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NEWSANAESTHESIA

ISSN 0959-2962 No. 313

AUGUST 2013

The NewsleTTer of The

AssociATioN of ANAesTheTisTs of GreAT BriTAiN

ANd irelANd

GAT ISSUE:

The future of our specialty

The changing landscape of training

The educational reform and what it all means

Anaesthesia News August 2013 • Issue 313 3

03 Editorial

04 President’s Report

05 Thinking about an Inter-Deanery Transfer? Now a centrally managed process

07 The changing landscape of training

10 Xenon anaesthesia becomes cool

13 Another cost saving exercise, but one which also seeks to recruit, retain and motivate?

14 Sign on the dotted line…

17 An update on GMC Position Statements of relevance to Anaesthesia and Intensive Care trainees

19 How many doctors? The Centre for Workforce Intelligence approach to medical workforce planning

22 The educational reform and what it all means

25 The Shape of Training Review

27 Your Letters 28 The MSc in Regional Anaesthesia, a new innovative Training Scheme

31 Anaesthesia Digested 32 Particles 34 2013 AAGBI Annual Congress Art Exhibition, Dublin

contents

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The Association of Anaesthetists of Great Britain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: [email protected]: www.aagbi.org

Anaesthesia NewsChair Editorial Board: Felicity Plaat Editors: Kate O’Connor and Caroline Wilson (GAT), Val Bythell, Richard Griffiths, Nancy Redfern, Sean Tighe, Iain Wilson and Tom WoodcockAddress for all correspondence, advertising or submissions: Email: [email protected]: www.aagbi.org/publications/anaesthesia-news

Design: Christopher SteerAAGBI Website & Publications Officer Telephone: 020 7631 8803Email: [email protected]: Portland Print

Copyright 2013 The Association of Anaesthetists of Great Britain and Ireland

The Association cannot be responsible for the statements or views of the contributors. No part of this newsletter may be reproduced without prior permission.

Advertisements are accepted in good faith. Readers are reminded that Anaesthesia News cannot be held responsible in any way for the quality or correctness of products or services offered in advertisements.

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Editorial

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07

The future of our specialty

Welcome to this year’s GAT Edition of Anaesthesia News. With so many changes currently taking place within the NHS, it is difficult to predict what the future of our specialty will be. Within this edition we hope to inform you of some of the recent changes and important issues currently facing both our specialty and medical training as a whole.

With reviews and reforms already in progress, we have asked experts from several organisations how they are attempting to shape our future workforce. We also hear a light-hearted opinion, from Mr and Mrs Harrop-Griffiths, on the future of medical training.

Dr Nav Chana’s article, ‘The Educational reforms and what it all means’, sets out to clarify the roles of the new Health Education England and Local Education and Training Boards. Mr Ian Edwards, a senior analyst for the Centre for Workforce Intelligence, describes how workforce numbers are calculated using complex models, their recent work on the future consultant workforce and an in-depth analysis specific to our specialty, which is currently ongoing. Dr Peter Nightingale, who is a member of the expert review group for the Shape of Training Review, explains the rationale behind the review and its progress so far. With numerous documents produced over the last 12 months we felt that it would be useful to provide summaries to aid in their comprehension. These include the Department of Health’s two documents, the ‘Scoping report on the contract for doctors in training’ and the ‘Remuneration of doctors and dentists review of compensation levels, incentives, and clinical excellence and distinction award scheme’ document, as well as two GMC position statements specifically related to specialty training.

This edition also includes information for those interested in applying for an MSc in Regional Anaesthesia, or for an Inter-deanery transfer, which is now a national application process. We also hear how the anaesthetic agent Xenon is already being used in UK clinical research. With the current financial climate and Xenon’s current high cost, it is unlikely to reach the mass market just yet.

We hope that you enjoy reading this edition. If you have any comments or suggestions regarding this issue or future GAT pages, please email us on [email protected] caroline wilson

The Xenon image on the front cover and within the Xenon article was originally published on the website www.periodictable.com and is reproduced with the permission of the website publishers.

2013 Course Dates Location Organisers8–9 July Brighton(A) Dr Susanne Krone19–20 September Liverpool Dr Steve Roberts29–30 November Nottingham (A) Dr Nigel Bedforth

Faculty will vary depending on location

10% Discount for ESRA members – 15% Discount for RA-UK (FULL) members. Cost: £400 / £500 (A) including a CD with presentations and course notes. Pre-course material can be downloaded once registered on the course – including US physics, anatomy of the brachial / lumbar plexus, current articles of interest and MCQ’s. A pre course questionnaire will be sent 30 days before each course.

ProgrammeDay 1• Ultrasoundappearanceofthenerves•Machinecharacteristicsandset-up•Imagingandneedlingtechniques•Commonapproachestothebrachialplexus/upper/lowerlimb•Workshops–usingphantoms/models/cadavericprosections(A)

Day 2•Consent/trainingandimagestorage•Upper/lowerlimbtechniques•Abdominal/thoracictechniques•Cervicalplexus/spinal/epidural/painprocedures•Workshops–usingphantoms/models/cadavericprosections(A)

(A) – Anatomy based courses / with cadaveric prosections

These courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with SonoSite Ltd for training in ultrasound guided regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.

For further information and to register logon to www.sonositeeducation.co.uk

UltrasoUnd gUided regional anaesthesia – beyond introdUctory

FUJIFILMSonoSite,Inc,.theSonoSitelogoandothertrademarksnotownedbythirdpartiesareregisteredandunregisteredtrademarksofFUJIFILMSonoSite,Inc.invariousjurisdictions.Allothertrademarksarethepropertyoftheirrespectiveowners.

©2013FUJIFILMSonoSite,Inc.Allrightsreserved.163303/13

2013 coUrse dates:

Introductory Ultrasound Guided Regional Anaesthesia16-17 September 25-26 November

Ultrasound Guided Venous Access 23 May 10 October

Ultrasound Guided Critical Care13 June 14 November

All courses qualify for CPD Accreditation.

Venue: SonoSite Education Centre, 240 Butterfield, Great Marlings, Luton, Bedfordshire LU2 8DL

For the full listing of SonoSite training and education courses, dates and to register go to:

www.sonositeeducation.co.uk

SonoSite, the world leader and specialist in hand-carried ultrasound, has teamed up with some of the leading specialists in the medical industry to design a series of courses, for both novice and experienced users, focusing on point-of-care ultrasound.

Introductory Ultrasound Guided Regional Anaesthesia The two-day introductory course is designed to teach those who have little or no experience in the use of ultrasound in their normal daily practice. The course comprises of didactic lectures on the physics of ultrasound, ultrasound anatomy and regional anaesthesia techniques. The lectures and hands-on sessions will concentrate on the brachial plexus, upper and lower limb blocks.

Ultrasound Guided Venous Access This one-day course is aimed at physicians and nurses involved with line placement and comprises didactic lectures, ultrasound of the neck, hands-on training with live models, in-vitro training in ultrasound guided puncture and demonstration of ultrasound guided central venous access. The emphasis is on jugular venous access, but femoral, subclavian and arm vein access will also be discussed.

Ultrasound Guided Critical Care This one-day course is aimed at all critical care physicians and surgeons. The programme is suitable for those who already have some basic ultrasound experience as well as those who are new to the clinical applications of focused ultrasound at the patient bedside. The course is suitable for consultant and middle grade clinicians across the spectrum of specialities (Emergency Medicine, Acute Medicine, Surgery, Paediatrics and Intensive Care Medicine for children or adults).

Fees: £375 (two-day courses) includes VAT, lunch, refreshments and course materials. £260 (one-day courses) includes VAT, lunch, refreshments and course materials.

If you have any questions or should need further information please e-mail: [email protected]

UltrasoUnd training coUrses


Thinking about an

Inter-Deanery Transfer?

Now a centrally managed process

The inter-deanery Transfer (idT) process was set up in 2008, after lobbying by the BMA’s Junior doctors committee, to allow trainees to transfer between UK deaneries part way through their training programme rather than applying through the standard application process for a new post at the desired deanery.

It was designed to permit trainees to move, as a result of a change in circumstances that could not have been reasonably foreseen prior to the acceptance of the original training post. Examples of such changes in circumstance include personal illness, caring responsibilities or relocation of a spouse/partner. The original process was relatively complicated and time consuming, with both releasing and receiving deaneries holding panels to assess all IDT applications and make the decision whether or not to allow a transfer to take place. The information supplied by trainees demonstrating necessity of transfer was often patchy with no obvious clear change in circumstances, making it very difficult to grant the request for transfer, and trainees were often not clear as to what constituted appropriate grounds for transfer. This resulted in a large number of appeals and the need for additional panels reconsidering the original decision in the light of further supporting evidence provided by the trainee. In addition, different deaneries developed their own ‘local’ way of assessing applications to ensure the most in need were transferred first. This was not standardised across the UK and so high priority for one deanery may not have been considered high priority for another.

Eventually, with growing numbers of trainees applying for transfer, the need for each deanery to convene panels to discuss both outgoing and incoming applications and appeals, along with the poor quality of supporting information provided by some applicants, the postgraduate deans decided it was too resource intensive, that they no longer wanted to run an IDT process unless it was updated.

Therefore, in order to enable transfers to continue, the process is now centrally managed by the London Deanery. This means that trainees complete a single application online which will allow them to apply to up to three different deaneries for transfer. As all forms are assessed centrally, all trainees will be treated the same, making the process fairer. The requirements for supporting evidence have been standardised and clearly stated. It is hoped that this will reduce the number of poor quality applications by trainees who perhaps have not fully understood the process. There is also real time computerised management of vacancies – something that was not easily achieveable under the old system – ensuring the number of transfers is optimised.

