the surgical care team and improving surgical training
TRANSCRIPT
The Surgical Care Team and Improving Surgical Training
Update and Feedback from Pilot sites
Ian Eardley
Vice President, Royal College of Surgeons of
England
Context
Context
Loss of Autonomy
Loss of the “Effort –Reward”
relationship
Loss of Support
Structures
“Many seem condemned to
spending years rootlessly
shuffling from one place to
another like lost luggage,
buffeted about by a
promotion system that
seems to be little more than
a lottery”
Professor Sir Simon Wessely
Context
71.3%67.0%
64.4%
58.5%
52.0% 50.4%
4.6% 6.1%9.4% 11.3% 13.1% 13.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2011 2012 2013 2014 2015 2016
Entering Specialty Training Taking Career Break
Context: GMC survey (2014)
77.1%
78.4%
81.6%
83.4%84.1% 83.8%
85.6%
88.6%
70%
75%
80%
85%
90%
Surgery Medicine Emergencymedicine
Psychiatry Ophthalmology Radiology Anaesthesia General practice
Trainee Satisfaction
Context: GMC survey (2014)
72.1%
77.2%
86.5%
60%
65%
70%
75%
80%
85%
90%
Foundation Core Specialty
Surgical Trainee Satisfaction
Improving Surgical Training
• HEE commissioned report
• Initiated in March 2015
• Report by October 2015
• Remit of the Report
• Potential ways of improving surgical
training
• Description of potential models
• Feasibility of a pilot
• Financial modelling
• Stakeholder feedback
• Recommendations for further work
• Recommendations regarding a pilot
The Problem
The need to be trained
The need to deliver the
service
Evidence: Full Shift Rotas ……
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
5 6 7 8 9 10
Numbers in cell
Daytime shifts
Extended days andweekends
Night time shifts
Evidence: Logbook experience ……
• Appendicectomy
• E-logbook
• 2,032 core trainees
Mean Min Max
Assisting 6 0 49
Supervised scrubbed
6 0 61
Supervised unscrubbed
0 0 23
Performed 1 0 60
Conclusions
Imbalance of service and
training
Inadequate time for training
Inflexible training process
Especially in the early years of training
Main Recommendations
• Re-structuring of rotas
• Minimum of 10 in a full shift “cell”
• Use of a non-medical workforce within the on call rota at “core” trainee level
• Competence based progression with minimum and maximum duration
• Enhanced selection
• Run through progression
• Enhanced assessment and ARCP
• Enhanced training
• Time for training
• Enhanced trainer training
• “Apprenticeship” with longer attachments
• Curriculum modification
• Broader base
• Entrustable Professional Activities (EPAs)
• Embedded, enhanced simulation (boot camps)
• Surgically themed FY2
• Funded, QA, Nationally selected sub-specialist Fellowship training
Current Status
• General surgery• Pilot to commence 2018
• Recruit into ST1
• SAC has agreed to support “run-through” with bench-marking at ST3
• Around 80 UK posts volunteered to be part of the pilot (including all Core posts in Scotland)
• Urology• Urology (run-through) pilot to commence 2019
• Vascular surgery• Vascular run-through pilot to commence 2019
• Trauma and Orthopaedic• Exploring possibility of a run-through pilot to commence 2019/20
Timeline: General Surgery
No. Milestone – Decision/Delivery Point Target Date
1 Research from RCSEng Extended Surgical Team project published April 2016
2Support obtained from NHS England and NHS Improvement to principles of service changes/new service model
June 2016
3 Draft curriculum written September 2016
4 Pilot site recruitment commences September 2016
5 Pilot sites agreed February 2017
6 GMC approve curriculum September 2017
7 Recruitment of trainees commences November 2017
8 Trainee interviews heldJanuary – February 2018
9 Trainee offers made March 2018
10 Trainee places confirmed April 2018
11 Pilot training programme commences August 2018
Current Status: Pilot Sites
SchoolApplication
receivedNo. Pilot sites Locations
East Midlands Yes 2 Nottingham and Derby
East of England Yes 2 Cambridge and Norwich
North East Yes 3 Gateshead, Northumbria, Newcastle
North West Yes 2 Manchester, Liverpool
Scotland Yes Multiple To be confirmed
South West (Severn) Yes 1 Gloucester
Wales Yes 4 Swansea, Cardiff, Newport
Yorkshire Yes 4 Doncaster, Hull, Sheffield, Leeds
KSS Yes 2 East Kent, Medway
London Yes 2 North Central and East London
15
Issues and Concerns
• Practicalities of a Pilot
• Acceptance that it will run side by side with “conventional training”
• Availability of the non-medical workforce
• Advanced Clinical Practitioners, Surgical Care Practitioners, Physician Associates
• Competence based progression
• How to do it?
