NHS BOARD MEETING. 27 August Subject: Purpose: Recommendation:

NHS BOARD MEETING 27 August 2008 Subject: Purpose: Recommendation: MODERNISING MEDICAL CAREERS (MMC) UPDATE 2008 Provide the NHS Board with a position statement in relation to the ongoing implementation of MMC The Board is invited to consider, make comment upon and approve or amend as appropriate these proposals. 1. Background 1.1 At the NHS Board meeting on 23 July 2008, the Board received a verbal report from the Executive Medical Director on the shortfall of trainee doctors recruited and the implications on service delivery. 1.2 Historically, before MMC, NHS Ayrshire and Arran - like many other Boards with district general hospitals - had relatively low numbers of Specialty Registrars and therefore employed significantly high proportions of Senior House Officer (SHO) Doctors (trainees). The Chief Medical Officer's report Unfinished Business identified that SHO doctors had no clear educational or career pathways, no defined educational goals, no limit to time spent in the grade and a lack of distinction between service and training. Some SHO Doctors would remain in this type of post for many years before competing for and securing a Specialty Registrar appointment, which would lead them to a Certificate of Completion of Specialty Training and eligibility to apply for Consultant Positions. Other challenges to the existing apprentice medical training ethos were also identified in the report and included the impact of contract changes, e.g. to the length of the working week, and the developments in medical science. Modernising Medical Careers (MMC) was launched in February 2003 by the four UK Health Departments after widespread consultation around the Chief Medical Officer's report Unfinished Business. It was based on the principles outlined below: More medical care should be provided by fully trained doctors, rather than by trainees. National standards for training should be established accompanied by comprehensive curricula for each specialty. Competencies should be assessed at regular intervals. 1

All trainers and supervisors should be highly trained and given the right support to fulfill their roles. 1.3 The Modernising Medical Careers (MMC) programme is delivering radical change aimed at driving up the quality of care for patients through reform and improvement in postgraduate medical education and training. It sets a new direction from Foundation programmes through to Certificate of Completion of Training (CCT). The changes ensure improved standards of patient care/patient safety, by developing practitioners who are; receptive to the needs of patients and the NHS responsible and accountable for their actions in respect of these needs. This requires the demonstration of a variety of well defined competencies for doctors in training. The Modernising Medical Careers (MMC) programme leads trainee doctors through a 2 year foundation programme of holistic training and education, dealing with areas as diverse as team-working and patient safety. Foundation programmes are followed by Specialty and General Practice training programmes leading to a Certificate of Completion of Training (CCT) and entry to the Specialist or General Practice Register of the General Medical Council. As well as improving the education of trainees, MMC allows completion of training with less delay. It also permits the service to move towards a career grade based operation with less reliance on junior training doctors for provision of care. 1.4 Ayrshire and Arran NHS Board is committed to delivering excellent services for its population in partnership with its staff and in the context of local, regional and national priorities and strategies. In order to ensure sustainability of high quality, safe services the Board has taken a proactive approach over the last 3 years to the implementation of Modernising Medical Careers in order to minimise the risks that changing from one system to another will bring. In anticipation of these issues NHS Ayrshire and Arran centralised paediatric in-patient services on the Crosshouse site in 2006 and proposed the separation of planned and unscheduled services. The concept of multidisciplinary team work was also embraced, with particular attention given to the development of advanced practice roles across a number of specialty areas. 1.5 The impact of MMC on the service is complex. Prior to Foundation and Specialty Training commencement in August 2006 and 2007 respectively, it was anticipated that service delivery would be open to being affected in a number of ways and these issues still remain. Recruitment Moving to a single common start date of 1st August 2008 for all trainees and so therefore recruiting in direct competition with services across all of the UK has made it more difficult to predict the actual numbers of new recruits who will turn up. For example, trainees offered a post within a Board, and who accept, are able to withdraw and take up offers that better fit their career aspirations elsewhere, whether in Scotland or the rest of the UK, within the same recruitment round and at any time up to the start of the post. Appointments to specialities 2007 and 2008 training numbers have been sustained at 2006 levels. It is the intention, as advised from the centre, that in subsequent years the training post numbers will reduce. This is due to start in August 2009. At this time there will also be a shift in the spectrum of posts, with 2

