
2. Postgraduate Deaneries should be reviewed to ensure they deliver against guiding
principles (flexibility, aspiration to excellence) and NHS priority of equity of access
3. PMETB merged within GMC offering:
Economy of scale
A common approach
Linkage of accreditation with registration
Sharing of quality enhancement expertise
Reporting direct to Parliament, rather than through monopoly employer
4. The structure of Postgraduate Training should be modified to provide a broad
based platform for subsequent higher specialist training, increased flexibility,
the valuing of experience and the promotion of excellence
5.MTAS was criticised
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Postgraduate training – Inquiry recommendations
‘Stand Alone’ PractitionerMedicalstudent
Consultant
CCT
SpecialistMedical School
MedicalDegree
Pre-registrationdoctor
Postgraduate trainee
F1
Full GMC registration
Registered Doctor Specialist Registrar
Computer adaptive
tests
• 1 year• Attends
‘Graduate’school
• Guaranteed place for UKMG
• Linked to medicalschool
• Trust Registrar position
• Routes for higher specialist Training
• GP Registrar
Trust Registrar
GP
• Several Core Specialty stems
• 3 years• 6 x 6 month positions• May interrupt training
for up to 12 months• Integrated ‘Masters’
programmes available- Research- Education- Management- Global health
Specialtyassessmentsat selection
centres
PMETBCESR
Optional higher
specialist exams
Competitiveselectionprocess
* stems include for example Medicine, Surgery, Diagnostic, ‘Hybrid’ and GP training. NB the term ‘specialty’ has no formal legal significance in these examples
‘Higher specialist Training’
Core Speciality Training
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CHAPTER VIII
D Raj
RESEARCH
AUDIT
ETHICAL ISSUES
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RESEARCHWhat is research?
Define it. Visit your hospital’s and NHS R&D website.http://www.dh.gov.uk/en/Policyandguidance/Researchanddevelopment/index.htm
What is the importance of research in our practice?
• Reliable research based information is fundamental to the successful
implementation of clinical governance. Delivery of patient care, planning,
organisation and management of services and education of those who provide
that care should be based on well researched practice.
• Advances boundaries of scientific knowledge
• Helps in developing logical thought, critical analysis and self reliance
• Enables interpretation and evaluation of research undertaken by others
• Improves job prospects
• Helps in pursuing an academic career
• How to implement in the clinical practice?
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RESEARCH FRAMEWORK
What is a research framework?
RESEARCH FRAMEWORK
Aim, objectives and hypothesis.Resources, ethics, communication and accessConstruction of instrument and equipmentPilot studyData collectionData preparation and analysisPresentation of findingsEvaluationDissemination of findings
A research framework is about how you implement a project in an organized way.
There has to be clear aims and objectives. You should have a hypothesis. Enough
resources should be there in terms of the money, man power and time. If the research
has not been done before, you need to do a pilot study to see if the research is feasible.
Data collection, data analysis and involvement of a statistician at the beginning of the
project is very important. So, it is very important to involve everybody in the
research framework at the beginning and at the hypothesis stage.
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RESEARCH GOVERNANCE
What is the role of research governance?
RESEARCH GOVERNANCE
• Research governance framework sets out standards , standards , deliverydelivery mechanisms and monitoring arrangements for all research which relates to the responsibility of secretary of state for health.
• It is for all who participate in research, host, fund, manage and undertake research.
• It improves research quality and safeguards public by• Enhancing ethicalethical and scientificscientific quality• Promoting good medical practice• Reducing adverse incidents and ensuring lessons all learnt• Preventing poor performance and misconduct
http://www.dh.gov.uk/en/Policyandguidance/Researchanddevelopment/A-Z/Researchgovernance/index.htm
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LEVEL OF EVIDENCE FOR PRIMARY
RESEARCH QUESTION
Types of Studies
Therapeutic Studies—Investigating the Results
of Treatment
Prognostic Studies—Investigating the Effect
of a Patient Characteristic on the Outcome of Disease
Diagnostic Studies—Investigating a Diagnostic Test
Economic and Decision Analyses—Developing an
Economic or Decision Model
Level I High-quality randomized controlled trial with statistically significant difference or no statistically significant difference but narrow confidence intervals Systematic review2 of Level-I randomized controlled trials (and study results were homogeneous3)
High-quality prospective study4 (all patients were enrolled at the same point in their disease with ≥80% follow-up of enrolled patients) Systematic review2 of Level-I studies
Testing of previously developed diagnostic criteria in series of consecutive patients (with universally applied reference "gold" standard) Systematic review2 of Level-I studies
Sensible costs and alternatives; values obtained from many studies; multiway sensitivity analyses Systematic review2 of Level-I studies
Level II Lesser-quality randomized controlled trial (e.g., <80% follow-up, no blinding, or improper randomization) Prospective4 comparative study5 Systematic review2 of Level-II studies or Level-I studies with inconsistent results
Retrospective6 study Untreated controls from a randomized controlled trial Lesser-quality prospective study (e.g., patients enrolled at different points in their disease or <80% follow-up) Systematic review2 of Level-II studies
Development of diagnostic criteria on basis of consecutive patients (with universally applied reference "gold" standard) Systematic review2 of Level-II studies
Sensible costs and alternatives; values obtained from limited studies; multiway sensitivity analyses
Systematic review2 of Level-II studies
Level III Case-control study7 Retrospective6
comparative study5 Systematic review2 of Level-III studies
Case-control study7 Study of nonconsecutive patients (without consistently applied reference "gold" standard) Systematic review2 of Level-III studies
Analyses based on limited alternatives and costs; poor estimates Systematic review2 of Level-III studies
Level IV Case series8 Case series Case-control study Poor reference standard
No sensitivity analyses
Level V Expert opinion Expert opinion Expert opinion Expert opinion
1. A complete assessment of the quality of individual studies requires critical appraisal of all aspects of the study design.2. A combination of results from two or more prior studies.3. Studies provided consistent results.4. Study was started before the first patient enrolled.5. Patients treated one way (e.g., with cemented hip arthroplasty) compared with patients treated another way (e.g., with
cementless hip arthroplasty) at the same institution.6. Study was started after the first patient enrolled.7. Patients identified for the study on the basis of their outcome (e.g., failed total hip arthroplasty), called "cases," are
compared with those who did not have the outcome (e.g., had a successful total hip arthroplasty), called "controls."8. Patients treated one way with no comparison group of patients treated another way.
This chart was adapted from material published by the Centre for Evidence-Based Medicine, Oxford, UK. For more information, please see www.cebm.net.
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http://www2.ejbjs.org/misc/instrux.shtml (scroll down, you will see the level of evidence)
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AUDIT
What is an audit? How does an audit help you in your clinical practice?
An audit is to make sure that the clinical practice is meeting the standard. It is a
dynamic and cyclical process. You define their standards and monitor it. There
should be a monitoring process, eventually you analyse the result and match it again
to the set standards. If the standard is poor then you have to find out what is the cause
of it and re-do the audit again. It is very important that once you have started the audit
the audit loop is closed. It might not be possible in one audit, and till the audit loop is
closed it has to be done again and again. It has got a great role in maintaining the
highest standard practice and it is one of the most important pillars of the clinical
governance.
http://en.wikipedia.org/wiki/Clinical_audit
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AUDIT
Audit is a dynamic, cyclical process (audit loop) in which standards are defined and data collected and monitored against these standards
( Practice vs. Standard)
Define standards
Makes changes Monitor against standards
Analyse results
Plan changes
ETHICAL ISSUES
Ethical issues are common questions in interviews.
You will be given scenarios and will be asked to discuss the problem.
Example:
Case 1: A 75-year-old gentleman presents with a carcinoma of prostrate and
advanced metastases. He has got severe internal bleeding.
Case 2: A 40-year-old lady presents with carcinoma of breast and advanced
metastasis. She is in a severe internal bleeding situation.
Case 3: A 25 years old was involved in a Road Traffic accident (RTA). He is
bleeding heavily. He is in a haemorrhagic shock.
At a small cottage hospital you have resources to deal with one patient only. How will
you deal with the situation? Who will you treat first?
ETHICAL ISSUES
•No discrimination for age•Non committal•Team decision: most important
Autonomy – individual dignityBeneficence – balance risk and benefitNon- mal efficience – minimising harmJustice – fairness(non)Prejudice
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There is no right or wrong answer. You have to discuss this situation. The
decision has to be taken as a team. If I work in a small hospital and I don’t have any
doctor colleagues, I will discuss it with the senior sister in charge, senior manager and
the whole team. I should use phone and discuss with my colleague at the tertiary care
centre.
I will review the situation retrospectively.
I will get feedback from the team and the tertiary referral centre.
There should not be any discrimination of age. Individual dignity is important. One
should balance risk v/s benefit. Whatever you do, you should minimise loss. One
should be fair and there should not be any prejudice. All the actions you discussed
should be recorded for further reference.
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CHAPTER IXD Raj
CLINICAL GOVERNANCEMULTIDISCIPLINARY TEAM
NATIONAL HEALTH SERVICENICE
OTHER ISSUES
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CLINICAL GOVERNANCE
What is a Clinical Governance?
How does it help in your clinical practice?
CLINICAL GOVERNANCE
Defin ition: A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in wh ich excellence in clin ical care will flourish.
• Clin ical audit
• Risk management• Continuous professional development
• Accreditation of health care providers
• Research and development• Staff management
• Patient feedback
Clinical governance is a frame work to make sure that the NHS is providing the
highest level of patient care. There are several features of clinical governance 1.
Clinical audit. 2. Risk management. 3. Continuous professional development 4.
Accreditation of health care providers 5. Research and development 6. Staff
management 7. Patient feed back. You should be able to discuss all these issues at
length.
Website: http://www.clinicalgovernance.scot.nhs.uk/
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IMPLEMENTATION OF CLINICAL GOVERNANCEHow will you implement Clinical governance?How you make sure that in your Unit /Department good Clinical Governance is practiced?
CLINICAL GOVERNANCE
Implementation requires:• Transformation of culture• Ways of working• Attitude• System in local NHS organisations• Active leadership
Requires changes at 3 levels• Individual health care professions- need to embrace change, adopting reflective
practice, which places patient at the centre of their thinking• Team- multidisciplinary groups, where understanding about roles, sharing of
information and knowledge about support for each other becomes part of everyday practice
• Organisation- needs to put in place systems and local arrangements to support such teams and assure the quality of care provided. Commitment and leadership from board and throughout organisations is clearly crucial.