Unlike the previous IDT process, there is no way to appeal a decision, except where there has been variance from the published processes. Previously, most appeals arose because candidates had not supplied the right information or made their cases within the rules, but the new system makes this almost impossible to do. In addition, the postgraduate deans stated that appeals were not acceptable to them.

There are two windows of application a year in April and October via an online portal managed by the London Deanery. The portal contains comprehensive information regarding transfers, but in brief the significant changes in circumstances considered at IDT are• new personal disability as defined by

the Equality Act 2010 (usually a health condition that has lasted at least 12 months, is either chronic or likely to recur) or

• a significant change to caring responsibilities or

• a significant change to parental responsibilities or

• a significant change to circumstances relating to a committed relationship

Those applicants with a new personal disability are given priority when allocating posts once eligibility for transfer has been confirmed. As under the previous system trainees will not usually be permitted to transfer in the first year of a training programme, or if they have not achieved an outcome 1 at ARCP. In addition, as before, transfer will only be possible for an eligible trainee if a suitable post is available in the receiving deanery. If there is no such post, the trainee may need to apply again in the subsequent transfer window.

Further information is available on the London deanery website at http://www.londondeanery.ac.uk/var/idt and the process will be reviewed on an on-going basis.

dr heidi MounsleyBMA JDC RepresentativeCo-opted GAT Committee Member

Although the primary focuses of the AAGBI’s work in promoting safety, education and research are the care of patients and the wellbeing of the organisation’s members in the United Kingdom and the Republic of Ireland, the AAGBI has a remit that extends well beyond the borders of the British Isles. This broader view of the delivery of safe anaesthetic care manifests itself in the activities of the AAGBI’s International Relations Committee and in our support of charities such as Lifebox (www.lifebox.org) that seek to promote safe patient care in developing countries. We also have strong links with sister organisations in Europe and farther abroad, and as AAGBI President I have regular interactions with the heads of national societies of anaesthesia at meetings of the European Society of Anaesthesiology (ESA) and the World Federation of Societies of Anaesthesiologists (WFSA). I also take part in annual meetings of a body called the Common Issues Group (CIG) – a form of G8 for anaesthesia that could perhaps be called “A6”, as it brings together the leaders of the national anaesthesia societies of the UK, USA, Canada, Australia, New Zealand and South Africa. We met recently in the rain-soaked province of Alberta, Canada, and spent a fascinating day discussing issues of concern to all the countries.

It will come as no surprise to learn that we spent much of our time talking about training and workforce issues. The UK and Ireland are not alone in experiencing problems that relate to public finances, changes in the nature of healthcare delivery, and the eternal problem of matching the number of anaesthetists in training with the demand for trained anaesthetists. With all six presidents being fifty-something years old and with thirty-something years’ experience of medicine, our combined 180 years of experience in six different healthcare systems allowed us to reach a number of conclusions, without perhaps being able to offer quite as many solutions.

Workforce planning is far from being an exact scienceEach country has its own approach to workforce planning, ranging from tight central control of the number of trainees in the whole country, through control that is devolved to geographical subdivisions such as states or provinces, to an open system in which hospitals employ the number of anaesthetic trainees that they want and the country’s Royal College or equivalent structures and validates training. Although the systems differ, the result is the same: rarely does the number of anaesthetists reaching the end of their training match the number of consultant posts available to them. In the relatively recent past, the similar training and easy passage of senior trainees between Commonwealth countries allowed some flexibility if workforce planning was inaccurate. However, the current situation is far from conducive to this exchange of personnel. All the A6 countries, with the possible exception of South Africa, have more anaesthetists coming to the end of training than they need. Put simply, the traditional idea that if the practice of anaesthesia in the UK changes so as to become less attractive, trainees can easily find posts in English-speaking Commonwealth countries is becoming more difficult to put into practice, and is likely soon to become almost impossible. Even in the USA, there is an oversupply of anaesthesia deliverers. I use the slightly awkward phrase “anaesthesia deliverers” because, uniquely amongst the A6 countries, anaesthesia in the USA is not routinely delivered solely by medically qualified anaesthetists. Nurse anesthetists are being trained in ever-increasing numbers, and the historic friction between these two groups is increasing in part because they are competing for employment. The result of the

current workforce mismatches in the six countries is that trainees who might reasonably have expected that on completion of their training they would be able to find the sort of permanent post that they want in the geographical area that they favour are being increasingly disappointed.

Things seem to go in cyclesAll at the meeting were agreed that things in medicine seem to go in cycles. Within their combined medical memories, the Presidents could recall eras in which permanent posts were easy to come by and times in which the competition for desirable jobs was intense. We were agreed that the current situation, even viewed with a long historical perspective, is deteriorating at a faster rate than we could recall, and that the financial pressures on the healthcare systems of some countries blamed on the “Credit Crunch” and its financial sequelae mean that the permanent posts on offer at the end of training are not as well paid as before and that the working conditions are becoming less advantageous.

Times of hardship are also times of flexibility and effortBefore the leaders of the six countries descended into the usual conversation expected of what might politely be described as “senior anaesthetists”, i.e. a series of comments about how tough it was in the past with 1:3 rotas, three-day weekends and 100-hour working weeks, there was agreement that when jobs are in short supply, trainees may have to accept posts that may not be ideal in terms of clinical content and geography – a certain amount of flexibility is needed. In addition, additional effort is important in difficult times in order to maximise opportunities to embellish curricula vitae (CVs) and become as competitive as possible when applying for posts, while maintaining the high quality of the one’s CV even after acquiring a permanent post so that you remain “marketable”, such that if a more attractive permanent post becomes available, you are a serious contender for appointment.

SolutionsIt is undoubtedly the role of those in authority to try to match the number of trainees to the number of permanent posts available to them. The RCoA and CAI are not alone in making strenuous efforts to make workforce calculations that add up, but it is an uphill task that is made ever harder by the increasing rate of medicopolitical change and threats to the nature of medical training. The AAGBI believes that trainees deserve to have access to the right number of suitable permanent posts when they complete their training, and that neither getting stuck in an eternal “Locum Consultant” holding pattern nor being forced to go abroad to seek employment are acceptable. As the main professional representative society in anaesthesia in the UK and Ireland, the AAGBI will continue to work with GAT to support trainees in these troubled times. We are rapidly expanding the opportunities we offer to trainees to enhance their CVs by showcasing their research, audit and case reports in our major national meetings: the GAT Annual Scientific Meeting, WSM London and the AAGBI’s Annual Congress – go to www.aagbi.org for details. If you have suggestions for how the AAGBI can further help trainees, please contact me on [email protected] - we are always listening.

william harrop-GriffithsPresident, AAGBI

President's RepoRtPlus ça change, plus c’est la même chose?


The changing landscape of training dr william harrop-Griffiths, Consultant Anaesthetist

dr Jane harrop-Griffiths, General Practitioner

As usual, dr Mr harrop-Griffiths goes first.

It was a Thursday afternoon much like any other. The sunshine that limped down Praed Street was distinctly hazy: it could have been pollution, burning tallow from the local MacDonald’s, or smoke from the enormous bong in the hands of a local resident outside the Paddington Needle Exchange. In the Resuscitation Room of St Mary’s Hospital A&E Department, three members of the same family were trying hard to die, while a dozen people around each were trying even harder to stop them succeeding. The Resus Room does good business from Oxford Street. Tourists flock there to shop, moving from one side of the road to the other, across what looks exactly like a pedestrian precinct. Only it isn’t. Buses use this road. Eco-buses that move noiselessly, while both saving the planet and taking you to Finchley. They are huge and red. You can’t miss them. Only you can - if you live in a country where cars drive on the wrong side of the road - you simply look the wrong way and find yourself in abrupt physical contact with a 12-ton vehicle moving at 20 mph. It is an unfair fight; the bus always wins.

In Bay 1, the father has a fatal head injury. In Bay 2, his 14-year-old son has rib fractures, a fractured pelvis and is cardiovascularly unstable – something inside is bleeding – a lot. In Bay 3, his 12-year-old sister is “lucky”: she only has bilateral leg fractures. All those around the three victims are working quickly, quietly and together: the Trauma Team Leads, anaesthetists, A&E docs, neurosurgeons, cardiothoracic surgeons, general surgeons, radiologists, paediatrician and nurses.

I went to theatre with the 14-year-old. We were there for three hours fixing a hole in the bowel, a liver laceration and a spleen that looked like someone had stamped on it. He bled a bit but we got him upstairs to the ICU in decent shape. He’ll do. I went down to the department, poured a coffee and put the radio on. There was a news item about plans to transform primary care and divert newly qualified doctors away from hospital specialties and towards general practice. A health minister of a minor but enthusiastic sort said: “By moving more doctors to primary care, we can stop people going to A&E and release pressure on the hospital system, while improving the overall health of the population”. What on God’s earth was this pipsqueak politician prattling about? On which planet exactly will an increase in GP numbers have any effect whatsoever on the number of tourists flattened by a Number 72 on its silent way to Finchley – unless you line up the GPs either side of Oxford Street wearing yellow

tabards and get them to escort tourists across the road. The pubescent politico then said that the numbers training in hospital specialties would be decreased to allow the increase in GP trainees. Brilliant planning: decrease the numbers in exactly the specialties you need if you have a contretemps with a big red one on Oxford Street on a Thursday afternoon. I turned the radio off, fumed impotently for ten minutes and had a shower.