more posts at the higher end of the training continuum. This will put further pressure on Hospital at Night (H@N) rotas due to reduced numbers of trainees at the lower end of the training continuum; those being the roles that contribute to H@N rotas. Competency Based Training - Following the implementation of MMC specialty training in August 2007, as anticipated, trainees now have a different set of skills and experience than before. This has resulted in a reduced ability to deliver service loads as less time and fewer experienced individual specialty posts are available for this. 1.6 A local MMC Project Board Team, MMC Project Board and Clinical Reference Group are in place in NHS Ayrshire and Arran to develop solutions to the predicted issues on service-by-service assessments in critical delivery areas and to ensure the building of sustainable solutions in the short, medium and long term. 2 Current Situation 2.1 Recruitment of junior doctors is conducted by NHS Education for Scotland, with the overall number of programme slots determined by Scottish Government. Following 3 rounds of recruitment for August 2008, (1 national and 2 regional) a number of vacancies remained. A further round of local recruitment was held and, as at 21 August, 17 training post vacancies (10.3% of the total) remain in NHS Ayrshire and Arran. These are spread across a range of specialties as shown in Table 1 with acute medicine most severely affected. Table 1. List of Vacant MMC Posts. Specialty Programme Slots Vacancies Core Medical Training 11 2 Specialty Medical Training 10 2 Trauma and Orthopaedics 14 2 Psychiatry 16 2 Anaesthetics 14 1 Urology 5 1 Ear Nose and Throat 6 1 Obstetrics and Gynaecology 15 2 Accident and Emergency 15 1 General Surgery 14 1 Paediatrics 16 1 Palliative care 2 1 2.2 The above shortfalls have exposed the Board to risks around: ensuring the short term safe and sustainable delivery of its services in hospitals rota compliance against training and employment standards; recruitment and retention of doctors; 3

longer term sustainability to deliver safe and high quality services. The Board was initially made aware of this position at the beginning of July when the results of the national recruitment rounds became available. Since then extensive activity has taken place to recover the position and to construct contingency plans to ensure business continuity in the face of anticipated stresses, e.g. sick leave and other unpredictable absences, on the system. Noteworthy in that respect has been the construction of a strategic approach that has identified the maintenance of unscheduled care and associated in-patient work as the core priority against elective and outpatient activity. All of the above specialties, with the exception of palliative care, contribute to hospital at night and emergency receiving across Ayrshire. 3 Solutions in place 3.1 Immediate and short term solutions: Continue to recruit a combination of clinical fellow / Locum Appointments to Training and or staff grade posts on both sites; however following the 3 rounds of recruitment described above and a further local round it would appear that the UK pool at clinical fellow (training grade) level is diminishing Trainee Doctors provide a significant contribution to out of hours service provision through participation on Hospital at Night rotas. Considerable rota and associated service redesign has been undertaken due to the reduction in numbers. For example planned medical rotas for Crosshouse and Ayr Hospitals for August 2008 were for 24 and 18 doctors respectively. In terms of European Working Time Compliance and the associated New Deal Agreement for doctors in training the new rotas were banded at 2b. In band 2b rotas the doctors are working over 48 hours but less than 1/3 of the total hours are unsocial, this rota attracts a 50% supplement to the base salary. The current rota schemes are based on a minimum of 20 and 16 with additions to be added as further appointments are made. The redesigned medicine rotas on both sites protect out of hours (unsocial) and receiving shifts but correspondingly significantly reduce daytime in-patient and outpatient cover. Based on the projected numbers in post in August, at times this will result in 1 trainee per 35 in-patient beds which is an extremely intensive workload for the trainees and does not give the desired doctor patient ratio to which the Board would aspire. This may necessitate the cancellation of out-patient and elective work to allow consultants to care for emergency admissions and associated in-patients. The new rotas have been designed to accommodate reduced numbers and comply with the requirements laid down by New Deal standards and will be subject to approval by The Regional New Deal Support Team. On paper, the Rotas band at a 2b in Ayr which as described above attracts a 50% supplement to the base salary and 2a at Crosshouse which requires the doctors to work in excess of 48 hours with more than 1/3 of the hours devoted to unsocial hours. This attracts an 80% supplement to base salary. Whilst these types of rotas are acceptable they do not allow us to progress as planned with meeting 2009 New Deal Compliance in terms of the 48 hour maximum working week target. It also impacts upon compliance with the training 4