Implementation of clinical governance requires transformation of culture,
ways of working, attitude, and systems in the local NHS organization. It was
introduced in 1999. It is practiced in all trusts of the National Health Service.
Some hospitals are running slightly better than the other hospitals. I think it is
again about the change of cultures, ways of working and attitude.
How are you going to assist in improving clinical governance? Here is an example. We have clinical governance running in our hospital. We realized that fracture neck of femur patients in our hospital are waiting for a longer period before they are operated. We felt that they needed to be dealt with quickly. We developed a trauma nurse coordinator whose job was to look after only the fracture neck of femur patients. Her job description was carefully designed. She will liaise with the surgeon, ward, anaesthetist, operating theatre and the care of the elderly doctors. An audit done after one year showed that this system was working. The one year morbidity and mortality had reduced significantly (P value <0.05). This is an example of good clinical governance.
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MULTI-DISCIPLINARY TEAM
• Healthcare is increasingly provided by multidisciplinary teams. Working in a
team does not change your personal accountability for your professional
conduct and the care you provide. When working as a team, you must:
• Respect the skills and contribution of your colleagues
• Maintain professional relationship with patients
• Communicate effectively with colleagues within and outside trust
• Make sure that your patients and colleagues understand your professional
status and specialty, your role and responsibilities in the team and who is
responsible for each aspect of patient’s care
• Participate in regular review and audit of standards and performance of the
team, taking steps to remedy any deficiencies;
• Be willing to deal openly and supportively with problems in the performance,
conduct or health of team members
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THE STRUCTURE OF THE NHS
Hospitals in the NHS are managed by NHS trusts (sometimes called acute trusts) and are run by a trust board. These trusts make sure that hospitals provide high quality health care, and that they spend their money efficiently. Mental health trusts and ambulance trusts have a similar structure but tend to cover wider areas. There are almost 300 hospital, mental health and ambulance trusts, and 152 primary care trusts in England.
Primary care is provided in your local community via your local GP, NHS walk-in centre, dentist, pharmacist and optician. NHS Direct is also responsible for providing healthcare advice and information 24 hours a day via the internet and over the telephone.
All hospital and mental health trusts are dependent on primary care trusts (PCTs) commissioning services such as elective surgery, outpatient visits and other treatments from them, but PCTs also run community-based hospitals and provide services such as district nursing and health promotion.
PCTs still tend to commission many services from their local hospital. However, under the patient choice initiative, anyone needing elective hospital treatment will be offered a choice of where it is carried out, including independent sector treatment centres (ISTCs) run by private companies.
Strategic health authorities (SHAs) cover large areas – typically neighbouring counties or large city areas – and are responsible for overseeing other NHS organisations in their area and leading on issues such as workforce development and capacity.
As per NHS White paper lots of changes are going to take place in the structure of NHS. Please read the NHS White paper and make yourself aware of the current changes taking place. The PCTs will terminate in2013 and will be replaced by GP consortia. SHAs also will change and new structure will take place which is still taking a shape.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
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WHITE PAPEREquity and excellence: Liberating the NHS
The NHS White Paper, Equity and excellence: Liberating the NHS, sets out the Government's long-term vision for the future of the NHS. The vision builds on the core values and principles of the NHS - a comprehensive service, available to all, free at the point of use, based on need, not ability to pay. It sets out how we will:• put patients at the heart of everything the NHS does;
• focus on continuously improving those things that really matter to
patients - the outcome of their healthcare; and
• empower and liberate clinicians to innovate, with the freedom to focus
on improving healthcare services
Salient features
• GP consortium will replace PCT ( PCT will cease to function in 2013)
• SHA will be replaced by some other similar organisation
Please go to the following website and download the document and go through it. Keep yourself updated
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf
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The following is the proposed structure of the NHS
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AUTHORITIES AND TRUSTS
Authorities and Trusts are the different types of organisations that run the NHS at a local level. The whole of England is split into 10 Strategic Health Authorities (SHAs). These organisations were set up in 2002 to develop plans for improving health services in their local area and to make sure their local NHS organisations were performing well.
Within each SHA, the NHS is split into various types of Trusts that take responsibility for running the different NHS services in your local area.
The different Trust types are:
• Acute Trusts • Ambulance Trusts • Care Trusts • Mental Health Trusts • Primary Care Trusts (PCTs)
/
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STRATEGIC HEALTH AUTHORITIES
Created by the Government in 2002 to manage the local NHS on behalf of the Secretary of State, there were originally 28 Strategic Health Authorities (SHAs). On 1 July 2006, this number was reduced to 10. Fewer, more strategic organisations will deliver stronger commissioning functions, leading to improved services for patients and better value for money for the taxpayer. Strategic Health Authorities are responsible for:
• Developing plans for improving health services in their local area • Making sure local health services are of a high quality and are performing well • Increasing the capacity of local health services - so they can provide more
services • Making sure national priorities - for example, programmes for improving
cancer services - are integrated into local health service plans
Strategic Health Authorities manage the NHS locally and are a key link between the Department of Health and the NHS.
As per NHS White paper lots of changes are going to take place in the structure of NHS. Please read the NHS White paper and make yourself aware of the current changes taking place. SHAs will terminate in 2013. A new structure will replace them. It is still taking shape.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
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NICE (National Institute of Clinical
Excellence)http://www.nice.org.uk/
• It is a part of the National Health Service (NHS), and its role is to provide
patients, health professionals and the public with authoritative, robust and
reliable guidance on current “best practice”.
• It was set up as a Special Health Authority for England and Wales on 1 April
1999. Technology appraisals - guidance on the use of new and existing
medicines and treatments within the NHS in England and Wales.
• Clinical guidelines - guidance on the appropriate treatment and care of people
with specific diseases and conditions within the NHS in England and Wales.
• Interventional procedures - guidance on whether interventional procedures
used for diagnosis or treatment are safe enough and work well enough for
routine use in England, Wales and Scotland.
• Guidelines Colorectal/ Breast/ Vascular
• Orthopaedic
Technology appraisals - guidance on the use of new and existing medicines
and treatments within the NHS in England and Wales.
• Clinical guidelines - guidance on the appropriate treatment and care of people
with specific diseases and conditions within the NHS in England and Wales.
• Interventional procedures - guidance on whether interventional procedures
used for diagnosis or treatment are safe enough and work well enough for
routine use in England, Wales and Scotland.
• Relevant Guidelines in progress
For each specialty there are some guidelines. You need to know thes guidelines.
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FOUNDATION HOSPITALWhat are the NHS foundation trusts?
The Health and Social Care Act 2003 establishes NHS foundation trusts as
independent public benefit corporations and will be modelled on co-operative
and mutual traditions.
1. They are controlled and run locally, not nationally. Local public accountability
will replace central state control,
2. They have increased freedoms to retain any operating surpluses and access a
wider range of options for capital funding to invest in delivery of new
services, recruit and employ their own staff,
3. They have to deliver on national targets and standards like the rest of the NHS,
but NHS foundation trusts will be free to decide how they achieve this,
4. They are not subject to directions from the Secretary of State for Health, are
not subject to performance management by strategic health authorities and the
Department of Health.
Aims of NHS foundation trusts
NHS foundation trusts form part of a major programme of investment, expansion and
reform of the NHS over a ten year period. This programme will deliver the vision of
the NHS Plan for prompt, convenient and high quality services, with patients treated
as partners and staff fairly treated and properly rewarded. Within a framework of clear
national standards, subject to independent inspection, power is being devolved to
locally run services with the freedom to innovate and improve care for patients. The
programme builds on the values of the NHS; services will be centred around the needs
of patients so that wherever NHS patients are treated they receive high quality care,
free at the point of use and based on clinical need, not ability to pay.
NHS foundation trusts are at the cutting edge of the programme. They are part of the
NHS, providing care for NHS patients but with the freedom to improve services for
patients without interference from Whitehall. The Government believes that securing
sustained improvements in NHS performance can only happen when staff have more
control and local communities have a bigger say over how hospitals are run. The aim
is to harness the creative energy and expertise of managers and clinical staff,
recognizing the skills and knowledge that they have.
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Purpose of NHS foundation trusts:
The Health and Social Care (Community Health and Standards) Act establishes NHS
foundation trusts as independent public benefit corporations. Public benefit
corporations are a new type of organisation, specially developed to reflect the unique
aims and responsibilities of NHS foundation trusts.
The purpose of NHS foundation trusts is to provide and develop services for NHS
patients. They are part of the NHS, and subject to NHS systems of inspection. They
treat NHS patients according to NHS principles and NHS standards, but they are
controlled and run locally, not nationally. Transferring ownership and accountability
from Whitehall to the local community means that NHS foundation trusts are able to
tailor their services to best meet the needs of the local population, and to tackle health
inequalities, whilst working within a framework of national standards.
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PRIMARY CARE TRUSTS
Primary Care Trusts bring together the primary care services (eg. GP Practices
and Community Nursing Services) in a particular area and work to develop these
services in response to the needs of the local community.
The main roles of a PCT are to:
• Improve the health of local people and reduce inequalities in health.
• Provide effective and responsive local health services.
• Commission the best possible services for local people from NHS hospitals
(NHS Trusts).
• PCTs act as sub-committees of Health Authorities.
• PCTs have a duty to work in partnership with other local organisations and
neighbourhood services ( e.g. social services, housing, service user and
community groups, other PCG/Ts, NHS Trusts).
• PCT will control 80% of the health budget by 2004.
As per NHS White paper lots of changes are going to take place in the structure of NHS. Please read the NHS White paper and make yourself aware of the current changes taking place. The PCTs will cease functioning by 20133. Their role will be taken over by GP consortium.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic
yAndGuidance/DH_117353
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NHS LITIGATION AGENCY (NHSLA)
The NHSLA handles negligence claims and works to improve risk management practices in the NHS.
