The Surgical Care Team and Improving Surgical Training

Transcription

1 The Surgical Care Team and Improving Surgical Training Update and Feedback from Pilot sites Ian Eardley Vice President, Royal College of Surgeons of England

2 Context

3 Context Loss of Support Structures Loss of Autonomy Loss of the Effort Reward relationship 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

4 Context 80% 70% 60% 50% 71.3% 67.0% 64.4% 58.5% 52.0% 50.4% 40% 30% 20% 10% 4.6% 6.1% 9.4% 11.3% 13.1% 13.1% 0% Entering Specialty Training Taking Career Break

5 Context: GMC survey (2014) 90% Trainee Satisfaction 88.6% 85% 83.4% 84.1% 83.8% 85.6% 81.6% 80% 77.1% 78.4% 75% 70% Surgery Medicine Emergency medicine Psychiatry Ophthalmology Radiology Anaesthesia General practice

6 Context: GMC survey (2014) 90% 85% 80% Surgical Trainee Satisfaction 77.2% 86.5% 75% 70% 72.1% 65% 60% Foundation Core Specialty

7 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

8 The Problem The need to be trained The need to deliver the service

9 Evidence: Full Shift Rotas 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Numbers in cell Daytime shifts Extended days and weekends Night time shifts

10 Evidence: Logbook experience Appendicectomy E-logbook 2,032 core trainees Mean Min Max Assisting Supervised scrubbed Supervised unscrubbed Performed

11 Conclusions Imbalance of service and training Especially in the early years of training Inflexible training process Inadequate time for training

12 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

13 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

14 Timeline: General Surgery No. Milestone Decision/Delivery Point Target Date 1 Research from RCSEng Extended Surgical Team project published April Support obtained from NHS England and NHS Improvement to principles of service changes/new service model June Draft curriculum written September Pilot site recruitment commences September Pilot sites agreed February GMC approve curriculum September Recruitment of trainees commences November Trainee interviews held January February Trainee offers made March Trainee places confirmed April Pilot training programme commences August 2018

15 Current Status: Pilot Sites School Application received No. 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

16 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

17 Availability of the Non-Medical Workforce

18 Extended Team Project: Objectives 1. To undertake a task analysis to understand a. 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

19 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 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

20 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 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

21 Surgical Care Team Project: Case Studies Newcastle : Cardiothoracic Aintree : Anaesthetics Colorectal North Tees: General Surgery T&O Urology Birmingham : OMFS Norwich: Anaesthetics T&O Cardiff : Vascular General Surgery Urology Cheltenham : Vascular London (St. George s): Breast ENT Neurosurgery OMFS Paediatric Plastic T&O Urology Ashford : Colorectal Urology

22 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

23 Who are the Surgical Care Team?

24 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)

25 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

26 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

27 Support for Indirect Supervision 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. NET: Happy with all tasks First hospital consultation Diagnosing patients for a minor Carrying out minor surgical Assessing the symptoms for a Setting up the operating theatre Inserting drips and catheters Assessing and managing wounds Taking blood samples Assisting with the preparation of 44% 67% 67% 74% 83% 91% 94% 94% 98% 98% 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.

28 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

29 Discussion