standards and so will result in fewer opportunities to achieve training competencies than previously provided and preferred in terms of this important function. These training specific issues have been raised with the Deanery. Annual leave has been factored in to the Rota; however any sickness absence and trainees study leave will further compromise the rota and have a negative impact, either further reducing daytime cover or necessitating trainees to change shifts to cover out of hours work or for the organisation to employ locum doctors where this is possible. This will further impact on the ability to deliver patient care. Over the past year it has become apparent that when absence occurs it has become extremely difficult to secure cover from locum agencies. The agencies have advised us that the number of doctors registered with them has reduced dramatically whilst the number of requests for locum cover has increased substantially. Contingency plans have taken this difficulty into account. Following recent discussions with the Deanery and senior clinicians it was decided to withdraw trainees from outpatient clinic activity to secure the clinically agreed priorities around inpatient work and to achieve an acceptable intensity of workload for the trainees. This is a short term measure as the training gained within the out patient clinic is a valuable and essential part of the training curriculum. This has resulted in a reduction in available clinic slots on both hospital sites and will have a significant effect on service access for patients and on our ability to meet outpatient waiting times and targets. Data on this impact, including patient complaints, is being collected. Recovery plans against the national efficiency, access and treatment targets are also being constructed. The decision to remove trainees from outpatient work is being reviewed on a fortnightly basis. Trainees will be reintroduced to out patient work when clinicians are content that there is appropriate medical cover for inpatient services. A concerted effort has been initiated to implement redesign work which has already commenced. This work is to ensure: appropriate referral policies and protocols are in place; working and effective discharge planning is undertaken, and patients are discharged safely, timeously and effectively with the correct support in place. Further withdrawal from training posts in Trauma and Orthopaedics and or unexpected sickness absence, accompanied by inability to recruit or secure locum cover will seriously jeopardise our ability to provide safe high quality service on both sites. Contingency plans are being developed to address such eventualities. The impact of these changes has effectively been to require the Board to accelerate all solutions which will address the impact of MMC issues. At the Clinical Resource Group meeting on 18 August 2008, it was agreed to appoint 2 Accident and Emergency consultants as identified in Review of Service, to enable the provision of extended hours sessions on both sites. A proposal will go to the next meeting of the Integrated Care Modernisation Board to use the balance of the money to appoint 3 Acute Receiving Physicians to lead development of a common approach to the delivery of 5

assessment unit delivery on both sites. The MMC issue means that these solutions will have to be delivered not just more quickly but in a more pressurised environment. Senior clinical and management staff are developing a programme against this and the first wave of immediate required investment for the multidisciplinary solutions will be in place for start September 2008. Further actions will be delivered for the first quarter of 2009 so that the Board can have systems in place to be in a flexible and resilient position to sustain safe clinical service with appropriate training opportunities against the next round of MMC in August 2009. Winter planning - within the Board, one of the responses to the increased clinical pressures experienced over winter has been to open more beds and increase junior medical staff to treat the additional numbers of patients. It is predicted that as a consequence of the above pressures our ability to respond in this way will be curtailed and hence the solutions being proposed for immediate MMC relief are also planned to help address this scenario. A short focused workforce planning exercise is currently underway to identify the immediate steps required to move in the longer term towards a trained doctor service. The service for the future requires having minimal reliance on trainee doctors, taking all opportunities to develop a range of clinical roles and planning appropriate timelines. This work will be further discussed with the Board at the October meeting. 3.2 Medium term solution: Considerable rota and service redesign has been, and is being, undertaken due to the reduction in numbers in all the specialities shown in Table 1 and at present if no further withdrawals by trainees are experienced, we will continue to be able to provide all services on their present sites. The reduction in numbers participating on the Hospital at Night (h@n) rotas make the rotas extremely fragile and impact seriously on daytime ward cover, particularly in Medicine and Trauma and Orthopaedics. In anticipation of known shortfalls from 2009 due to removal of Fixed Term Specialty Training Appointments, Hospital at Day solutions have been introduced in Trauma and Orthopaedics, Medicine and Neonatology. These solutions build on the Hospital at Night concept of introducing advanced nurse practitioners into daytime work to provide additional capacity within the team. Similar solutions are in the planning stages for ENT, Obstetrics and Gynaecology, Neonatology and Psychiatry. As part of the solutions in these areas, key roles will be provided by advanced nurse practitioners. There will also be an increase in clinical support workers and administration roles accompanied by significant service redesign. The majority of these posts are still in the early stages of development and education and therefore unable to provide the type and level of support necessary from 1 August 2008. Where we have had Advanced Neonatal Nurse Practitioners in place for the past few years, these posts are now contributing, as assessed by a national evaluation, some functions at middle grade training doctor level. Further changes to paediatric and neonatal medical training may necessitate future increases in Neonatal Nurse Practitioner numbers. This work is being undertaken at National, Regional and local planning levels. 6