They are also responsible for resolving disputes between practitioners and primary care trusts, giving
advice to the NHS on human rights case law and handling equal pay claims on behalf of the NHS.
http://www.nhsla.com/home.htm
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RISK MANAGEMENT
RISK MANAGEMENT
• Formal and systematic process to identify and analyse risk and take remedial action to reduce or eliminate risk of harm to patients, staff and organisation
• Critical incident reporting• Clinical audit• Confidential enquiry• Complaints procedures• Observation of staff• Investigation Committee’s report• Accreditation visit reports• Patient satisfaction surveys
http://www.nhsla.com/RiskManagement/
Risk management was introduced by the department of health to make sure that we
analyse the problem, learn from it and practice it so that it does not reoccur leading to
an improved health care service. This is about critical incident reporting, audit,
confidential enquiry, and so on. This is not however about blaming somebody and
loosing a job. This is about studying why something happened, defining the situation,
analysing the cause, learning from it, re-practicing it, and re-auditing it to make sure
that a change has taken place for a better patient care.
NHSLA – Risk assessment
http://www.nhsla.com/RiskManagement/
A key function for the NHSLA, as set out in their Framework Document, is to “contribute to the incentives for reducing the number of negligent or preventable incidents”. They aim to achieve this through an extensive risk management programme.
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NHSLA standards and assessments The core of their risk management programme is provided by a range of NHSLA standards and assessments. Most Healthcare organisations are regularly assessed against these risk management standards which have been specifically developed to reflect issues which arise in the negligence claims reported to the NHSLA. There is a set of risk management standards for each type of healthcare organisation incorporating organisational, clinical, and health & safety risks:
• NHSLA Acute, Community, Mental Health & Learning Disability and Independent Sector
Standards - 2011/12
• NHSLA Ambulance Standards - 2011/12 In addition, there is a separate set of clinical risk management standards for NHS maternity services.
• CNST Maternity Standards - 2011/12 NHS organisations which provide labour ward services are subject to assessment against both the NHSLA Acute (or Community) Standards and CNST Maternity Standards.
All the NHSLA Standards are divided into three “levels”: one, two and three. NHS organisations which achieve success at level one in the relevant standards receive a 10% discount on their CNST and RPST contributions, with discounts of 20% and 30% available to those passing the higher levels. The CNST Maternity Standards are also divided into three levels and organisations successful at assessment receive a discount of 10%, 20% or 30% from the maternity portion of their CNST contribution. Organisations at level 1 are assessed against the relevant standard(s) once every two years and those at levels 2 and 3 at least once in any three year period, although organisations may request an earlier assessment if they wish to move up a level. Organisations that drop to Level 0 or fail to attain Level 1 will be placed under improvement measures and must undertake a Level 1 assessment within six months of the date of their unsuccessful assessment. Organisations which fail an assessment and fall to Level 1 or 2 are required to be assessed at the level assigned in the following financial year.
All assessments take place over two days and are carried out on behalf of the NHSLA by Det Norske
Veritas Ltd., who are responsible for much of the day-to-day administration of our risk management
programmes. Details of the assessment levels achieved by healthcare organisations are updated
monthly in our Factsheet 4 .
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NATIONAL PATIENT SAFETY AGENCY
(NPSA)http://www.npsa.nhs.uk/
They lead and contribute to improved, safe patient care by informing, supporting and influencing organisations and people working in the health sector. They are an Arm’s Length Body of the Department of Health and through their three divisions cover the UK health service. National Reporting and Learning ServiceAims to reduce risks to patients receiving NHS care and improve safety. National Clinical Assessment Service Supports the resolution of concerns about the performance of individual clinical practitioners to help ensure their practice is safe and valued. National Research Ethics ServiceProtects the rights, safety, dignity and well-being of research participants that are part of clinical trials and other research within the NHS. They also commission and monitor: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Confidential Enquiry into Maternal and Child HealthNational Confidential Enquiry into Patient Outcome and Death
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NATIONAL TARRIFF AND PAYMENT BY
RESULT (PbR)
Payment by results
http://www.dh.gov.uk/en/Managingyourorganisation/NHSFinancialReforms/index.htm
The aim of Payment by Results (PbR) is to provide a transparent, rules-based system for paying trusts. It will reward efficiency, support patient choice and diversity and encourage activity for sustainable waiting time reductions. Payment will be linked to activity and adjusted for case mix. Importantly, this system will ensure a fair and consistent basis for hospital funding rather than being reliant principally on historic budgets and the negotiating skills of individual managers.
Background
The NHS Plan (July 2000) introduced the Government’s intention to link the allocation of funds to hospitals to the activity they undertake. It stated that in order to get the best from extra resources there would be major changes to the way money flows around the NHS and differentiation between incentives for routine surgery and those for emergency admissions. Hospitals would be paid for the elective activity they undertake and this is a system of payment by results. This reformed financial system offers the right incentives to reward good performance, to support sustainable reductions in waiting times for patients and to make the best use of available capacity.
Historically, hospitals were paid according to “block contracts” – a fixed sum of money for a broadly specified service – or “cost and volume” contracts which attempted to specify in more detail the activity and payment. But there was no incentive for providers to increase throughput, since they got no additional funding.
The Department of Health consulted on its plans for introducing PbR in ‘NHS Financial Reforms: Introducing Payment by Results’ on 15 October 2002 and published its response on 10 February 2003.
• Response to Reforming NHS Financial Flows: Introducing Payment by Results: Response issued 10 February 2003
The Department of Health undertook a further consultation on 7 August 2003 - Payment by Results: Preparing for 2005.
• Payment by Results Preparing for 2005 : consultation outcome
Payment by Results is being implemented incrementally both in terms of scope and financial impact. In terms of scope, the system began in a small way in 2003-04, was extended in 2004-05, and, for the majority of trusts, included only elective care in 2005/06. In 2006/07 the scope of payment by results was extended to include non-elective, accident & emergency, out-patient and emergency admissions for all trusts.
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2007/08 marked a year of consolidation with no significant changes to the tariff. The financial impact of PbR has also been introduced gradually with a four year transition path which comes to an end in 2008-09.
On 17 March 2006 Sir Ian Carruthers, the acting Chief Executive of the NHS, announced that he had asked John Lawlor, the Chief Executive of Harrogate and District NHS Foundation Trust, to lead an independent review of the process followed by the Department of Health to set the national tariff for services within the scope of Payment by Results for 2006/07.
• Independent review results
We are working with a range of stakeholders to develop the tariff, in particular to support wider healthcare policy to provide care closer to home. We have published indicative tariffs for unbundling aspects of the tariff embedded in acute care, including rehabilitation and some diagnostics to support the NHS in developing local tariffs to deliver services that meet the needs and choice of patients.
In the longer term, we are looking to continually refine the tariff and extend the scope of payment by results where clinically appropriate and economically sensible.
The Department of Health published the Options for the Future of Payment by Results: 2008/09 – 2010/11 consultation on 15 March 2007.
• Options for the Future of Payment by Results: 2008/09 to 2010/11
The consultation document outlined proposals to strengthen the existing building blocks of payment by results policy including classification, currency and costing as well as ideas about how the policy can be developed and administered over the next few years. We will report the findings of the consultation later in 2007.
Confirmation of Payment by Results (PbR) arrangements for 2011-12
From the links below you will be able to access information and guidance in support of Payment by Results in 2011-12.The road-testing of the 2011-12 tariff and draft guidance concluded on 21 January 2011. Details of the small number of changes that have been made to some of the prices and exclusions lists that we released at road-test are contained in the letter from David Flory.The 2011-12 PbR guidance has been clarified and expanded in a number of areas, in response to feedback received at road-test.
BEST PRACTICE TARIFF
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http://www.dh.gov.uk/en/Managingyourorganisation/NHSFinancialReforms/DH_105
080
"Best practice tariffs represent one of the enablers for the NHS to improve quality, by reducing unexplained variation and universalising best practice. With best practice defined as care, that is both clinical and cost-effective, these tariffs will also help the NHS deliver the productivity gains required to meet the tough financial challenges ahead.
The aim is to have tariffs that are structured and priced appropriately both to incentivise and adequately reimburse for the costs of high quality care.
There is no one definition of what best practice looks like. A specific model will be developed for each of the service areas, each tailored to the characteristics of clinical best practice in that area and the availability, quality and flow of data.Best practice tariffs for 2011/12
Set out below are some of the new approaches and service areas for which we are considering setting best practice tariffs in 2011-12. Once we have finished the investigation into the suitability and feasibility of these service areas we aim to confirm the package on this webpage.
If you would like to be involved in the development of these tariffs then please get in touch via
interventional Radiology
Interventional Radiology is an alternative procedure to open surgery for a range of procedures e.g. Uterine Fibroid Embolisation as one the alternatives to hysterectomy. Less invasive procedures such as Interventional Radiology facilitate decreased lengths of stay, leading to lower unit costs for providers and commissioners and improved patient experience. Day case / Short Stay
There are a number of procedures where it is best practice to perform them as a day case where clinically appropriate. The British Association of Day Surgery (BADS) have suggested the day case rates which would be appropriate in most cases. The model used in 2010-11 for cholecystectromy will be developed for a selection of other high volume procedures from the BADS directory of procedures where there is a significant gap between the current national day case rate and that which BADs say is achievable.Again, the intention of this approach is to encourage better value and better quality treatment for patients.
Some of the procedures we are considering for 2011-12 are:
- Procedures for breast surgery- Procedures for hernia repair- Operations to manage female incontinence
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- Some orthopaedic surgery such as bunion operations- Procedures for prostate resectionBest Value Tariffs
An alternative approach to linking payment to clinical characteristics is to set tariff prices normatively i.e. what the cost should be if best practice is followed rather than the national average of reference costs. Normative pricing represents an alternative incentive model to change practice.To avoid the need for commissioners to monitor provider performance against the best practice criteria in order to make payment, this approach is only likely to be appropriate to service areas where the cost of meeting best practice is below the national average cost. Of course, commissioners will want know about the quality of service provided for other reasons.
Clearly, this approach is different to any of those adopted in 2010-11 and we will work closely with the relevant clinical experts as well as providers and commissioners to ensure that there are no perverse clinical incentives and that any financial impact is manageable.
Further developments to existing service areas
We will continue with the process to develop a best practice tariff for adult renal dialysis.Following on from the best practice tariff for acute stroke care we plan to develop a tariff for follow-up services for patients who have had a mini-stroke (known as a transient-ischaemic attack or TIA).