Since then, I have reflected and reached the view that there are perhaps some people whom we could readily lose from hospitals. Remembering the scenes of those around the trauma victims who were using their knowledge, skills and experience to give them a chance of survival, I was able to identify a group that was notably absent: physicians. There were no thoughtful diabetologists there. No cerebral rheumatologists. Not a single immunologist in a bow tie. When the call goes out to tell A&E that the helicopter is bringing yet another unstable stabbing victim, the doors do not swing wide to admit a panting endocrinologist who, as a key member of the Adult Trauma Team, has just sprinted across from clinic. And yet, when the major committees of the hospital

A ‘his and hers’ view

INNOVATIONAAGBI

The Annual AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain

www.aagbi.org/research/innovation

The Association of Anaesthetists of Great Britain and ireland invites applications for the 2014 AAGBi Prize for innovation in Anaesthesia, critical care and Pain. This prize is open to all anaesthetists, intensivists and pain specialists based in Great Britain and ireland. The emphasis is on new ideas contributing to patient safety, high quality clinical care and improvements in the working environment. The entries will be judged by a panel of experts in respective fields.

Applicants should complete the application form that can be found on the AAGBI website www.aagbi.org/research/innovation.

The closing date for applications is Monday 30 September 2013.

Three prizes will be awarded and the winners will be invited to present their work and collect their prizes at the Winter Scientific Meeting in London on 16 January 2014.

8 Anaesthesia News August 2013 • Issue 313

meet to decide matters of import such as management structure, Clinical Excellence Awards or budgets, you cannot move for medics. Unfair fulmination about physicians aside, there may be something in my paranoid ramblings. There are undoubtedly specialists whose work is primarily clinic-based and who do not need lodgings in the hospital, and whose talents could readily be transferred to a primary care environment to the clinical and fiscal benefit of all. However, the transfer of a few physicians will not be enough to allow the Government and the Centre for Workforce Intelligence (CFWI) to achieve their goals. I worry that the reduction in hospital specialty trainees, that will be needed to fuel the expansion of general practice, will be implemented across the board. Those specialties whose activities will not be decreased by the enhancements to primary care, such as acute medical specialties and in particular anaesthesia, will have to share and suffer the consequences, with a reduction in trainee numbers.

Will better primary care decrease the trauma load on hospitals? No. Will it decrease the number of operations performed in the UK for breast cancer? Of course not. What about surgery for fractured neck of femur, peripheral vascular disease, bowel cancer, arthritis… Wait a moment. If the overall health of the population were to increase because of improvements in primary care, perhaps we would see a decrease in the need for surgery and anaesthesia? Greater bone density and falls prevention in the elderly, better diabetic care, better diets and less obesity, better hypertension diagnosis and management… it just might work – after a while.

so here are my current views:

• Moving more doctors to primary care makes sense but do not expect the miracle cures to happen overnight.

• With increasing demands for 24/7 consultant-delivered care in acute specialties, now is not the time to decrease the numbers being trained in anaesthesia, surgery, obstetrics, A&E and acute medicine.

• There are some medical specialties that could readily be moved out of hospitals. Please.

• We must not make the same mistake as Nye Bevan in 1948: we should not convince ourselves that healthcare spending will decrease because substantial changes to the way we manage healthcare will make such a difference to the nation’s health that fewer people will get ill and need NHS services. It didn’t happen then and it won’t happen now.

My final words for trainees in anaesthesia are: DON’T PANIC! The plans for medical graduates in the next few years should not have adverse effects on those in anaesthetics training or those starting their anaesthetics training soon. Even our College would not agree to a substantial decrease in training numbers in order to aid a redirection towards general practice – I hope.

And now dr Mrs harrop-Griffiths:

Doctors’ training must evolve to reflect and accommodate changes in healthcare provision, or the young doctor of tomorrow will not be able to work within the system created. As a result of the White Paper ‘Liberating the NHS’ (2010), changes were set in motion that have radically altered the way we are now look after patients - whether we like it or not. Care is moving towards being community-based, with a seamless patient journey from GP to specialist and back to GP, integrating social care along the way. We are not there yet but we are striving to achieve this, as it seems to be the right thing for patients.

General practice is facing the challenge of an ageing population with increasingly complex co-morbidities. The structural changes that the NHS is undergoing will demand much more from GPs in terms of clinical, managerial and leadership skills. More and more patients will be treated outside hospital, in their homes and in communities. This will demand more GPs with different training, spending longer with their patients. An increase in GP trainee numbers, as confirmed by the CFWI reports, is going to be essential to provide a workface that can manage this workload increase. However, there is debate over where these extra trainees will come from. Initially, it was believed that medical students would be encouraged to take a GP training route rather than a clinical specialist one. However, with the move towards a consultant-led service there will need to be an increase in specialist numbers too. Balancing this need with the delay between students entering medical school and exiting training with CCTs is tricky and is something that successive governments consistently fail to achieve.

There is little debate over the need to increase GP training from three to four years – this is planned for 2014, as are changes in the curriculum to incorporate areas such as leadership, research and teaching. GP training is still largely a one-to-one apprenticeship, which has served us well since the 1950s, and this model of learning is unlikely to change. In fact, it is likely to be expanded to encourage core trainees from other specialties such as medicine, psychiatry and paediatrics to undergo further training in GP to encourage a primary care interest and build upon the recent development of community specialists. This is a move welcomed by current GP trainees, who feel that secondary care colleagues have little understanding of the role of the modern day GP and, as such, fail to understand the importance of communicating the total hospital experience on discharge. The hope is that by having some primary care training, the secondary care specialist will have a better understanding of what is feasible in the community and what is not.

So, life in GP-land is changing rapidly: the GPs of tomorrow will be working in a very different way from the GPs of today. They will have a longer and even broader training, with an increasing requirement for support from specialist community physicians. In a similar vein, the specialist of tomorrow will be working differently, with a greater emphasis on community-based clinics and working with the GP, even sharing facilities.

Where does the anaesthetist fit in? Until now, there has been no indication that trainees in anaesthesia or surgery should even contemplate spending time in primary care. However, would it allow a greater understanding of the needs of the patient after discharge? Would it alter the way pain relief is prescribed? Would it improve the anaesthetist’s communication skills (the 10-minute consultation is the GP’s skill par excellence!)? Would it teach anaesthetists the skill of managing uncertainty?

Perhaps the issue is not whether there should be more doctors becoming GPs, but whether now is the time to look at the nature of specialist training, and ask whether it is appropriate for the changing roles of all doctors – all doctors, that is, apart from anaesthetists (according to my husband).

The landscape is changing.Change can be good. GPs are ready to give it a go.Are you?

The nomination, accompanied by a citation of up to 1000 words, should be sent to the Honorary Secretary at

[email protected] 5pm on Monday 16th September 2013

Evelyn Baker MedalNicola HeardEducational Events Manager

Direct Line: +44 (0) 20 7631 8805

21 Portland Place, London W1B 1PY

T: +44 (0) 20 7631 1650

F: +44 (0) 20 7631 4352

E: [email protected]

w: www.aagbi.org

The Evelyn Baker award was instigated by Dr Margaret Branthwaite in 1998, dedicated to the memory of one of her former patients at the Royal Brompton Hospital. The award is made for outstanding clinical competence, recognising the ‘unsung heroes’ of clinical anaesthesia and related practice. The defining characteristics of clinical competence are deemed to be technical proficiency, consistently reliable clinical judgement and wisdom and skill in communicating with patients, their relatives and colleagues. The ability to train and enthuse trainee colleagues is seen as an integral part of communication skill, extending beyond formal teaching of academic presentation. Nominees should normally still be in clinical practice.

Dr John Cole (Sheffield) was the first winner of the Evelyn Baker medal in 1998, followed by Dr Meena Choksi (Pontypridd) in 1999, Dr Neil Schofield (Oxford) in 2000, Dr Brian Steer (Eastbourne) in 2001, Dr Mark Crosse (Southampton) in 2002, Dr Paul Monks (London) in 2003, Dr Margo Lewis (Birmingham) in 2004, Dr Douglas Turner (Leicester) in 2005, Dr Martin Coates (Plymouth) in 2006, Dr Gareth Charlton (Southampton) in 2007, Dr Neville Robinson (London) in 2008, Dr Fred Roberts (Exeter) in 2009, Dr Sudheer Medakkar (Torquay) in 2010, Dr Keith Clayton (Coventry) in 2011 and Dr John Windsor (London) in 2012.

Nominations are now invited for the award to be presented at WSM London in January 2014 and may be made by any member of the Association to any practising anaesthetist who is also a member of the Association. Examples of successful previous nominations are available on request, and should include an indication that the nominee has broad support within their department.

An award for outstanding clinical competence

Course features: Live theatre link demonstrating techniques of upper limb blocks

Small group workshops on scanning techniques on human models

Practical hands-on training in probe handling and needling techniques on animal models and gel-phantoms

thursday 28 November 2013royal Derby Hospital

We work on the premise “the right block in the right place works every time!”the programme is dedicated to upper limb regional

anaesthesia with an emphasis on practical, hands-on ultrasound training experience.

10th royal Derby Hospital upper Limb regional anaesthesia Course

Course Organisers: Dr Adrian Searle and Dr Zahid SheikhApplication forms and more information from:Course secretary Mrs. Shirley [email protected] tel. 01332 787195Royal Derby Hospital, Anaesthetic Office, Uttoxeter Road, Derby DE22 3NE

G11948/0513

the leading centre in the delivery of awake upper limb regional anaesthesia in the uK presents:

CME approved 5 points

Course fee: £150

Sponsored by:-

G11948-ANAESTHESIA course advert-2013.indd 1 22/5/13 13:11:49

Evidence-based medicine postgraduate course at

Teesside UniversityThe School of Health & Social Care in partnership with experienced clinicians is now offering a new 3-tiered bespoke master’s course for trainees in perioperative medicine, anaesthesia and pain. The flexibility of the course offers you a combination of attendance and distance learning opportunities.

Topics include:• evidence-based medicine • statistics• research methods• quality improvement

Course available as:• PgCert 1 year• PgDip 2 years• MSc 3 years

Find out moreT: 01642 384176 E: [email protected]/health&socialcare

10 Anaesthesia News August 2013 • Issue 313 Anaesthesia News August 2013 • Issue 313 11

had been working there for a year and was conducting a study to show that Xenon and opiate infusions do not cause apoptosis in the neonatal brain – another piece in the jigsaw to prove that Xenon was safe.