• Service engagement
• Rota re-design
• Time for training
• Funding for the non-medical workforce
• Run through training
• Role and effectiveness of ARCP
• Benchmarking
• Evaluation
• How to determine whether the pilot has worked better than traditional training pathway
Availability of the Non-Medical Workforce
Extended Team Project: Objectives
1. To undertake a task analysis to
understanda. What tasks that foundation and core
trainees currently undertake
b. Which tasks could potentially be done by
other members of an extended surgical
team (EST)
2. To gain a better understanding of the
skills and competencies of different
potential members of the EST
3. To develop new models of inpatient
care for the wider surgical team that
seek to improve:a. The quality of patient care
b. The quality of surgical training
Surgical Care Team Project: Trainee Survey
Key findings:
1. Service requirements dominate
trainee time on shift
2. There is a mismatch between the
time trainees spend on certain
tasks, and the perceived
educational value they place on
that task
13
15
7
86
104
106
83
16
70
9
2
26
13
11
19
13
10
4
60
53
62
103
16
30
33
34
67
16
54
19
Receiving bedside teaching
Attending formal/didactic teaching
Attending simulation…
Undertaking ward rounds
Completing discharge paperwork…
Other administrative tasks
Clerking and admitting new patients
In meetings (e.g. MDT, M&M)
Performing simple procedures on…
Performing core surgical skills and…
In theatre as primary surgeon
In theatre as an assistant
In theatre observing surgery
In outpatient clinics
Undertaking audit, research or CPD
Foundation trainees Surgical trainees
Surgical Care Team Project: Trainee Survey
Key findings:
1. Service requirements dominate
trainee time on shift
2. There is a mismatch between the
time trainees spend on certain
tasks, and the perceived
educational value they place on
that task
13
15
7
86
104
106
83
16
70
9
2
26
13
11
19
13
10
4
60
53
62
103
16
30
33
34
67
16
54
19
Receiving bedside teaching
Attending formal/didactic teaching
Attending simulation…
Undertaking ward rounds
Completing discharge paperwork…
Other administrative tasks
Clerking and admitting new patients
In meetings (e.g. MDT, M&M)
Performing simple procedures on…
Performing core surgical skills and…
In theatre as primary surgeon
In theatre as an assistant
In theatre observing surgery
In outpatient clinics
Undertaking audit, research or CPD
Foundation trainees Surgical trainees
Surgical Care Team Project: Case Studies
Newcastle :
Cardiothoracic
North Tees:
General Surgery
T&O
Urology
London (St. George’s):
Breast
ENT
Neurosurgery
OMFS
Paediatric
Plastic
T&O
Urology
Ashford :
Colorectal
Urology
Cheltenham :
Vascular
Cardiff :
Vascular
General Surgery
Urology
Norwich:
Anaesthetics
T&OBirmingham :
OMFS
Aintree :
Anaesthetics
Colorectal
The Surgical Care Team
Experiences of these sites were overwhelmingly positive:• Better continuity of care for patients• Greater efficiency of discharge and in theatres • Smoother running clinics• Enhanced surgical training
Who are the Surgical Care Team?
Ongoing Work
• Communications
• Multimedia, online information for professionals & employers (July ongoing)• Career pathways
• Description of roles
• Media work (April ongoing)
• Regulatory work (including work with HEE)
• Ongoing Research
• Patient perceptions of the EST (April-Sept) (HEE funded)
• Support for the Extended Team
• Surgical Care Team to be included in Council debate on re-organisation of
Membership categories (April ongoing)
• Standards document (Out to consultation)
• (Development of portfolio for credentialling)
Regulatory Issues
• Physician Associates are currently unregulated
• Consultation
• Consultation on regulation to begin (likely) Autumn 2017
• If there is support, then would need a change in law
• Legislation
• Brexit makes significant legislation unlikely in this Parliament
• A section 60 order is possible as a means of delivering regulation, but unlikely to
be delivered before 2019/20
• HEE currently proposing regulation for “Medical Associate
Professionals”
• Physician Associates
• Surgical Care Practitioners
• Physician Associate Anaesthesia
• Advanced Critical Care Practitioners
Patient Perspectives
• A series of focus groups with
patients preceded the
quantitative survey, which
examined themes and
language
• 200 respondents took part in a
20 minute CATI questionnaire
exploring:• Support for the proposition
• Key expectations of role
• Regulation of the team
• Preferences to be notified
Support for Indirect Supervision
98%
98%
94%
94%
91%
83%
74%
67%
67%
44%
Assisting with the preparation of…
Taking blood samples
Assessing and managing wounds
Inserting drips and catheters
Setting up the operating theatre…
Assessing the symptoms for a…
Carrying out minor surgical…
Diagnosing patients for a minor…
First hospital consultation
NET: Happy with all tasks
Tasks you would be happy being carried out by someone who is not a doctor,
under indirect supervision
• Support for nurses and health practitioners
to carry out ‘routine’ non-surgical
procedures, and prepare patients for
surgery with indirect supervision.
• There is less support for the same health
care workers to do initial assessment or
diagnosis and less than half would be
happy for all to be done by trained
practitioners.
Summary
• The Improving Surgical Training project will launch with
General Surgery in August 2018
• A central component of the project is an enhanced role
for the Surgical Care Team
Discussion