Information on the 2010/11 best practice tariffs
If you have a query about the 2010-11 best practice tariffs then there are a variety of sources of information we recommend that you consult in the first instance. If your query cannot be answered by this information then please submit your query following the process detailed below.The first port of call should be Section 6 of the 2010-11 PbR Guidance. Given that best practice tariffs are a new concept introduced for the first time in 2010-11, we have intentionally provided more detailed guidance than other sections.
It is hoped that relevant information not contained in the guidance is either referenced below or provided in an answer to one of the FAQs, available in the ‘PbR in 2010-11’ section of the PbR website.
Listed below are additional sources of information that were not available at the time of the guidance being published. As further information becomes available we continue to update this page.
Cataracts Pathway
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Further information about the cataracts extract is available in the SUS R7 e-learning tool available from the weblink below
• Connecting for health - SUS (opens new window) Fragility Hip Fracture CareAdditional information relating to the element of the tariff price conditional on meeting the clinical characteristics of best practice can be found on the National Hip Fracture Database website. As further information becomes available it will be published on the NHFD website.
• NHFD: hip fracture (opens new window) Acute Stroke CareThe NHS Stroke Improvement website continues to be updated for case studies, information and useful resources:
• National Stroke Improvement Initiative (opens new window)
Evaluation of the 2010-11 tariffs
The PbR team plan to evaluate the first wave of the best practice tariffs. We expect the evaluation to look at both the implementation of the tariffs as well as the impact that they have had on changing clinical practice.
One of the main reasons for evaluating the tariffs is to inform development of the policy and future tariffs. We hope therefore to feed initial findings from the evaluation into the development of the 2011-12 set of tariffs
Query process
NHS trusts or PCTs should contact SHA PbR leads in the first instance with queries, outstanding and new. If the query can still not be answered, then SHA PbR leads will contact DH for clarification/ answers. This is appropriate for both e-mails and telephone calls.
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INDEPENDENT SECTOR TREATMENT
CENTRES (ISTC)http://en.wikipedia.org/wiki/Independent_sector_treatment_centre
Independent sector treatment centres (ISTCs) are private-sector owned treatment
centres contracted within the English National Health Service to treat NHS patients
free at the point of use, like any other NHS hospital. They are sometimes referred to
as 'surgicentres' or ‘specialist hospitals’.
ISTCs are normally co-located with NHS hospitals. They perform common elective
(i.e. non-emergency) surgery and diagnostic procedures and tests in the same way as
NHS hospitals. Typically they undertake 'bulk' surgery such as hip
replacements, cataract operations or MRIscans rather than more complex operations
such as neurosurgery. Since specialised treatment centers concentrate on a set type of
procedures they are able to streamline the patient care pathway,[1] resulting in an
improved patient experience[2] and helping the NHS to quickly meet waiting time
targets.[3]
Wave I ISTCs currently work on pre-arranged central government bulk contracts
nominally at or below the national tariff [2] on which NHS hospitals can charge
commissioning NHS Primary Care Trusts. These contracts include a profit margin and
the treatments are paid for in advance by central government whether or not the
numbers paid for are taken up and regardless of success rates. The rationale is that the
waiting times for patients are cut by separating routine elective surgery and tests from
emergency work.
Referral rates vary across the country, with some ISTCs performing as much 115% of
their contracted volumes but with the average referral rate around 85%. According to
the NHS Partners Network, which represents private providers working within the
health service, GP referral rates are rising as patients report positive experiences back
to their GPs.[4]
A critique of this development is that difficult and expensive work is left for the NHS
hospitals to do, increasing their marginal costs and making them appear less
'efficient'. Recent opinion printed in the British Medical Journal (BMJ vol 332 11
March 2006) has also suggested that treatments may be proportionally less successful
in ISTCs due to the employment of inexperienced or less fully trained staff with less
backup than the NHS facilities. This could result in the NHS having to fund difficult
revision operations (insofar as they can be so revised) and would defeat the object of
the exercise. However, a subsequent study conducted by the researchers from London
School of Hygiene & Tropical Medicine and the Royal College of Surgeons of
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England confirmed the high quality of care, concluding that “patients undergoing
cataract surgery or hip replacements in ISTCs achieved a slightly greater
improvement … than those treated in NHS facilities” and “Patients treated in ISTCs
were less likely to report post-operative problems than those treated in NHS
facilities…”(BMC Health Services Research 2008. 8:78).[5]
In the 2008 Healthcare Commission 2008 NHS Inpatient Survey,[6] ISTCs scored
highly on a number of measures, including overall quality of care.[7]
The NHS Plan originally conceived of opening eight treatment centres by 2005, but
by August 2005 at least 25 had been opened, with more being planned. A second
Wave of ISTCs was completed in 2009 and those marked the end of the centrally
planned centres.[8] Moving forward, local PCTs will make decisions on how best to
work with their local ISTCs after the initial five year contracts have expired.[9]
In 2009 a British Medical Journal paper concluded that up to £927m of the £1.5bn
first wave of ISTC contracts "may have been paid to ISTCs for patients who did not
receive treatment".[10] This was based on a Scottish example and does not in fact
reflect the experience of the English ISTC program, where referrals have been more
inline with the expectations of the original contracts and continue to grow.
Issues
1. ASA grade 1s treated at ISTC / NHS hospitals2. Cherry picking3. Training4. Dealing with complications5. Continuity of care6. Audit / Research
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NATIONAL TARGETSTARGETS
The Department of health has set out targets for improvement in all aspects of health
and treatment of disease.
You need to know the targets related to your subspecialty.
Example: The following is an example in the Scottish NHS set out in the year 2003
Teenage Pregnancy
20% reduction in teenage pregnancies amongst those aged 13-15: target date 2010.
Dental Health
Children aged 12 should have, on average, no more than 1.5 teeth decayed, missing
or filled: target date 2005.
At least 80% of dentate adults aged 35-44 should have at least 21 or more standing
teeth: target date 2008.
Less than 5% of 45-54 age group to have no natural teeth by 2010.
60% of 5 year old children should have no cavities, fillings, extractions: target date
2010.
Smoking
Reduce smoking among young people (12-15 age group) to 11%: target date 2010.
Reduce the rate of smoking among adults (16-64 age group) in all social classes to
31%: target date 2010.
Reduce the proportion of women who smoke during pregnancy by 9% to 20%: target
date 2010.
Alcohol Misuse
Males aged 16-64 - reduce incidence exceeding weekly limit of 21 units to 29%:
target date 2010.
Females aged 16-64 - reduce incidence exceeding weekly limit of 14 units to 11%:
target date 2010.
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Reduce the frequency and level of drinking of 12-15 age group by 4% to 16%: target
date 2010.
Drug Misuse
Reverse upward trend in drug related deaths and reduce the total number by 25%:
target date 2005.
Increase the number of drug users in contact with drug treatment/care services in
community by at least 10% every year: target date 2005.
Reduce the proportion of drug users who inject and the proportion of injecting users
sharing needles and syringes by 20% by 2005.
Reduce the proportion of injecting drug users sharing needles and syringes by 20%:
target date 2005.
Reduce percentage of injecting drug users testing antibody positive for the PC by
20%: target date 2005.
Physical Activity
50% of all adults (aged 16+) accumulating a minimum of 30 minutes per day of
moderate physical activity on 5 or more days per week.
80% of all children (aged 2-15) accumulating one hour per day of physical activity on
5 or more days per week.
Breast Feeding
More than 50% of women should breast feed their babies at 6 weeks: target date 2005.
Diet
Increase the proportion of the population consuming increased levels of fruits and
vegetables, carbohydrates and fish as defined by the Scottish Dietary Targets: target
date 2005.
Increase the proportion of the population consuming decreased levels of fat, sugar and
salt as defined by the Scottish Dietary Targets: target date 2005.
Immunisation/Vaccination
70% of over 65s vaccinated against flu: annual target.
95% uptake target for all childhood vaccinations (ongoing).
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Low Birth Weight Babies
To reduce incidence of low birth weight babies by 10%: target date 2005.
Eye and Dental Checks
We will invest in health promotion and, as a priority, we will systematically introduce
free eye and dental checks for all before 2007.
Hearing Tests
We will introduce hearing tests for all new born babies.
DELAYED DISCHARGE
National Delayed Discharge Plan targets to be set for each individual NHS Board
following evaluation of Local Joint Action Plans to sustain progress in reducing
delayed discharge numbers. Focus of planning will be to continue to relieve pressure
on the acute sector; to look at whole systems re-design and capacity planning and to
consider the development of appropriate convalescent care which should be outcomes
focused rehabilitative care rather than the creation of new convalescent homes.
We will invest 30m per annum for 3 years to provide 1,000 community and
convalescent places for people leaving hospital.
48-HOUR ACCESS
We will ensure that anyone contacting their GP surgery has guaranteed access to a
GP, nurse or other health care professional within 48 hours by April 2004.
CANCER
20% reduction in the age standardised mortality rate from cancer in people aged under
75: target date 2010.
For targets on Waiting Times refer to Waiting Times Priority.
Breast screening target 70%: ongoing.
Cervical screening target 80%: ongoing.
CHD/STROKE
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50% reduction in the age standardised mortality rate from CHD in people aged under
75: target date 2010.
50% reduction in the age standardised mortality rate from stroke in people aged under
75: target date 2010.
For targets on Waiting Times refer to Waiting Times Priority.
MENTAL HEALTH
Reduce National Suicide Rate by 20% by 2013 (Suicide Prevention Strategy Dec
2002).
Closure of all long-stay institutions for people with learning disabilities: target date
2005.
HEALTHCARE ACQUIRED INFECTION
Implement Full Technical Requirements of the Glennie Recommendations for
Decontamination of Medical Equipment and Devices by 31 March 2004.
WAITING TIMES
Hospital In-Patient and Day Case Treatment
No patient with a guarantee should wait longer than 12 months for in-patient or day
case treatment. This will be reduced to 9 months from 31 December 2003 and to 6
months from 31 December 2005.
These targets are firm guarantees. If a patient's host NHS Board is unable to provide
treatment within the target time, the patient will be offered treatment elsewhere in the
NHS, in the private sector in Scotland, or England, or overseas.