I was interviewed and took up post in November 2011. I have taken a break from my clinical training, I was very fortunate to have an OOPE (Out of Program Experience) approved at short notice and in my final year of training. I am registered for a PhD looking at the sedative properties of Xenon in neonates. The Clinical Trial was still undergoing the final stages of approval when I started. Being a trial using a new drug and a new delivery system meant there was a lot of paperwork to complete and have approved by the MHRA (Medicines and Healthcare Products Regulatory Agency). It was interesting to be involved in the final stages of preparation for an RCT. Another Clinical Research Fellow was appointed at the same as me; Elisa, is a final year Neonatology trainee. When I first started in post she was still working clinically on our NICU for one month and I hung out with her for several shifts. I have completed my advanced training in Paediatric Anaesthetics which included three months working on cardiac Intensive Care at Great Ormond Street Hospital , but having never worked on a neonatal unit it was really helpful to attend some delivery room resuscitations and generally get a feel for how a general NICU worked.

We attended a course, “Consent in Paediatric Research” and received training in the study protocol and delivery of Xenon. We were ready to go. I was given the job of registering our trial

I am a final year anaesthetics trainee in East London and have been working as a Clinical Research Fellow at Bristol University for eighteen months. I am employed by a Professor of Neonatology, Marianne Thoresen, who has spent most of her career working to improve the lives of children with cerebral palsy. Her clinical research has made a major contribution to therapeutic cooling becoming standard therapy for full term neonates with perinatal asphyxia.

Approximately five years ago she entered into collaboration with Dr John Dingley, an anaesthetist from Swansea. He had been using the inert gas Xenon in research and knew that neurons in culture exposed to 100% Xenon didn’t die despite a lack of oxygen. Together they showed that inhalation of Xenon, combined with cooling, provided additional neuroprotection to cooling alone in neonatal rats, with an experimental model of hypoxic brain injury. He designed and built a closed breathing circuit which could deliver Xenon to neonatal pigs weighing around 2 kg and further work confirmed that Xenon provided additional neuroprotection to cooling in this large animal model too. This paved the way for the first human baby to receive Xenon in 2010. Fourteen babies received Xenon in this feasibility study; the first received three hours of 25% Xenon, building up to the final four babies receiving 18 hours at 50% - the dose shown to be neuro-protective in the neonatal pig model.

After the feasibility study had proven it was possible and safe to give Xenon to babies, ethical approval was granted for a Randomised Controlled Trial (RCT); CoolXenon2, which is where I come in. I was lucky enough to see Professor Thoresen present the preliminary results of the feasibility study at the Association of Paediatric Anaesthetists annual meeting in Torquay in May 2011. She said she was looking for a Fellow to join her team, so at lunch I introduced myself and was invited to visit her lab in Bristol. I visited in the summer and watched a neonatal pig be sedated, intubated and ventilated, then cooled and administered Xenon via the closed breathing system. The Research Fellow carrying out the experiment

“Beep, beep, beep”, i awake, it’s dark, “beep, beep”, i fumble for the pager on my dressing table, “beep, beep”, press the button to shut it up. i breathe a sigh of relief. i look at the alarm clock screen, “02:55” it shines. My heart sinks, i’m tired; i wish i had gone to bed before midnight. i swing my legs out from under the duvet and sit on the edge of the bed. “Please call NesT urgently”, the pager screen tells me. i remember then that this might be what i have been waiting for; this might be the night when i finally get to deliver Xenon to a baby in an ambulance, a world first…

Xenon anaesthesia becomescool

on the Clinical Trials.gov website and soon after, in May 2012, the trial opened. Our babies are all full term neonates, born in poor condition and resuscitated at birth. Many are born outside of our trust within the Southwest neonatal network. One of us travels with the Newborn Emergency Stabilisation and Transport Team (NEST) as we need to consent the parents. Our protocol is very precise; cooling must have been commenced by three hours of life and 50% Xenon delivery within five hours. This has meant that in some cases we have not made it back to Bristol in time. Dr Dingley

has addressed this by building a version of the system which we can take in the ambulance.

Which brings me back to the “beep, beep, beep” at the beginning of this article. I phoned the NEST and was told a baby had been born in poor condition. We had been called at around one hour of age. I arrived at the base hospital. We were slightly delayed because the transfer team was already with another baby elsewhere and I had to wait for them to come back. It gave me time to get everything ready and double, then triple, then quadruple check it all. I filled a balloon with Xenon, another with the mixture of Xenon, oxygen and air needed to prime the breathing circuit and made sure all the other equipment I needed was ready and in my transfer bag.

We arrived at the referring Trust at around three hours of life and after an initial look at the baby

and confirming that the entry criteria were fulfilled I went to meet the parents. I explained who I was and told them all about the trial. They were immediately keen to consent as they felt it would help the chances for their baby. I emphasized that they should consent only if they wanted to help us answer the question of whether Xenon, added to the cooling therapy, does indeed work as it does in animal models. I told them that the duration of therapy and dose

The world’s first portable Xenon delivery system.



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had been decided from animal models and we do not know it is optimal. I left them alone for ten minutes to read our information sheet, aware that time was ticking on rapidly. They called me back, they wanted to say yes. After signing the consent form they watched me open the envelope; “Xenon + cooling”. I explained to them that 5 hours of life was rapidly approaching and that I had with me a transport system to deliver Xenon. I told them that their baby would be the first baby to use the system.

I returned to the baby’s cot and told the staff and doctors that the parents had consented and that we were randomised to the treatment arm. The babies in our trial need to be intubated with a cuffed endotracheal tube as it is a closed breathing system and the referring doctor quickly organised to re-intubate.

I finished the preparation of the system, filling it with carbon dioxide absorbent, inserting all the gas sensors, attaching a test lung and ensuring there were no leaks. I attached my gas mixture balloon and prepared to purge the circuit. I only had one chance; if there were any leaks the Xenon would be lost and that would be this baby’s opportunity to take part over. I squeezed all the gas in and closed the circuit, keeping my fingers crossed. I watched the Xenon and oxygen concentration settle at 30% and 40% respectively as the ventilator pushed the gas around the system and mixed the gas; perfect.

Then we moved the baby and all monitoring across to the transport incubator, attached them to the Xenon breathing circuit and reached 50% Xenon delivery with only minutes to go before the five hours of age limit.

I have been a trainee in Anaesthetics since 2003 and was an Emergency medicine trainee before that. I sometimes think it’s funny that I have left behind the excitement of trauma and anaesthetics at the Royal London hospital and entered the nerdy bookish world of research. Riding into Bristol in rush hour that morning, delivering the first mobile Xenon anaesthetic, I realised that research can be just as exciting.

dr hannah GillClinical Research Fellow

The “remuneration of doctors and dentists review of compensation levels, incentives, and clinical excellence and distinction award scheme” document proposes a shift towards performance based awards schemes and pay progression. This article attempts to summarise the changes proposed.

Another cost saving exercise, but one which also seeks to recruit, retain and motivate?

BackgroundThe reward scheme has been in existence since 1948. Three quarters of an NHS Consultant’s salary is due to their basic pay. The current basic pay scale has eight pay points in England, Scotland & Northern Ireland. Points 2 to 5 are awarded annually for the first four years in post, points 6 to 8 after each subsequent five years of service, thus taking 19 years for a consultant to reach the maximum pay band. Pay progression is currently dependent on the individual fulfilling their job plan and length of service. In Wales, awards are made on a ‘time served’ basis on top of the basic pay scale.

The secretary of state for health, the right honourable Andrew Lansley CBE, MP, commissioned a UK-wide review of compensation levels, incentives, and of the clinical excellence and distinction award schemes for NHS consultants. The review body on doctors and dentists’ remuneration published their review in December 2012.

Key Observations• Pay Progression - There is a need for an efficient management

system at local hospital level, which assesses consultants on a performance basis for pay progression rather than on length of service.

• Principal Consultant Grade - Experienced high performing consultants should be promoted for undertaking roles within service delivery, expertise or leadership, to Principal Consultant Grade. These consultants will receive a pay rise of 10% on promotion. The number of posts should be decided locally depending on local needs.

Recommendations • Awards - There is a need to have schemes which reward

consultants who work not only towards individual development, but also the progression of the NHS through research, teaching, professional development or developing innovative practise.

• Local Awards - There should be a local transparent, fair and equitable awards scheme, linked to performance appraisals, and given to consultants who excel beyond their job plans. There should be measurable targets linked to the objectives of both the employing organisation and individual. Consultants cannot self nominate. The awards should be non-consolidated and non-pensionable and should be awarded in a competitive

environment, to a small number of consultants who provide excellent contribution to the NHS in that year. There should be regular appraisal of the individuals holding the awards.

• Publish data - The local departments should annually publish data regarding the details of the level of funding available for the local awards and the details of the awards given.

• National Awards - Consultants can self nominate. The awarding body should assess consultants depending on the quality of the online application and individual merits. The awards should be held for a maximum of 5 years, but the length will depend on the impact of the achievements. Consultants can be awarded local and national awards simultaneously. The consultants will need an annual sign-off from the Chief Executive of the employing organisation for the duration that they hold the awards. The awards should not be repeated and should not include a grace period.

• Clinical academics - The contribution done by clinic academics is very important to the progress of medicine, and thus should be remunerated alongside clinical excellence.

• Pensions Issue & Transition - Both local and national awards should be made non-pensionable. The existing awards are no longer pensionable for future services, the transition for which should be done carefully over a suitable period to avoid the existing award holders from retiring early.