3.3 Longer term solutions: Historically, pre MMC as described in paragraph 1.2, NHS Ayrshire & Arran had low numbers of Specialty Registrars (old Training grades) the solution to this was to appoint above the norm in terms of a proportion of staff grade and trust doctors i.e. non-consultant, non-training grades. The impact of the introduction in the current year of the replacement contract for the previous non-consultant, non-training grade doctors remains to be determined. However the absorption of significant numbers from that cohort into current training programmes to fill some of the gaps described means that recruitment within this group is also likely to be uncertain. The new contract terms make out of hours work for speciality doctors a significantly more expensive option than previously. Future medical workforce planning will have to take this into account. Robust medical workforce planning must be undertaken in conjunction with service provision and any potential redesign. It is recognised that the reduction in trainee doctor numbers will seriously impact on service provision and that we will need to look to the whole health care team to pick up some of the roles traditionally provided by trainees. Some of these roles will be provided by trained doctors others by the wider multidisciplinary team. Future Rota design must take account of difficulties in the lack of locums, therefore include resilience in the system to be able to move trainees and/ or other grades of Doctor to cover out of hours period should the need arise. 4. Contingency Planning and Escalation Procedure 4.1 In view of the fragility of the rotas contingency plans have been developed to enable appropriately proportionate and phased escalations to ensure that the Board can sustain safe patient services in the face of further unpredictable rota pressures. There are 3 response levels planned whose key features are as follows 1. Phase 1 usual procedure Local operational resolution led by the general management and clinical staff for the area concerned supported by the Medical Staffing Department to achieve local solutions e.g. swapping rota slots, employing locums etc 2. Phase 2 escalations. Hospital based redeployment of non-training staff, consultants and other grades of staff away from elective and outpatient work to support the prioritised inpatient and unscheduled services. 3. Phase 3 escalations. If we are unable to secure appropriate medical cover to sustain 2 acute sites then at this stage a decision regarding closing beds and escalation processes around this would require to be considered. This will be in line with the way operational pressures are dealt with, for 7

example, ward closures due to unexpected staff absence. The decision making process against this scheme will follow the existing processes involving duty manager and Director on call assisted specifically from Phase 2 by a parallel on call rota provided by Executive Medical Director and Associate Medical Directors. This latter will ensure that the Directors and Duty managers will be appropriately supported to take the necessary corporate clinical decisions flowing from the above. 5 Engagement 5.1 The speed of development of the MMC issue has not permitted normal full stakeholder discussions. Nonetheless, a multi-disciplinary approach, including communications with general medical practitioners, has been taken to consider the potential risks and agree solutions. Communications with hospital and community clinicians has been achieved 5.2 The Executive Medical Director and Assistant Director Medical and Nursing Workforce Development have been liasing with Scottish Government NHS Education for Scotland and the Regional Medical Workforce Training Distribution Group to ensure these issues are reported at the highest level. 5.3 Following discussion with the Chief Nursing Officer / Interim Director of Workforce, we have been advised that Scottish Government will : Assist with the communication process where there is a national issue. Commence work to agree numbers for 2009 with reassurance that redistribution of trainees will be addressed Explore the prospect of an international recruitment process for doctors where the UK pool is exhausted. Continue to explore and support the wider workforce implications / support / role development. 5.4 Where significant and permanent changes to service provision or to roles and responsibilities occurs engagement and consultation will be undertaken in accordance with NHS Ayrshire and Arran policy and procedure. 6 Resources 6.1 Considerable work has been undertaken to identify key risk areas for 2008/09 and to develop solutions in response to these issues. Recurring funding of 400,000 was secured for the period 2008/09. At its meeting on 4 February 2008 the Project Board prioritised issues and agreed solutions to be implemented for the period 2008/09 Annex 1. These measures demonstrate the multidisciplinary route being pursed for long term safe and sustainable services for NHS Ayrshire and Arran. 6.2 Key solutions already in place have had recurring funding released. Funding not released by month 4 has been held pending further reprioritisation against the present circumstances. 6.3 In order to move us towards the future of a trained doctor service, it is estimated that around 1million full year cost might be required in year to initiate the necessary programmes. A further paper will be brought to the October Board 8

7 Risks meeting which will present the immediate actions and indicate full year costs. Medium and long term actions will be brought to the December Board meeting 7.1 The current rota is fragile. Every effort is being undertaken to seek and ensure early implementation of agreed solutions to minimise risk to service provision and to ensure sustainability and safety of services in the short, medium and long term. 8. Impact Assessment 8.1 Equality and Diversity Impact assessment is an integral part of all recruitment processes. 9 Conclusion 9.1 In conclusion, it is clear that NHS Ayrshire and Arran is exposed to considerable risks flowing from the 2008 MMC recruitment process that can be summarised under six main headings: 1. On call medical rota cover compliance in both the short and longer terms. 2. Significant concern regarding access to service due to the operational medical cover required to address patient needs. 3. Significant challenges against the Board s ability to deliver to a number of Scottish Government and operational targets e.g. waiting times. 4. The capacity and capability to pump prime and accelerate the multidisciplinary innovations needed to secure current and future safe, sustainable services. 5. The ability to deliver the required quality and compliance against training for junior medical staff. 6. The management of the financial pressures flowing from the need to introduce the solutions described. The Board is presented with the actions taken to address this and the steps planned to support the continued delivery of safe, sustainable hospital services. The Board is invited to consider, make comment upon and approve or amend as appropriate these proposals. Dr Robert Masterton Executive Medical Director [Diane Murray} 9