Coronary Heart Disease
By 31 October 2001 women who have breast cancer and need urgent treatment will
get it within one month where appropriate.
By 31 October 2001 the maximum wait from urgent referral to treatment for
children's cancer and acute leukaemia will be one month.
By 31 December 2005 no patient urgently referred for cancer treatment should wait
more than 2 months.
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Coronary Heart Disease
From 31 December 2002 the maximum wait for angiography will be 12 weeks from
seeing a specialist. This will be reduced to 8 weeks from 31 December 2004.
Out-Patients
By 31 December 2005 no patient should wait more than 6 months for a first out-
patient appointment with a consultant, following referral by GMP/GDP.
Primary Care
We will ensure that anyone contacting their GP surgery has guaranteed access to a
GP, nurse or other health care professional within 48 hours by April 2004.
PATIENT FOCUS/PUBLIC INVOLVEMENT
Each NHS Board/health system identifies strategic leadership at Director level to
achieve implementation of an integrated approach to patient focus and public
involvement across their area.
Each NHS Board/health system agrees a strategy and framework for implementing an
integrated approach to patient focus and public involvement with SEHD by October
2003.
The agreed frameworks should set out:
How action to support staff build the capacity of patients, carers and the public to be
involved as equal partners in decision about service development will become an
integral part of Boards' strategic planning arrangements
proposals for a sustained programme of training in patient focus and public
involvement for all staff;
action to develop CHP's capacity to involve front line staff, patients, carers and the
public in development is detailed over the next 3 years.
FINANCIAL BREAK-EVEN
NHS Boards to: operate within their revenue resource limit; operate within their
capital resource limit; meet their cash requirement (PAF: Nov 2002).
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NHS Trusts to: break even taking one year with another; stay within their capital
resource limit (PAF: Nov 2002).
SERVICE RE-DESIGN
NHS Boards to form a Service Re-Design Committee with involvement of clinicians.
NHS Boards to submit a Change and Innovation Plan.
We will support Change and Innovation through a series of national collaboratives
including major priorities such as cancer, out-patient waiting, primary care access and
emergency medical admissions.
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CARE QUALITY COMMISSION (CQC)http://www.cqc.org.uk/
The Care Quality Commission is the independent regulator of health and social care in England. Our aim is to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in people’s own homes, or elsewhere.
They regulate health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. And, they protect the rights of people detained under the Mental Health Act.
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LORD DARZI’S NHS NEXT STAGE REVIEW
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825
In exchange for these new powers and new management positions, clinicians will be expected to use their professional skills to assess the evidence base for service reconfigurations and the distribution of resources.
Hospital doctors will hold their own budgets and GPs will have greater freedom under practice based commissioning.
"Patients, the public and staff alike expect to see clinical leaders explicitly making the case for these changes to services which evidence shows will improve patient care," the review states. The review follows resistance from a number of clinicians across the NHS to the regionalisation of specialist services.
But Lord Darzi said a new accountability structure would ensure high-quality clinical leadership that would be measured in terms of overall outcomes for patients. Medical training programmes will now include management and leadership skills as standard.
The workforce report also commits to implementing Sir John Tooke's recommendation to establish a new body, Medical Education England, to scrutinise the quality of training and design training pathways.
Training for other professional groups will be commissioned by strategic health authorities, guided by another new body, the Centre for Excellence, which will gather and analyse data to effectively model future demand for different specialties.
Mirroring reforms elsewhere in the NHS, deaneries will need to establish a formal split between the commissioning and provision of training and education. This will help ensure objective assessments of the quality of training programmes, the report says.
With the shift towards more primary care, the workforce strategy places particular emphasis on GPs. Eight hundred extra GP training places will be made available to meet the ambition that "at least" half of all doctors entering specialist training do so as GPs.
This will be done using "existing resources", but a new transparent tariff whereby up to £4.3bn training funds follow the students will guard against the "raids" on training funds seen over the last few years.
The report also commits the DH to a review of healthcare professions not currently regulated. It specifically mentions clinical psychologists. "Those workers whose role involves significant risk should have proportionate assurance arrangements to ensure safe and high-quality care for patients," Lord Darzi's report says.
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NHS NEXT STAGE REVIEW: IMPACT AND EQUALITY IMPACT ASSESSMENTS
Introduction 1. The final report of the NHS Next Stage Review - High Quality Care for All - sets out an overarching vision for the future of the NHS. This document does not attempt to assess the impact or equality impact of individual proposals but sets out the background, overarching vision and next steps. Impact Assessments and Equality Impact Assessments for specific proposals will be published as they are further developed in consultation with stakeholders over the coming months.
Background
2. Lord Darzi was asked by the Prime Minister, Chancellor and Secretary of State for Health to lead a review of the NHS in England in July 2007. The Review has been driven through a strong engagement process in every NHS region. Clinical Working Groups were established in each NHS region (Strategic Health Authorities) to identify potential improvements to local services. In total 74 such groups, led by 2000 frontline clinicians (doctors, nurses and other health and social care professionals), have examined services across eight or more ‘pathways of care’ from maternity to end-of-life, engaging with patients, NHS staff, stakeholders and the public.
3. The Clinical Working Groups have developed improved ‘models of care’ based firmly on the best available clinical evidence and the needs and preferences of local users. Each Strategic Health Authority has now published its long-term vision for improving health and healthcare in its region based on the work of these groups.
4. These visions will now be turned into practical action locally and delivered on the ground, with local communities engaged and proposals developed and taken forward transparently based on the best available clinical evidence. The key priorities emerging from the visions include: • Stronger and more proactive focus on public health and helping people stay healthy, with more support to tackle childhood obesity, alcohol misuse and smoking. • Clearer and simpler routes to finding the right care 24/7. • As much care as possible delivered closer to home, with treatment of major trauma, heart attack and stroke care within specialised centres. • Improving the lives of those with long-term conditions by ensuring that patients can take a full part in their own treatment and care, including the 1use of health plans and more assistive technology to help people manage their own conditions. • Improving patient experience by ensuring privacy, dignity and cleanliness, and by providing more information and choice.
5. The local visions challenge the Department of Health to enable and empower the local NHS to deliver the priorities and improvements that have been agreed locally. In particular they challenge the Department to
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support and enable: • Integrating care around the needs of patients and empowering people to better manage their own care. • Empowering patients with better information to enable a different quality of conversation between professionals and patients. • Prioritising patient safety and recognising, sharing and adopting best practice. • Bringing the benefits of innovation directly to patients more rapidly, with stronger and deeper local partnerships.
6. The key themes set out in the local visions are summarised in Chapter 1 of High Quality Care for All.Impact Assessment
7. The NHS Next Stage Review’s terms of reference were to “help local patients, staff and the public in making the changes they need and want in their local NHS”. The purpose of the final report, and rationale for government intervention, is to respond to the challenges that they have identified and deliver the improvements to the system that will enable local priorities to be met most effectively. Chapter 2 of High Quality Care for Allsets out in more detail this case for change. By taking the approach of building an enabling system that supports local decision-making the Government has sought to minimise the additional burdens placed upon the NHS.
8. The development of High Quality Care for All has been taken forward through a series of national workstreams. Seven of these have been supported by national working groups that have brought together key stakeholders and clinical leaders to consider the issues raised locally. These groups were: • Quality improvement - the vision and strategy for quality improvement and the measurement, systems and incentives to drive it. 2• Innovation - to speed, spread and imbed innovation in health and social care, in terms of pharmaceuticals, clinical practice and delivery models and management. • Primary and community care strategy - to deal with the barriers and enablers to change identified locally, including identifying how the contractual and commissioning arrangements for primary medical care can continue to evolve to reflect trends and challenges. • Workforce - the commissioning and provision of planning, education and training. • Leadership - clinical and non-clinical, medical and non-medical. • Informatics - information needs, system and management structures; maximising the benefits for patient care of the national programme for IT. • Systems and incentives - any other systems and incentives that the local groups have said are needed to support the changes they have suggested.
9. The national workstreams have developed policy proposals (summarised in the summary letter within High Quality Care for All and identified the
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need for Impact Assessments. Impact Assessments have been published alongside High Quality Care for All to accompany the separate publication of the NHS Next Stage Review documents: • A consultation on an NHS Constitution (30 June) • NHS Next Stage Review: A Quality Workforce (30 June)
10. Impact Assessments will also be published to accompany the separate publication of: • NHS Next Stage Review: Our vision for primary and community care(3 July) • A Health Informatics Review Report (10 July)
11. Impact Assessments for other policy proposals announced in High Quality Care for All will be published as these are further developed and implementation plans drawn up over the coming months. Subject to the detailed analysis that will be developed in the Impact Assessments to be published later, it is the Department’s assessment that the benefits of the proposals far outweigh the costs.
12. Taken as a package the proposals will help transform the quality of care patients experience and their relationship with health and healthcare. 3They will support and empower the frontline of the NHS in delivering the visions that have been developed and agreed locally. Benefits, Costs and Risks
13. This document does not attempt to discuss the options assessment process or assess the costs, benefits or risks for particular proposals. The number and diversity of proposals prohibits an overall summary of their costs and benefits in this document and, in many cases, the details of implementation are dependent on further consideration of options and discussions with stakeholders. These will inform the development of specific Impact Assessments, outlining the benefits, costs and risks, in line with the individual timescales for each proposal. This document commits the Department of Health to publishing Impact Assessments for the proposals set out in High Quality Care for All as appropriate as they are further developed over the coming months. Policy evaluation
14. As the Department of Health develops the policy proposals further, it will do so in partnership with NHS organisations and stakeholders to ensure that the benefits identified are fully realised. The Department will also commission independent scientific evaluation to ensure transparency and public accountability. Equality Impact
15. The Department of Health is committed to promoting equality and diversity. High Quality Care for All welcomes the excellent opportunity that the Review has provided for the Department to pursue it duties to promote equality and reduce discrimination under the Equality and Human Rights Act.
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16. The Review has focussed on a range of measures that are aimed at improving access to care and the personalisation of treatment. It has also looked at the role of staff in decision-making, alongside their career progression, education and training.