• Governance of award scheme- As mentioned before the awards should be carried out with transparency, fairness and equality. To make the process transparent it is important for the national awards committee to be comprised of equal numbers of lay people, clinicians and employers.

• Royal colleges - The work done for the Royal colleges should be appropriately recognised through the award scheme.

ConclusionsThe review body has proposed an integrated package addressing local awards, national awards and changes to the pay scale (progression, and a new principal consultant grade) linked to performance. The aim of the package is to “recruit, retain and motivate consultants” and to make the incentive scheme affordable.

Ulka Paralkar,Elected member of GAT committeeAnaesthetic SpR Guys & St Thomas’ Hospital

This article seeks to summarise the contents of the review document, and does not represent the opinion or commentary of the author.


References: 1. NHS employers. Scoping report on the contract for doctors in training – June 2011.

[online] [accessed 7 April 2013] <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/127309/FINAL-PDF-revised-for-DH.pdf.pdf>

2. Review Body on Doctors’ and Dentists’ Remuneration. Forty-First Report 2013. [online] [accessed 7 April 2013] <http://www.ome.uk.com/DDRB_Reports.aspx>

3. Professor Sir John Temple (Medical Education England). Time for Training: A Review of the impact of the European Working Time Directive on the quality of training – May 2010. [online] [accessed 7 April 2013] <http://www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20Version.pdf>

4. BMA. In depth: Junior and consultant contract proposals. [online] [accessed 14 April 2013] <http://bma.org.uk/news-views-analysis/in-depth-junior-consultant-contracts>

5. Department of Health. Doctors’ contracts fit for 21st century, 12 December 2012. [online] [accessed 14 April 2013] <https://www.gov.uk/government/news/doctors-contracts-fit-for-the-21st-century>

2. Work-life balance

• issUe - The banding system does not reflect well on intensity of work and has resulted in some employers using rigid shift patterns. The level of pay banding depends on a definition of “antisocial hours” but is not related to other aspects of work-life balance and job satisfaction including job stability, continuity of trainer-trainee interaction, and formal training opportunities.

• recoMMeNdATioN - A single contract for trainees so that all trainees have the same fair conditions be they hospital doctor, GP speciality trainee or dental trainee. More support for doctors’ work/life balance, including recommendations that junior doctors are given more notice before moving geographical location for training rotations.

3. Cost

Without sounding too cynical, there is the issue of the £3 billion. Dan Poulter, the Health Minister, has assured the BMA that, although the contract should be “affordable”, cost will not be spared at the expense of adequate training. At a time when junior doctors are seeing more and more cuts (in-hospital accommodation, relocation expenses) it’s hard to be reassured that our current salary is not at risk.

As a result of this publication, a press release by the Department of Health instigated the first move for contract renegotiation by accepting these recommendations for discussion. Current talks with the BMA are underway to clarify some of the above terminology and provide some concrete outcomes. Some initial concerns have already been raised about the non-pensionable nature of the banding supplements and its long-term financial implications. In addition, pay progression, which is currently based on years of service, is at risk of being applicable only to grade.

In our current climate of restructuring with ventures such as the Shape of Training Review, revalidation, and workforce planning all broaching the horizon, this upheaval of contractual agreement seems perilously close to knocking trainees off balance. Talks are imminent, and targets to draw up a new contract approach this coming academic year 2013/2014. Even though the scoping report endorses trainee interests’ at its forefront, it seems sensible to continue voicing our opinions, via the BMA JDC, to ensure that this wave of new reforms, transforming training as we know it, does not undercut us.

elaine Yip,CT2 Anaesthetics South East Scotland Deanery

In December 2012, NHS employers published their long awaited “Scoping report on the contract for doctors in training – June 2011” . Recent media and TV coverage has helped to raise the profile of trainee doctors and the tension between service delivery and training. But are these issues being addressed to benefit both patient care and our welfare?

With the current junior doctors’ contract being over 12 years old, NHS employers have been under some pressure from The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) to rethink this nationally negotiated pay structure. The review takes into account views from the British Medical Association (BMA), BMA Junior Doctors’ Committee (BMA JDC) and the British Dental Association.

HISTORYThe current contract was agreed upon in 2000, in response to concerns regarding junior doctors’ working hours. Its remit was to ensure that all trainees had reduced working hours in adherence with the European Working Time Directive (EWTD now European Working Time Regulations EWTR) originally signed in 1991. This ‘New Deal’ contract aimed to provide financial disincentives for employers relying on junior doctors working long hours. This was achieved by the introduction of a banding system, whereby doctors received banding supplements between 20 to 80% of their basic salary pay in accordance to the number, intensity, and “unsocial nature” of hours and type of working pattern. Those rotas not compliant with the EWTD were paid a supplement of 100%. Employers were forced to comply or face huge salary costs.

WHAT’S CHANGED?The DDRB and NHS employers have now deemed this contract “unfit for purpose”. Why is this and what do they recommend?

1. Training

• issUe - Professor Sir John Temple’s prominent report (Time for Training, May 2010) examines the impact of the EWTR on the ability of the NHS to deliver training within the 48-hour working week. With on-call duties and restricted rota hours, he voiced concern that the high quality training required to complete a CCT in any particular speciality had been compromised. Stating “training is patient safety for the next 30 years” Temple warns that the future of healthcare depends on the quality of tomorrow’s consultants. His report argues for a contract “that will allow clear provision for training requirements, working hours, rest period stipulations and pay banding structures which can be modified to support a 48-hour week and align with the EWTR requirements.”

• recoMMeNdATioN - More flexible working patterns and better training.

Who’s WhoNhs employers (set up in 2004) is part of the NHS confederation, and is the voice of employers advising on workforce issues.

The Nhs confederation is a company and charity, the membership body for all organisations that commission and provide NHS services.

dh – The department of health is a Governmental department. It is no longer involved with day-to-day management of the NHS but gives evidence for the DDRB to review.

ddrB – The review Body on doctors’ and dentists’ remuneration (set up in 1971) is part of the Office of Manpower Economics, an independent public body that makes recommendations to the Department of Health.

Key points of the Report• £3 billion spent on trainee doctors’ salary• Replace banding pay scales• Single contract for all trainees (GP, hospital, or dentist)• Flexibility and support for work/life balance• Greater focus on training

Sign on the dotted line…

School of Medicine

PRIMARY FRCA OSCE/VIVA COURSE

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VENUE: Clinical Education Centre, Leicester Royal Infirmary

FEE: Thursday OSCE £135.00 Friday SOE/VIVA £135.00 Thursday & Friday: £250.00 Lunch/refreshments and car parking (if required) included Please Note: Accommodation is NOT included

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An update on GMc Position statements of relevance to Anaesthesia and intensive care trainees

In November 2012 the General Medical Council (GMC) released two position statements of relevance to both trainees and trainers.

Time out of Training: Implemented 1st April 2013

This position statement provides guidance to Postgraduate Deaneries, Medical Royal Colleges/Faculties, trainees and trainers on the management of absences from training and their affect on a trainee’s Certificate of Completion of Training (CCT) date. The guidance standardises the management of absences across specialties and reflects the move to competency rather than time based training and shorter working hours.

The GMC has determined that within each 12 month training period where a trainee has been absent for a total of 14 days or more (when they should normally have been at work) a review of whether the trainee needs to have their CCT date extended will be triggered. All leave is included (e.g. maternity, paternity, parental, compassionate paid/unpaid, sickness) except study or annual leave and prospectively approved out of programme training/research (OOPT/R). This guidance does not affect a trainee’s right to take leave as necessary but is simply concerned with the effect of the absence on a trainee’s ability to satisfy the competency requirements of their curriculum.

The administration of the absence and any extension to training will be undertaken by the relevant Deanery in consultation with the Royal College of Anaesthetists (RCoA). The GMC supports Deaneries taking a flexible approach to implementation of the guidance to reflect the nature of each absence, the timing and the effect on a trainee’s competence. The GMC also supports the use of targeted training to assist trainees in attaining the necessary competencies without an extension to training. Practically it will mean that ARCP’s occurring a year post implementation will need to include a review of absence.

Until this new guidance was implemented anaesthetic trainees taking maternity leave could be given one period of three months exceptional leave (i.e. three months of maternity leave could be “counted” towards training). It was necessary for the trainee to demonstrate that they had satisfied the requirements of the curriculum and for the exceptional leave to be supported by the Training Programme Director and Regional Advisor. Exceptional leave already agreed will not be removed retrospectively but from the 1st of April 2013 it will no longer be granted. However, as the 2010 anaesthetic training programme is competency rather than time based, some adjustment of CCT date may be possible for any trainee who can demonstrate that he or she has achieved all the curriculum requirements. This would be decided on an individual basis by the ARCP panel and a recommendation made to the RCoA.

For the full position statement go to:http://www.gmc-uk.org/20121130_Time_out_of_Training_GMC_position_statement_Nov_2012.pdf.pdf_50666183.pdf.

Trainees unsure how this might affect them should contact their Head of School or ARCP Lead.

Moving to the Current Curriculum: Implementation to be completed by 31st December 2015

This position statement sets out the GMC’s requirements for all trainees who are working towards a CCT to transfer to the most recent GMC approved curriculum in their specialty by the 31st December 2015. Following a review the GMC concluded that for trainees to stay on the same version of a curriculum for the duration of their training, when it had been superseded by an updated version, was unsatisfactory. In the interests of patient safety and educational quality, all trainees should transfer to the most recent curriculum.

This guidance will ensure that in the future there will only be two approved curricula in each specialty, the “old” one in which trainees in their final year of training will remain and the current one.

The RCoA had an implementation plan for the introduction of the 2010 curriculum and this remains approved by the GMC subject to all trainees being transferred to the current curriculum by the 31st December 2015. On the 1st January 2016 all previous curricula and assessment systems will be decommissioned.