17. Given the potential of the proposals to affect patients, NHS staff and the public, most will need Equality Impact Assessments. To illustrate the potential equalities issues raised it is worth noting that:• All patients will, for the first time be guaranteed NICE approved drugs and treatments where clinicians recommend them, ending the postcode lottery on availability. Payments to hospitals will be influenced by patients own views on the successfulness of treatments and the quality of their experiences, further incentivising fair and personalised treatment for all. Access to care will be simplified with more of it available closer to peoples’ homes or on a walk-in basis. The proposed NHS Constitution includes a right to choice and 4information on quality so that patients are empowered to make informed choices. • Changes to workforce planning, education and training will affect many in the NHS’s 1.3 million strong workforce. Staff will be empoweredthrough clearer career progressions, a stronger focus on developing leadership skills and more control for clinicians over budgets and HR decisions. The draft NHS Constitution makes pledges on work and wellbeing, learning and development, and involvement and partnership that apply equally to all NHS staff and will help guarantee equality of treatment.
18. How measures such as these are implemented on the ground will be key from an equalities perspective. As part of the NHS Constitution proposed by the Review, which all NHS organisations would have a duty to take account of in their decisions and actions, the rights and responsibilities of patients and staff are safeguarded as follows: • Patients and the public have the right not to be discriminated against in the provision of NHS services, on grounds of disability, race, genderreligion or sexual orientation. • Staff have the right to work in a diverse working environment, free from discrimination on the basis of race, sexual orientation, sex, disability, age or religious belief. • Staff have the right be treated fairly in recruitment and career progression e.g. promotions to posts in the NHS. • Staff have the right to work in an environment where equality of opportunity is promoted for all those who work in it.
19. It is in accordance with these principles that the Next Stage Review proposals have been developed and will be taken forward.
20. Many of the NHS Next Stage Review proposals with the potential to have an impact on equalities issues will be set out in more detail in the strategy documents NHS Next Stage Review: A Quality Workforce and NHS Next Stage Review: Our vision for primary and community care, both of which are accompanied by their own Equality Impact Assessments.
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21. As with Impact Assessments, this document does not attempt to assess the equalities impact of the proposals but commits the Department of Health to publishing appropriate Equality Impact Assessments over the coming months as they are further developed in consultation with key stakeholders.
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CHAPTER X
SUMMARY
Mr Alok TekriwalConsultant Ophthalmic Surgeon
Pilgrim HospitalBoston
Lincolnshire
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Health system in the UK
Health structure & bodies
Clinical Governance
Good medical practice
Health policies
Medical training
IT
Others
Health structure
Department of health
Strategic health authority (SHA)
Primary care trust (PCT)
NHS Trusts
Care Quality Commission
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Department of health
• Government department providing guidance, information and support to NHS
trusts and PCTs
• Health is the second largest department. Annual budget £60 billion
• 7% of GDP (17% in USA)
• Secretary of health and 5 ministers
• 12 Directorates
• 5 Executive Agencies
NHS Estates
NHS Pensions agency
Medicines control agency
Medicines devices agency
NHS purchasing and supply agency
• Nondepartmental public bodies [NDPB]
o Executive
HCC – replaced CHI in 2004
English national board for nursing, midwifery, and mental health
o Advisory: 20
Committee of the safety of medicine, Advisory Committee on Distinction
Awards etc.
• Strategic Health Authorities: Replaced 95 health authorities in England
• PCTs
152
Group of GP practices and healthcare professionals (dentists, opticians,
pharmacists etc.)
151
Has funding for purchasing secondary care and specialist services in
hospitals
[Shifting the balance of power]
• NHS direct: 24 hour telephone advice
Strategic health authority (SHA)
• 28 Strategic Health Authorities were created by the Government in 2002 to manage
the local NHS on behalf of the Secretary of State.
• Responsible for performance and strategy setting of the local NHS and public health
• The health authorities have a strategic role. This means they are responsible for:
• Making sure local health services are of a high quality and are
performing well
• Increasing the capacity of local health services so they can
provide more services
• Developing plans for improving health services in their local area
• Making sure national priorities for example, programmes for
improving cancer services are integrated into local health service plans
• Planned reduction in numbers to 10
Strategic Health Authorities manage the NHS locally and are a key link between
the Department of Health and the NHS.
SHA will cease in 2013.
Primary care trust (PCT)
• 152 PCTs
152
• Remit is to improve local health by commissioning (not
providing) hospital and community health services
• Aims to improve contestability and deliver 15% pa savings
• PCT controlled by statutory board, accountable to SHA
• PBC to move commissioning from PCT to individual practices
• Receives a single fund
Incentive for better financial management
• PbR (payment by result)
• Practice based commissioning
• Foundation trusts
• Increased focus on financial management in ratings system
PCT is going to cease in 2013
NHS Trusts
Care Quality Commission
• Establised in July 2008
• Tough powers to inspect, investigate and intervene the health and social care
providers (residential care)
• Brings together the expertise of HCC, Commission for social care inspection, and
Mental Health Act Commission
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Clinical Governance
‘Clinical governance is a framework through which NHS organisations are
accountable for continuously improving the quality of their services and
safeguarding high standards of care, by creating an environment in which
excellence in clinical care will flourish’. [DoH website]
7 pillars (SPARE IT):
Staff management
Patient and Public involvement
Clinical audit
Clinical risk management
Clinical effectiveness
Information use
Training
Staff managementASSESSMENT
• Regular process
• Evidence collected about progress towards a goal
• Judgement made whether goal achieved
• 4 stages of a skill
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• Factual knows e.g. MCQs
• Clinical knows how to e.g. clinical exam
• Competence shows how to e.g. OSCE
• Action does e.g. trainer report, video consultations
APPRAISAL
• A process of facilitated selfreflection
• Confidential review of progress focusing on
• Past achievement
• Future activity
• Feedback on performance and assistance in career progression
(cf. assessment – The process of measuring progress against defined
criteria)
• Both appraiser and appraisee need to be trained
• There is a list of appraiser in every hospital
• Appraisal forms available from DoH site
5 aspects of appraisal (CREAM)
Clinical
Education
Research and audit
Approach
Management
• 7 steps of appraisal
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• Gathering information (appraisee)
• Reviewing information (appraiser)
• Meeting – understanding the individual in relation to work
(appraisee & appraiser)
• Reflection (appraisee & appraiser)
• Feedback – agreeing strength and development points
(appraisee & appraiser)
• Action plan (appraisee & appraiser)
• Fulfill action plan (appraisee)
Incorporate (anonymised) action into organisational planning
(organisation)
REVALIDATION
Sir Liam Donaldson’s (Chief Medical Officer) report on Revalidation (published Aug 2008). The important points:
o ALL doctors wishing to practise clinically will need to be relicensed by the GMC and those who are currently on the specialist register will also need to be recertified. Eventually all doctors will need to recertify in the specialty of their practice, and relicensing and recertification for revalidation will be a single process.
o All practising doctors will be given a licence by the GMC in 2009.o Relicensing will rely on the information derived from the annual appraisal which
will include evidence from clinical governance, performance, multisource feedback from peers, colleagues and patients. It will probably commence in 2010 or 2011
o Revalidation will normally take place every 5 years but appraisal will be annual.o
o Revalidation = Relicensing (all doctors) + Recertification (for
specialists)
o Doctors to demonstrate, on a regular basis, that they are uptodate and
fit to practice in their chosen field.
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o Issue has come about as public confidence in doctor’s low from Bristol
case, Shipman, Alder Hey Organs Enquiry etc.
o Based on annual appraisal
o Revalidation issues (based on good medical practice)
o Good clinical care
o Treatment in emergencies
o Good medical practice
o Teaching and training
o Maintaining trust
o Working with colleagues and in Team
o Health and conduct
Patient and Public involvement
Clinical audit• Are we doing what we ought to be doing (are we doing the right
thing the right way?)
(Research – what we ought to be doing)
• ‘Clinical audit is a quality improvement process that seeks to
improve patient care and outcomes through systematic review of care against explicit
criteria and the implementation of change’
• Systematic critical analysis of the quality of health care
STEPS:
• Observe clinical practice to determine audit theme
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• Set standard of care, guidelines and protocols using existing
research or evidence
• Monitor clinical practice and compare against these standards
• Implement change
• Close the audit loop – reaudit
MULTIDISCIPLINARY AUDIT:
• Analyses the patient journey rather than a single component of
care
• Cyclical process
• Audit is all about setting standards
• An audit must be governed by the principles of good practice
• Supports health professionals in making sure their patients
receive the best possible care
• Inform managers about the need for organisational change
• Gives public confidence
• Never involves experiments
• Never involves a completely new treatment
• May divide patients in different treatment groups, but after full
discussion with the patients and giving them a free choice
• There is no ethical problem if:
The data are taken from clinical records
The data is gathered from routine practice
There is no approach to patients
The data is only seen by the clinical team
In layman's terms, Clinical Audit is all about the quality of care given to patients.
It usually involves asking one or more of the following questions:
158
Did the patient get better?
Did we give the best available treatment?
Did we deliver that treatment in the best possible way?
Was treatment and care provided in the best possible environment?
RESEARCH
• Systematic investigation which aims to increase the sum of
knowledge
• Usually involves an attempt to test a hypothesis
• May involve the application of strict selection criteria to patients
with the same problems before they are entered into the research study
Clinical risk management Proper record keeping
Informed consent
Incidence reporting system in place
Complaint procedure in place
Induction programme for new staff
Identify, analyse and control risks
NATIONAL PATIENT SAFETY AGENCY (NPSA)
• Collecting and analysing information on adverse incidents
• Additional roles
Safety aspects of hospital design
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Cleanliness and food
Safe research [responsible for COREC (central office of
research & ethics committees)]
Doctors and dentists performance, through NCAS
(National clinical assessment service)
Confidential enquiries
• Has rolled out National Reporting and Learning System (NRLS),
a system for confidential and anonymous electronic national reporting system. One can
report through the local incidence route or directly to NRLS.
• Incidences, adverse events and near misses
• The agency is interested in learning why things go wrong, rather
than who made the error
NATIONAL CLINICAL ASSESSMENT AUTHORITY (NCAA)
• Undertakes assessment of doctors where local procedures have
not been effective or appropriate
• Protects patients and supports doctors
• Patient himself or one of the office bearer (MD, CE, clinical
director etc.) can contact
COMPLAINT PROCEDURES
3 stages
• Stage 1: Trust’s Complaint Manager
• response within 3 weeks
• clinician concerned involved in making a reply
• Stage 2: Independent review panel Established by Convener (Non
executive member of the trust)
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• Stage 3: Ombudsman
• Adults can make claim up to 3 years (?6 months) from the date of
being aware of potential problems
• Patients can get help from ICAS (independent complaints
advocacy service)
• Can also complain to professional body (GMC)
• Medical records kept for 10 years, obstetric 25 years, children’s
up to 25th birthday
• Commonest cause of complaint is poor communication. Others
are poor clinical care, physical or sexual assault, behavior, confidentiality breach,
improper consent
• The patients do not care how much you know unless they know
that you care
• Cannot use NHS complaints process if taking legal action
CONSENT:
3 conditions should be satisfied:
1. Patient must be competent to give consent
2. Patient should have sufficient information to make a choice
3. Consent must be given freely
Demand for efficiency and productivity puts strain on the ability to offer
time and empathy
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PATIENT CONFIDENTIALITY
THE CALDICOTT REPORT (1998):
6 PRINCIPLES:
Justify the purpose
do not use person identifiable information unless it is absolutely
essential
Use the minimum personidentifiable information
access to the person identifiable information should be on a strict
needtoknow basis
everyone with access to personidentifiable information should be
aware of their responsibilities
understand and comply with the law
CHILD PROTECTION
• Child protection register can be accessed from the A&E
• Child protection register is updated monthly
• Out of hours Emergency Social Services Team can be contacted
Clinical effectiveness• Practice of evidence based medicine
• NICE and NSF provide guidance
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE [NICE]
162
The National Institute for Health and Clinical Excellence (NICE) is the independent
organisation responsible for providing national guidance on the promotion of good health and
the prevention and treatment of ill health.
• Produces guidance in 3 areas of health
• Public health
promotion of good health;
prevention of ill health
• Health technologies
• Clinical practice
• NICE and NSF set clear national standards for NHS
• NHS obliged to make resources available, normally within 3 months (from
Jan 2002)
• Established 1999
• Special health authority
• Provides authoritative, robust and reliable guidance on current best practice
• National center for clinical audit has been incorporated in NICE
• Scotland – Scottish Intercollegiate Guidelines Network (SIGN)
NICE focuses on clinical conditions that have significant impact on public health, and aim to
improve standard of care and reduce variation in provision.
Information use
Training
163
Good medical practice
Good clinical care
Maintaining good medical practice (CPD)
Teaching, training, appraising, assessing
Relationship with patients
Working with colleagues
Probity
Health
Good clinical care
Providing a good standard of practice and care
Decisions about access to medical care
Treatment in emergencies
Maintaining good medical practice
Keeping up to date
Maintaining your performance
Teaching and training, appraising and assessing
Making assessments and providing references
Teaching and training
Relationships with patients
Obtaining consent
Respecting confidentiality
164
Maintaining trust
Good communication
Ending professional relationships with patients
Dealing with problems in professional practice
Conduct or performance of colleagues
Complaints and formal inquiries
Indemnity insurance
Working with colleagues
Treating colleagues fairly
Working in teams
Leading teams
Arranging cover
Taking up appointments
Sharing information with colleagues
Delegation and referral
Probity
Providing information about your services
Writing reports, giving evidence and signing documents
Research
Financial and commercial dealings
Conflicts of interest
Financial interests in hospitals, nursing homes and other medical
organisations
Health
165
If your health may put patients at risk
Health policies
NHS constitution
Highest quality care for all (Darzi)
Our NHS our future (Darzi)
NHS improvement plan 2004
NHS Plan 2000
New deal
NHS constitution
NHS
• Right to all NICE approved drugs and treatments
• Legal right of choice to any provider
• Right to be treated with dignity and respect
• Clean and safe environment
• Right to complaint and redress
• To be renewed every 10 years
Patients
• Patients to contribute to their own good health
• Keep appointments or cancel within a reasonable time
Staff
• Training and support provided
166
Highest quality care for all (Darzi)
(June 2008) (Quality at the heart of NHS)
NHS (Disease treatment)
• Giving patients more information and choice
• Measuring and publishing quality of care across the NHS
(Quality defined as clinically effective, personal and safe)
• All healthcare provider working for NHS will require by law to
publish ‘Quality Accounts’
• Right to all NICE approved drugs and treatments
• National Quality Board will advise the Ministers on the priorities for
NICE
• New NHS bestevidence service
• Legal right of choice to any provider
• Personal care plans for all 15 million patients with longterm
condition
• New personal budgets for 5000 patients with complex longterm
conditions
• Promote innovation; new partnership between NHS, universities and
industry
• Greater emphasis on community health services
Preventing disease – Promoting health
• Help people to stay healthy
• ‘Reduce your risk’ campaign for vascular checks
NHS Staff
167
• Frontline staff to initiate and lead changes
• No additional topdown targets beyond the minimum standards
• Clinical voice at every level – based on best medical evidence
• Clinical excellence award to be strengthened
OUR NHS, OUR FUTURE (DARZI REPORT)(Oct 2007)
5 elements
• FAIR
Equally available to all, reducing health inequalities
• PERSONALISED
Tailored to the needs and want of each individual
Patient choice
• New GP practices starting with 25% of poorest PCTs
• Health centres in easily accessible locations
• Greater flexibility of GP hours in evening and weekends
• EFFECTIVE
Deliver outcome that is best in the world
Establish a Health Innovation Council – discovery to adoption
• SAFE
Support NPSA in establishing a single point of access for
frontline workers to report incidents: Patient Safety Direct
New health and adult social care REGULATOR with tough
powers
Give matrons further powers – to report to the regulator
MRSA screening for all elective admission in 2008
& all emergency admission within 3 years
• LOCALLY ACCOUNTABLE NHS: Any major change in the local NHS
service should be clinically led and locally accountable
168
Change initiated only if there is a strong clinical basis
Consultation should proceed only where there is effective and
early engagement with public
Resources made available to open new facilities alongside old
ones closing
Independent clinical and managerial assessment
NHS IMPROVEMENT PLAN (2004)
• Choose and book (2005)
Unlimited patient choice of NHS provider + private provider who meets NHS
tariff/HCC standards (2008)
• Information about provider waiting time and quality of care
• 18 weeks patients journey (2008)
• Minimum 15% of operations/tests in private sector (2008)
• NHS Cancer plan (1 month to treatment 2008)
• PCT to control 80% of NHS budget
• Fewer national targets
CHOOSE AND BOOK
• Started in summer 2004
• Patients able to choose from Jan 2006
• Choice of 4 providers
• Can book the first appointment
169
18 WEEK PATHWAY
• By Dec 2008 maximum wait from referral to treatment for nonurgent
cases will be 18 weeks
OUR HEALTH, OUR CARE, OUR SAY
(A new direction for community services)
• Feb 2006
• Patientcentered community services
NHS PLAN 2000
Shifting the balance of power [2000]
• 10 year plan, developed after public consultation
• Consistently high standard of care
• Patient centered – services when they require and tailored to their
need
• Investment and increases in funding
• Modernising agency (now defunct) had been developed to lead all
these changes
• Health service fit for 21st century
The vision of NHS plan is to offer people fast and convenient care delivered to a
consistently high standard. Services will be available when people require them,
tailored to their individual needs.
• More and better paid staff
• Reduced waiting times and high quality care centered on patients
170
• Improvements in local hospitals and surgeries
• National standards – NICE (clinical and cost effectiveness of
available treatment), NSF (for consistency of care across the country)
• Demarcation between staff and barrier between services reduced
• Incentive for improved performance
• Decentralisation of services, patients empowered
• Plurality
• Patient choice
• Led by frontline devolved primary care
• Planning for 3/5 years
• DoH has created 10 task forces
• Locally PCTs will purchase services (outlined by NICE, NSF)
under the direction of SHA from hospital trusts, and clinical governance within the
hospitals will ensure that they are enacted locally. The HCC will inspect the trusts
regularly (5 years cycle) to ensure that these principles of practice are put into practice.
• 19,000 more doctors; 67,000 more nurses
NHS plan is consultant based not consultant led [Gary Francis BAPIO
May 2005]
AGENDA FOR CHANGE:
It is a new NHS pay and terms and conditions that apply to all directly employed
NHS staff except doctors, dentists and senior managers.
171
New deal
• An agreement made in 1991 between the government, NHS
executive, conference of medical royal colleges and the BMA
• It sets standards for hours worked, intensity of work,
accommodation and catering
Medical training
Royal Colleges
Deanery
Modernising medical career
Teaching skills
Royal Colleges
• Conducts the final professional examination
• Inspect and accredit training units
• Appoints advisors at local and regional level to assist the college
(SACs – specialist advisory committee)
• SACs are responsible to the joint committee of higher surgical
training (JCHST) of the college
The royal college sets the training standards and organizes examinations at the end
of the training period; whereas the postgraduate deans ensure that the standards are
met.
172
RITA (Record of intraining assessment)
Assessment is a formal process by which progress is measured
APPRAISAL: informal process by which a trainee and his trainer agree objective
for a training period.
Deanery
Modernising medical career
FOUNDATION PROGRAMME
• Focused on developing key competencies
• Move from experience/time based to competency/outcome based
training
• 2 years foundation programme has replaced the preregistration
and 1st year SHO positions
• F1 = PRHO
• F2 = SHO
• 1st cohort started in August 2005
• Medical students now have to apply for these posts on a national
basis.