There should therefore be arrangements in place within each School of Anaesthesia to ensure that all trainees will be transferred to the current curriculum within this time frame. The vast majority of trainees will now be following the 2010 curriculum for a CCT in anaesthetics, however if you are a trainee following the 2007 curriculum and are concerned that you may not complete your training before 31st December 2015, then you should speak to your Head of School to arrange transfer to the current curriculum when you would begin your next training year.

To read the full guidance including frequently asked questions go to: http://www.gmc-uk.org/20121130_Moving_to_current_curriculum_GMC_position_statement_Nov_2012.pdf.pdf_50665610.pdf.

dr sarah GibbGAT Vice Chair

Abstracts for presentation at WSM London 2014

CALL FOR ABSTRACTS

You are invited to submit an abstract for poster presentation at WSM London 2014. The deadline for submission is midnight on Monday 16 September 2013 and further instructions and information can be found on our WSM microsite: www.wsmlondon.org

After the deadline, a preliminary review of the abstracts received will determine which ones are accepted for poster presentation.

All accepted abstracts will be published in Anaesthesia in the form of a fully referenceable online supplement (NB Editor-in-Chief reserves the right to refuse publication, e.g. where there are major concerns over ethics and/or content).

Authors of the best poster(s) will be awarded ‘Editors’ Prizes’.

If you have any queries, please contact the AAGBI Secretariat on 020 7631 8807 / 8812 or [email protected]


The CfWI published ‘A strategic review of the future healthcare workforce: Informing medical and dental student intakes’ in December 2012. This report built on the previous one and was underpinned by the CfWI’s robust workforce planning framework and a new model of medical workforce system dynamics. Again the report forecast a significant increase in total doctor numbers, particularly in hospital specialties.

This article describes the CfWI’s approach to medical workforce modelling, summarises its recent work on anaesthetics, and introduces its in-depth review of anaesthetics and intensive care medicine (ICM), which began in June 2013.

The CfWI’s approach to workforce planning

Rather than attempt to predict the future, the CfWI has developed a scenario-based approach that recognises the complexity of factors influencing demand and supply, and the intrinsic uncertainty of the future. This framework is referred to as the robust workforce planning framework. The key benefits of this approach are to support longer-term planning, here looking out to 2040; to support more robust decision making, taking account of the uncertainties of the future; and to help decision-makers be more alert to emerging risks as the future unfolds.

The high-level framework is illustrated in Figure 1. The framework consists of four linked stages, the outputs from each stage feeding into the next. A major feature of the framework is the high degree of stakeholder involvement, which is critical to arrive at a shared view of future challenges, and in making policy decisions.

in february 2012 the centre for workforce intelligence (cfwi) published ‘shape of the Medical workforce: starting the debate on the future consultant workforce’. The report forecast an increase in the number of trained hospital doctors, which would result in an increase in consultant salary costs of approximately one third by 2020. while affordability is an important consideration, the forecast increase does provide opportunities for scenarios such as ‘consultant-present’ services, service redesign or alternative career paths. The cfwi also produced reports for each medical specialty with recommendations for national training numbers (NTNs).

How many doctors? The Centre for Workforce Intelligence approach to medical workforce planning

NEW for 2013! Anaesthesia Cases

Anaesthesia Cases is an on-line, editorially-reviewed, journal of case reports in anaesthesia, pain medicine and intensive care. Users are able to submit and search case reports – a brilliant resource for trainees and consultants!

Submit a case report today www.anaesthesiacases.org

■ Awake craniotomyDr P Farling and Mrs G Trimble, Royal Victoria Hospital

■ Interventional neuroradiologyDr P Flynn, Royal Victoria Hospital

■ Neuro critical careDr B Mullan, Royal Victoria Hospital

■ CPD and revalidationDr L Brennan, Cambridge

■ RA techniquesW Harrop-Griffiths, President, AAGBI

■ Children and consentDr L Brennan, Cambridge

■ Fluid administration in childrenDr S Lamont, Royal Belfast Hospital for Sick Children

■ This house believes that guidelines spell the death of professionalismDr A Harrop, Charing Cross Hospital and Dr W Griffiths, Hammersmith Hospital

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EVENTS

Trainee Presentation CompetitionPlease visit the RCoA Events page for more information (www.rcoa.ac.uk/education-and-eventswww.rcoa.ac.uk/education-and-events)

CPD STUDY DAY, BELFASTDate and venue:2 October 2013The Waterfront Hall, Belfast

Registration fee:£200 (£150 for registered trainees and affiliates)

Event organiser:Dr B Darling

Follow @rcoa_events

Apply:Apply: www.rcoa.ac.uk/eventsContact: 020 7092 1673 [email protected]

an-august.indd 2 06/06/2013 10:53

16th Anaesthesia,Critical Care and Pain Forum

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31 September -3 October2013

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Anaesthesia News is the official newsletter of the Association of Anaesthetists of Great Britain & ireland.

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Medical workforce system dynamics modelling

Due to the complexity of medical career paths the CfWI decided system dynamics modelling was most appropriate. This approach enables complex processes to be represented and complex datasets to be integrated. A graphical representation of the system enables stakeholders who understand the system well to sense-check and validate the model.

Two models were developed, one for the medical workforce and the other for the dental workforce. The models were built using Vensim DSS software and Microsoft Excel. A user interface was developed using Excel to enable team members to more easily use the model and carry out policy analysis. The Steer Davies Gleave Prize for System Dynamics was awarded to the CfWI for its work supporting the Health and Education National Strategic Exchange (HENSE) in 2012. Data availability and quality are crucial to workforce modelling. The majority of professional bodies collect workforce data. However, their requirements for data are sometimes different to the CfWI’s; meaning proxies and assumptions sometimes have to be agreed on as inputs to modelling.

The CfWI modelling team is in the process of developing a medical specialty supply model that will forecast future numbers of certification of completion of training (CCT) holders for any specialty. The model will use system dynamics software suited to the complex flows and delays in medical training. The model will allow the CfWI to test the potential impact on the workforce of changes to trainee numbers, training pathways etc.

Anaesthetics and intensive care medicine

The CfWI reviewed the anaesthetic and intensive care medicine workforces as part of our medical specialty reviews to make recommendations for NTNs in 2011. This report recommended a phased reduction of national training numbers over the next three years. The report was based on the data available at the time, which combined workforce data for both anaesthetics and ICM, and didn’t provide a sufficiently clear picture of each individual specialty. For this and other reasons the CfWI recommended a focused piece of work be undertaken for these specialities.

In response to our ‘Starting the debate on the future consultant workforce’ report the Royal College of Anaesthetists (RCoA) trainee and Group of Anaesthetists in Training (GAT) committees surveyed anaesthetics trainees and anaesthetists within five years of CCT about their career aspirations with reference to CfWI scenarios. The results showed that over 40 per cent of approximately 1800 respondents selected ‘business as usual’ as the most popular future scenario choice. Clearly policy decision-makers will need to be very mindful of workforce aspirations and intentions and manage any policy or structural changes with care. The CfWI applauds the proactive approach of the College and AAGBI in surveying its younger members.

In June 2013 the CfWI began an in-depth review of the anaesthetics and ICM specialty workforces following the robust approach described in this article. To help plan for the review the CfWI has had regular meetings with Richard Bryant (RCoA) and Daniel Waeland (FICM). The CfWI will be consulting with a range of experts across both specialties, so please contact Richard or Daniel at their respective organisations or email [email protected] if interested in contributing to the project.

Mr ian edwards,Senior Analyst, Centre for Workforce Intelligence

stage 1 - horizon scanning

Horizon scanning explores the potential challenges, opportunities and likely future developments that could influence workforce planning. These include technological, economic, environmental, political, social and ethical (TEEPSE) influences on an unfolding future. Some of these influences may be viewed as predetermined, such as an ageing population, and some may be more uncertain, such as technology advances. The horizon scanning can be broad or focused on specific areas. A dedicated web site (http://www.horizonscanning.org.uk) is used to collate a wide range of expert opinions and present key factors. The Joint Action on European Health Workforce Planning and Forecasting three-year programme has officially launched in Brussels. It involves all members of the European Commission’s Working Group on the European Workforce for Health.

The CfWI is leading one of the major work packages, a horizon scanning project focusing on the identification and classification of the various methodologies used to do qualitative health workforce planning across member states. We will work with representatives across Europe to estimate future skill and competencies needed in the health workforce over the next 20 years.

stage 2 – scenario generation

Scenario thinking focuses on how the future might evolve. Scenarios are essential for workforce planning since it is not possible to predict the long-term future accurately. Scenarios are particularly useful since a range of plausible futures can be generated and demand and supply projections made. Workforce plans can then be assessed against the scenarios for robustness. A baseline or ‘business-as-usual’ scenario is included to illustrate what might happen if present trends continue.

Scenarios are based around high-impact and high-uncertainty driving forces, which shape the future. The method used creates plausible stories about the future. These stories capture what might happen in a memorable way. The CfWI uses facilitated workshops to get wide involvement and agreement.

Following the scenario generation, the narrative stories need to be quantified. A unique feature of the framework is the use of a Delphi panel exercise to quantify key workforce variables. For example, in each future scenario will the population’s need for

doctors change and by how much? At what age will doctors retire, on average? Experts make quantitative judgments and share the reasoning behind them over several rounds to decrease uncertainty and refine the values.

stage 3 – workforce modelling

The purpose of workforce modelling is to project demand and supply for a range of plausible futures, as described by the scenarios. The CfWI then conducts further modelling to determine the robustness of policy options for achieving a sustainable balance of demand and supply. System dynamics modelling is used, since it is most appropriate to complex systems with feedback, such as health and social care workforce planning, and can easily be extended or revised to address additional issues as they arise.

The model takes several kinds of input, explained below.• Facts we know include the baseline data to populate the

model, including current training and workforce numbers.• Assumptions we make are predictable trends and assumptions

needed where key data is not available or is of poor quality.• Parameters that we can control define the policy choices

needed to secure adequate supply to meet forecast demand (e.g. student intake, specialty training numbers).

• Uncertainties we can quantify are intrinsically uncertain parameters that may vary by scenario (e.g. future healthcare needs).

• The model is formally tested and documented. The CfWI conducts sensitivity analysis to help understand the impact of changes in data on model outputs, and thus which are the most important for accuracy.

stage 4 – Policy analysis

Policy analysis focuses on analysing future uncertainties and the impact of policy options, and presenting the findings. By considering multiple future scenarios, different options can be tested to see which one is the most robust. There will be some that lead to favourable outcomes across all futures and others where the outcome is less clear. In these situations the relative probability of scenarios may need to be assessed, and scans made for signals that might indicate a particular scenario unfolding. In 2012 we applied our robust workforce planning framework to the future demand for and supply of doctors and dentists for the Health and Education National Strategic Exchange (HENSE) review group. The workforce modelling stage involved developing models to forecast the change in demand and supply for the medical and dental workforces looking ahead to 2040.

The Great Anaesthesia Bake is on in full force. As of June 2013, various hospital departments across the UK & Ireland have raised more than £3000 for Lifebox! This means more pulse oximeters in hospitals worldwide saving thousands of lives. We need more of you to swap the face masks, laryngoscopes and needles for aprons, ovens and mixing bowls and get baking! We hope you take inspiration from the photos of the wonderful cakes that have already been baked.

We’re encouraging all hospital anaesthetic departments to hold a baking sale for staff and patients before 31 August. Please email [email protected] for a fundraising pack or call 0203 286 0402 if you have any questions.

Great Ormond Street Hospital

Colchester General Hospital

University Hospital South Manchester

Great Anaesthesia launch at GAT


The educational reform and what it all means

What’s different?

On the 1st of April the new architecture of the NHS sprang into action. Health Education England (HEE) has been established as one of a number of “arms length” bodies in the NHS, having operated in shadow form since June last year. HEE has a simple purpose, namely to develop the workforce to improve the quality of health and healthcare to the patients and the public of England. It is a national leadership organisation with a central and strategic spine but most of its work will be exercised locally by 13 local education boards (LETBs) whose governing boards are in fact committees of HEE.

LETBs are now designated by their geography e.g. Health Education South London now replaces the term South London LETB.

For the rest of this article, however the term LETB will be used to denote the regional area covered by Health Education England.

figure 1: The education outcomes framework

Why has this happened?

The NHS employs roughly 1.4 million individuals and there is significant investment in education and training. Roughly £5 billion of the NHS budget is spent on education, training and workforce development in England. With the abolition of Strategic Health Authorities (SHAs) and Primary Care Trusts a new organisational structure has been set up to invest in workforce development and education and training for the NHS in England. The education reforms therefore enable a single organisation to be responsible for the entire workforce including medical, non-medical, professional and other staff working in the NHS. In addition, the responsibility stretches to all students and trainees. Thus all the traditional funding levies for education and workforce development will be strategically managed by HEE.

In the current economic challenges facing the NHS, there will clearly be a greater focus on patient experience, quality and safety of care and value for money.

The aspirations for the reform of education and training in the English NHS were set out in the white paper Liberating the NHS: Developing the Healthcare Workforce - From Design to Delivery (DH, 2010), namely to:

• Ensure sufficient numbers of appropriately trained staff (security of supply)

• Ensure the workforce responds to

local patient and population need and respond to changing service models (responds to demand)

• Deliver continuous improvement in the quality of education & training to build competent and capable staff (quality and safety)

• Ensure value for money for educational funding and demonstrate transparency (cost effective)

• Widen participation in order to ensure the workforce is reflective of the population and there are fair and equal opportunities for the NHS workforce to progress through leadership positions (equality and diversity)

Since then the NHS constitution (NHS 2013) has established the “principles and values” of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges what the NHS is committed to achieve. At high level the strategy for education and training must ensure that the following six key values are embedded in staff from the point of recruitment and throughout their working lives:

• Respect and dignity (so that each person is understood and valued whether they are a patient, a carer or a member of staff)

• Commitment to quality of care (including taking accountability and learning from mistakes)

• Compassion (and caring)• Improving lives (including a focus on

health and wellbeing)• Working together for patients (not just

the needs of the organisation)• Everyone counts (community and

population health focus)

The findings of the Francis Inquiry of Mid Staffordshire NHS Foundation Trust (Francis 2013) show that despite these commitments it is possible that the values that matter to patients, families, carers and communities can get lost within the machinery of the NHS.

HEE will be accountable to the Secretary of State who is shortly to publish a Mandate outlining the key strategic priorities for the organisation which is likely to include a greater emphasis on embedding the values of NHS constitution in all staff, a focus on care integration and ensuring the workforce can adapt to the challenges of an increasingly elderly population with multiple morbidities.

HEE will discharge most of its work locally through its 13 regional outposts: LETBs.

How will LETBs work?

From 1 April all 13 LETBs have been authorised through a process that has included an assessment of how they will work and fulfil their aspirations. Key to the design of the LETBs is that they are membership organisations involving providers of service, providers of education, service commissioners, regulatory and governing bodies.

The leadership team of a LETB is small, consisting of an independent chairperson and a small number of “mandated” executive roles including a Managing Director, a Director of Finance and a Director of Education Quality (DEQ). The governing body of a LETB is its board, which has a predominant employer/provider representation. This is important to ensure that investment in education and training is aligned to the needs of the service and supports innovation and the need for wider system reform. Most LETBs will also have a wider council or stakeholder representative forum to include patients, students and trainees, which will inform the LETB executive team and the Board on its strategy.

What about Deaneries?

The functions that used to reside within Deaneries now sit within the LETB. Each LETB will continue to have a Postgraduate Dean who will be the Responsible Officer (RO) for all doctors in postgraduate medical training. Most of the other staff, both clinical and administrative, will now sit within the LETB infrastructure.

What will LETBs do?

In the short term LETBs are managing the transition from the old system to the new system to ensure there is continuity for the essential “business as usual” functions for students, trainees and the professional development of existing staff.

Each LETB will publish a 5 year workforce and skills strategy, as well as develop an investment plan to deliver this. In time it is likely that the landscape for education and training will change to support the workforce transformation required to support new ways of working within the NHS.

Ultimately LETBs will be accountable for delivering against performance indicators derived from the domains within the Educational Outcomes Framework (DH, 2013) as shown in the figure below.

What does the future hold?

There is a growing realisation that, given the demographic changes to the population through ageing and the increasing prevalence of chronic disease, the balance between “reactive” healthcare based on illness should change to more planned, proactive and preventative healthcare.

Increasingly, therefore, there should be a focus on population based healthcare rather than current models of care which are often defined by the institutions. Population based healthcare can be defined as follows (Nuffield Trust 2013):

• A commitment to the health and wellbeing of local populations or communities

• Includes proactive, preventative care for healthy and chronically ill people

• Includes a focus on the distribution of health within populations

• It means proactive care for people attending regularly who are at risk of deteriorating health

• It means thinking about the health of people who have health needs but are not attending or being seen

The workforce development priorities and therefore education and training strategies across LETBs will need to embrace the constructs underpinning population based healthcare.

Embracing the traditional “mantra” of getting the right workforce numbers with the right skills and in the right settings has never been more important. It’s absolutely imperative that training programmes focus on quality and safety, but on forming productive partnerships between staff, learners, and patients.

Ultimately the challenge for LETBs will be to re-design education and training approaches from “single discipline to inter-professional models of practice” (Snowden et al, 2012), that reflect the values of patients and populations.

dr Nav chanaDirector of Education QualityHealth Education South London

References1. Department of Health. Liberating the NHS:

Developing the Healthcare Workforce. From design to delivery; 2010

2. Department of Health. The Education Outcomes Framework; 2013.

3. Francis R. Report into the Mid Staffordshire NHS Foundation Trust Public Enquiry. London: The Stationery Office; 2013

4. NHS. The NHS Constitution; 2013 [accessed 9 May 2013] Available from: www.gov.uk/government/uploads/system/uploads/attachment_data/file/170656/NHS_Constitution.pdf

5. Snowden A, Schnarr K, Hussein A and Alessi C. Measuring What Matters: the cost v values in Health Thorlby R. Reclaiming a population health perspective, future challenges for general practice. Nuffield Trust; 2013


The initiative is sponsored jointly by the Academy of Medical Royal Colleges (AoMRC), Conference of Postgraduate Medical Deans (COPMeD), General Medical Council (GMC), Health Education England (HEE), Medical Schools Council (MSC), NHS Education Scotland (NES), Northern Ireland Medical and Dental Training Agency (NIMDTA) and the Wales Deanery. As can be seen, the Review is UK-wide; the GMC provide the secretariat and policy support.

The Review is chaired by Professor David Greenaway, an economist and the Vice-Chancellor of Nottingham University. The Expert Advisory Group, of which I am a member, provides independent advice to help him identify issues and potential options for change. Members of the Group were selected for their independent expertise and advice rather than as representatives of any particular organisation. The Group meets regularly and spends considerable time discussing the possible impact of any suggested reforms to postgraduate medical education and training on employers, doctors in training and patients.

We are well aware of how our discussions could relate to the work of the Future Hospital Commission led by the Royal College of Physicians and are maintaining close links with it - www.rcplondon.ac.uk/projects/future-hospital-commission. As was suggested by Sir John Tooke, in his review of Modernising Medical Careers, there has been much interest in a more general approach to training. This would allow most trainees to choose one of a small number of broad specialty stems or family of practice, rather than pursuing a narrower specialist career immediately after foundation training; the way this would be funded has yet to be discussed in detail.