• The application has 12 sections with 4 points each; only first two
relates to academic achievements
173
• Consultants with whom the young doctors will be working has no
say in the selection process
• Old system will run in parallel till 2009
• 6 four months placements
• There will be educational and clinical supervisors (could be the
same person)
• The programme will give generic skills to junior doctors
• After completion of foundation programme a trainee can apply
for specialty training
• Basic specialist training programme in the following broad based
specialty areas:
• Medicine in general
• Surgery in general
• Child health
• GP
• Mental health
• Anesthesia
• Pathology in general
o 1 of 8 programmes, includes GP training
o From F2 competitive entry to either Runthrough’ training (7
years in ophthalmic) or fixedterm specialist training
TOOKES REPORT
• Oct 2007
WEAKNESSES IDENTIFIED
• Introduction to FY training had gone reasonably well, but not to
ST training
174
• The need to select subspecialty 6 months in FY2 is premature
• Selection to ST training was rushed and undervalued clinical
training
• Underestimated the number of IMG
• Ineffective communication with the medical profession
• Single changeover caused logistic problem
• Service element of ST reduced significantly
KEY RECOMMENDATIONS
• DH should consult with medical profession and NHS
• FY1 to be aligned to medical school. FY2 merged in 3 years core
training (six six months training)
• Entry to core training by computer adaptive test at the end of FY1
• Entry to ST3 by national assessment centre for each specialty
with CV and interview at deanery level;
3 times a year
• PMETB to be merged with GMC
• The position of overseas students graduating from UK
universities to be clarified with regard to their eligibility to PG training
• Include education and training in HCC performance reporting
regime
• Responsibility of the local delivery of training should be given to
the medical directors
• Funding issue to be addressed
Teaching skills
175
ADULT LEARNING
• Concrete experience Activist
• Reflective observation Reflector
• Conceptualisation – New ideas Theorist
• Active experimentation Pragmatist
• Seek feedback
TEACHING
• The students need to see the whole picture – the relevance of the
new ideas with respect to the whole
• Attention spam of adults is about 15 minutes
• Adults learn in different ways to children
• Plan learning objective
• Aims: general statements
Objectives: Specific, clear statements
• Establish mood and climate
• Assessment
• Question classification
i. Knowledge
ii. Comprehension
iii. Application
iv. Analysis
v. Synthesis
vi. Evaluation
• Giving Feedback
vii. Start with the positive
viii. Be specific
176
ix. Refer to behaviour which can be changed
x. Offer alternatives
xi. Be descriptive rather than evaluative
xii. Own the feedback
xiii. Leave the recipient with a choice
xiv. Think what it says about you
• Receiving feedback
xv. Listen to the feedback
xvi. Be clear about what is being said
xvii. Check it out with others
xviii. Ask for feedback that you do not get
xix. Decide what to do with the feedback
LEARNING APPROACHES:
SURFACE LEARNING:
• Accept ideas and information passively
DEEP LEARNING:
• Intention to understand material for oneself
Information technology (IT)
CONNECTING FOR HEALTH
• National IT network
• NHS Care records (CRS) across the country
• Choose and book
• PACS (Picture archiving and communication systems)
177
• Do once and share
• Support (financial, audit, target, governance data)
• Over £6 billion over next 10 years; increased to £20 billion
• Challenges – security, compatibility
Do Once and Share
• Software development programme which will integrate single record
keeping between primary and different departments in the secondary care.
• 45 pathways are being developed by individual action teams, 4 of which
are in ophthalmology
• Diabetic eye disease
• Cataract
• Glaucoma
• Followup
• Philosophy is to provide the right information at the right place at the
right time, without paper record and without duplication of data entry.
Others
New consultant contract
Business plan
Teamwork & Leadership skills
Resolving conflict, difficult colleague
European working time directive
DVLA
178
New consultant contract
• Consultant’s role better defined
• Recognition of oncall duties
• Significant increase in average career earnings
• Opportunity to undertake extra NHS work
• Prevents any conflict with private practice
• Maximum parttime contract abolished. Contract based solely on
agreed time and service commitments
• More equitable system of awarding clinical excellence awards
• Faster , fairer and more effective disciplinary procedure
PROGRAMMED ACTIVITIES:
• For full time consultants there will be 10 PA of 4 hours each.
They may be programmed in halfunits of 2 hours each.
• Separated into:
• Direct clinical care
• Supporting professional activities
• Training
• CPD
• Teaching
• audit
• job planning
• appraisal
• clinical management
• local clinical governance activities
• Additional responsibilities
• clinical audit lead
179
• clinical governance lead
• clinical tutor
• undergraduate and postgraduate dean
• Other duties
• Trade union work
• GMC work
• Royal College
• Work for various commissions and advisory committee
• There will be 7 PA for direct clinical care, and 3 for supporting
professional activities; 8 and 2 in the first phase of their career (within 7 years of being
appointed)
• Scope for extra PA
• Oncall paid separately up to 2 PA – 8% of salary
• Flexibility to vary the weekly PA within an annual total
Business plan
• How the service is delivered at the moment
• How the service could be delivered better in the future
• How can this change come about
SWOT (Strength, weakness, opportunities, threats)PEST (political, economical, social, technological) aspects
Difficult colleague
DIFFICULT COLLEAGUE:
• Difficult colleague may be colleague in difficulty
• Take the first opportunity; do not duck
• Listen, do not prejudge
180
• Negotiate with clear expectation
• Dealt with communication and understanding +/ disciplinary
action
CRIMINAL COLLEAGUE:
• Remove from clinical area – patient safety paramount
• Follow trust procedure
• Report to relevant person
WHISTLEBLOWING:
Report to clinical director if any of the following has been, is being or is likely to happen,
or deliberately concealed
• A criminal offence
• Failure to comply with legal obligation
• Miscarriage of justice
• Endangerment of health or safety of an individual
EUROPEAN WORKING TIME DIRECTIVE
• 58 hours maximum working week (48 by Aug 2009)
• Junior doctor not to work for more than 13 hours without 11
hours rest
• 24 hours of continuous rest in 7 days, or 48 hours of continuous
rest in 14 days
• 20 minutes of break every 6 hours
• 4 weeks of annual leave
• an average of maximum 8 hours of night work in 24 hours
181
CHAPTER XIR Sand
STANDARD QUESTIONSUSEFUL LINKS
STANDARD QUESTIONS
• Tell me about yourself?
• Why did you choose this hospital/university and how did you arrive at this
decision?
• Why do you want this job?
• Since you have been in medicine/orthopaedics/surgery, what is it that you are
proudest of?
• How have you changed personally since starting medicine?
• What was your best job and why?
• What was your worst job and why?
• Tell me about your hobbies/pastimes/adventures?
• Of the hobbies and interests listed on your resume what is your favourite and
tell me why?
• If you could change a decision you made whist in
medicine/orthopaedics/surgery what would you change and why?
• Tell me about your curriculum vitae.
• Describe a leadership role of yours and tell why you committed your time to
it?
• Give me an example of an idea that has come to you and what you did with it?
• Give me an example of a problem you solved and the process you used?
• Give me an example of the most creative project that you have worked on?
• What work experiences have been most valuable to you and why?
182
• What have the experiences on your resume taught you about managing and
working with people?
• Give me a situation in which you failed, and how you handled it?
• Why have you chosen this particular profession?
• What challenges are you looking for in a position?
• What goals have you set for yourself? How are you planning to achieve them?
• What is your most significant accomplishment so far?
• What motivates you?
• What turns you off?
• If I asked people who know you well to describe you, what three words would
they use?
• If I asked the people who know you for one reason why I shouldn't employ
you, what would they say?
• Recent political or medical news developments?
• What are your team-player qualities? Give examples
• What methods have you used or would you use to assess student learning?
• What characteristics do you think are important for this position?
• Name two management skills that you think you have?
• What characteristics are most important in a good manager? How have you
displayed one of them?
• We are looking at a lot of great candidates; why are you the best person for
this position?
• Increasing you may be confronted with more "modern" questions that are
designed to make you think:
• Describe a time in any job you’ve held when you were faced with problems or
pressures which tested your ability to cope. What did you do?
• Give an example to a time when you were unable to finish a task because to
did not have enough information to go on. Be specific.
183
• Give an example of a time when you have to be relatively quick in coming to a
decision.
• Tell me about a time when you had to use your spoken communication skills
in order to get a point across that was important to you?
• Can you tell me about a job experience in which you had to speak up in order
to be sure that other people knew what you though or felt?
• Give me an example of a time when you felt you were able to motivate your
colleagues or subordinates.
• What do you do when one of your team member is performing badly, just not
getting the job done? Give an example.
• When you had to do a job that was particularly uninteresting, how did you
deal with it?
• Give me an example of a specific occasion when you conformed to a policy
with which you did not agree.
• Describe a situation in which you felt it necessary to be very attentive to your
environment.
• Give an example of a time when you have to use your fact-finding skills to
gain information in order to solve a problem - then tell me how you analysed
the information to come to a decision.
• Give me an example of an important goal which you have set in the past and
tell me about your success in reaching it.
• Describe the most significant written document/report/presentation which you
have had to complete.
• Give me an example of a time when you have to go above and beyond the call
of duty in order to get a job done.
• Give me an example of a time when you were able to communicate with
another person, even though that individual may not have liked you
personally.
• Describe a situation in which you were effectively able to "read" another
person and tailor your actions according to your understanding of their
individual needs or values.
184
• What did you do in your last job in order to be effective with your
organisation and planning? Be specific.
• Describe a situation in your job when you could structure your own work
schedule. What did you do?
• Describe the most creative work-related project which you have carried out.
• Describe a time when you felt it was necessary to modify or change your
actions in order to respond to the needs of another person.
• What experience have you had with a misunderstanding with a customer or
fellow employee? How did you solve the problem?
• What did you do in your last job to contribute towards teamwork? Be specific.
• Give me an example of a problem which you faced on any job you have had
and tell me how you went about solving it.
• Describe a situation in which you were able to influence positively the action
of others in a desired direction.
185
USEFUL LINKS
• www.doh.gov.uk • www.gmc-uk.org• www.nhs.uk• The National Health Service (Appointment of Consultants) Regulations? Good
Practice Guidance January 2005• Maintaining High Professional Standards in the Modern NHS February 2005• Terms and Conditions of Service for NHS Consultants – 2003• Consultant Contract Implementation Team ? Modernization Agency• Medical Protection Society Website• Tooke report (http://www.mmcinquiry.org.uk/index.htm)
• NICE www.nice.org.uk
• NHS direct www.nhsdirect.nhs.uk
• NHS Magazine
• NHS risk management www.nhsla.com/RiskManagement
• Dr Fosters website www.drfoster.co.uk
• Clinical Governance
www.icservices.nhs.uk/clinicalgovernance/pages/cg_request.asp
• National newspapers: The Times, Guardian, The Independent (Read the
current NHS issues)
Good luck
R Sand & D Raj
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