Purpose of the Review

Following discussions within Medical Education England, now Health Education England (HEE), and preliminary meetings early in 2011, the Review was convened to consider formally what changes are needed to postgraduate medical training to ensure that it can meet the needs of patients in a changing health service. The Review will focus on postgraduate medical education and training, but include the transition from the Foundation Programme into specialty training, and then on to continuing professional development (CPD). The transition from Sixth Form into Medical School may also be considered.

Timeline of the Review

A final report with recommendations will go to the Sponsoring Board in autumn 2013. The report will set out the rationale behind, and recommendations for, any immediate changes, then changes in the medium term (2-5 years) and longer term (5-10 years plus). It is important that there is clarity on how changes might be implemented during the current training pathways.

Evidence gathering

An open call for written evidence was launched on 8 November 2012 and ran until 8 February 2013; circa 400 responses from groups and individuals were received. There have also been a series of targeted meetings with a wide range of stakeholders in all four countries. These have included discussions with the four Chief Medical Officers (CMOs) and the NHS Confederation.

The Shape of Training Review

A far ranging review of postgraduate medical training is in progress; the results of this endeavour could possibly revolutionise the way doctors are trained, the shape of the future workforce, and affect significantly how healthcare is delivered in the future.

Thurs 12th & Fri 13th September 2013

Crowne Plaza Hotel, Chester

Some of the confirmed topics include :Why we fail

Short & Long Term Effects of Acute Peri-operative PainEmbracing the Enemy within.

How formulation of medicines affect absorbtion & efficacy of analgesicsFentanyl patches in acute pain

Genetics & painQuantitative Sensory Testing (QST)

Paediatric Acute Pain UpdateShort presentations by Poster Competition winners

Acute Pain SIG meeting

Details & Bookings : Registration Fees :

NationalAcute Pain Symposium

23rd

Georgina HallTel : (0151) 522 0259Mob : 07901 717 380

E-mail : [email protected]

Consultants £345NCCG £345SpR & SHO £275Nurses £195

An interesting and varied program with first class speakers

Poster exhibition with 3 cash prizesSee what the innovators are doing around the country

The Nation's premier Acute Pain forumPlenty of interesting content for anyone involved in Acute Pain management

Comprehensive Trade exhibitionHear about & see the new & existing Acute Pain

related products

8 CPD points from the Royal College of Anaesthetists applied for

Informal Delegate Dinner - Brazilian RestaurantA wonderful relaxed and friendly evening.

A favorite amongst those who have attended before

This year's program features an interesting & controvertial debate :

"Chronic pain specialists, not anaesthetists, have the right skills to treat inpatient pain"Hear the pros & cons of this important topic and take part in the discussion


your lettersSEND YOUR LETTERS TO:The Editor, Anaesthesia News at

[email protected]

Please see instructions for authors on the AAGBI website

Seminars have been undertaken with those most involved in education and training as well as trainee and medical student workshops. There are on-going site visits to hospitals and general practices and focused invited oral evidence sessions have been underway since mid-April.

Developing Themes of the Review

As part of the gathering of evidence it proved useful to develop a series of questions.

If more GPs will be needed in the future, should we consider recruitment and selection processes into the various stages of medical education and training? Currently, at least 50% of medical students will need to practise in the community – are they aware of that?

Although all doctors should have grounding and understanding in academic medicine and research should all undertake academic or research work? Where should we position academic training – if any?

Where in training should certification be provided? Can it ever really be a Certificate of Completion of Training (CCT) accepting that education and training is on-going and likely to be life-long?

Should we move to a system of post CCT training in specialty areas with professional support e.g. mentoring of the new consultant while they develop mastery in a specific area? How will this affect SAS doctors; will such a grade be identifiable in the future?

How do we recognise the important contributions of a generalist versus the super specialist? Patients want a named person to look after them, and value continuity of care, but yet everyone wants to see the specialist! Will status for the generalist require monetary incentives? Should we be training specialist generalists who care for the patient throughout their hospital (and possibly into the community – think of the nursing home as an extended geriatric ward) and call in a SOD (single organ doctor) as required and work in partnership with them? Do medical students realise the limited number of training opportunities that will be available in some specialties as service starts to lead workforce planning. The output from a piece of bespoke research looking at international comparisons and experience should soon be available.

If we devise a new structure will there be a need for more mobility within the workforce? How are changes in the shape of training likely to impact on hospital service provision? Will reconfiguration be required? It will be necessary to look at the balance of the workforce between specialists and generalists, the breadth and scope of training options that might support greater flexibility during training and in the workforce, and how to address the tensions between obtaining training and providing service.

The written submissions helped identify information or points of view that will be developed in the oral evidence sessions. To aid this process a number of visual training pathway scenarios have been developed to stimulate debate on training trajectories and outcomes from training and life-long learning.

No matter how training might be reformed, lessons from recent high-profile scandals in the NHS suggest certain aspects are essential. The growing population of elderly patients with multiple co-morbidities means that most doctors will be caring for such patients either in acute or non-acute settings. Training, therefore, should give all doctors the ability to care for such patients and to

be able, in the appropriate specialties, to easily bridge the current divide between hospitals and care in the community, including social care.

It is likely, given the need to train doctors comfortable with providing care in many specialty areas, that there should be a longer period of time before they enter training in any specialty area of expertise they may wish to develop. These specialty training posts are likely to be scarce in certain specialties, and those that start differentiating earlier in their training may find job opportunities limited. Anaesthetists are amongst the groups that will enjoy more security of tenure because they are able to adapt to other areas of working quite readily.

For such a model to work doctors must have flexibility to move between roles and specialties at any point in their career and so the various College and Faculty curricula will undoubtedly need to become looser; much as they were before the rigidity imposed by the former Postgraduate Medical Education Training Board. Training may well become more outcome- and portfolio-based, with doctors able to transfer their competencies as they move through their training. Such doctors, in training or other posts, should have appropriate support and supervision with the intensity of supervision shifting to more indirect support and mentoring as they progress.

It is likely that any new system of training will recognise that doctors learn and perform better when there is continuity in their training by working with specific trainers in a consistent team (possibly a plea for some sort of ‘Firm’ structure?). Rotations will need to be longer and in hospitals where there is enough clinical material and supervision for their specific training needs. With the reduction in trainee numbers imminent in many specialties, and in England the Education Outcomes Framework and commissioning of training, it is expected that not all hospitals or departments within a hospital will have trainees. Those that train doctors must foster learning environments and have the capacity and resources to support training. Doctors need time to learn skills, and practical opportunities to achieve mastery, whilst providing care to patients. Employers must recognise the need for doctors to continue their learning and development throughout their working lives.

How to become involved

If you would like further information on the review, its progress and key discussion areas, then please visit the website - www.shapeoftraining.co.uk.

I would be more than happy to discuss any thoughts you may have so feel free to contact me directly - [email protected].

dr Peter Nightingale FRCA, FRCP, FFICM, FRCP Edin

Dear Editor,

flushed with success.

We would like to report an incident involving an A3 triple-lumen infusion administration device used for total intravenous anaesthesia in a paediatric patient. This device has three extensions; an anti-reflux line for intravenous fluids and two other extensions with anti-siphon valves for propofol and another infusion (usually an opioid).

Prior to use an attempt was made to flush all the lumens of the device, but the green anti-siphon valve was found to be blocked and not functional when we tried to flush it with remifentanil whilst the syringe was in the pump. The other two extensions had been successfully flushed with normal saline and propofol. Fortunately it was possible for us to identify this issue prior to connection to the patient. Following this we disengaged the assembly and flushed each extension again with saline, checking no side clamps had been accidently applied. This simple method identified the blocked valve.

We checked to see if there were any other problems in our institute with this current batch of devices, but none were identified. We contacted the company to investigate if this issue had been previously identified and reported, which wasn’t the case.

The SALG1 and AAGBI have introduced guidelines for checks that should take place so that the incidence of awareness is minimised; these include the use of administration sets containing anti-reflux and anti-siphon valves. However, in spite of these checks and the use of appropriate equipment, error can still potentially lead to mishaps. Thus it is recommended that the lumens of any administration set should be carefully flushed to check all extensions are functional prior to use. This is particularly important with clear solutions, as it may not be immediately apparent that the lumen has failed to flush.

dr c Vaidyanath, ST6 Anaesthetics, Department of Anaesthesia,

Birmingham Children’s Hospital

dr o Bagshaw, Consultant Anaesthetist, Department of Anaesthesia,

Birmingham Children’s Hospital

Reference1. SALG, Guaranteeing drug delivery in total intravenous anaesthesia, October 2009.

functioning anti-siphon valve

Blocked valve

The Preoperative Association2013 National Conference

7th November 2013York Racecourse

York

PREOP2 Poster_Layout 1 14/03/2013 09:59 Page 1

TRAINEEHANDBOOKELEVENTH EDITION

the eleventh edition of the AAGBi trainees handbook will be launched this year

The handbook is moving with the times and this year will be produced as a fully functional on-line resource for the first time.

further information will be available in the summer at:

www.aagbi.org/professionals/trainees


In order to meet demand head on and raise standards, the Norwich Medical School at University of East Anglia (UEA) now offers a Masters degree in Regional Anaesthesia. Underpinned by support from all major UK authorities in the field, including Regional Anaesthesia United Kingdom (RA-UK), the Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the course offers the most rigorous and direct route to formal qualification in RA currently available in the UK, and possibly worldwide.

The MSc in RA has a trusted heritage with it’s pioneering sister course now well into it’s third successful year. Three cohorts of trainees have now undertaken the Master of Surgery in Oncoplastic Breast Surgery (OPBS) course, the first of which are now attributing to the Masters course raised levels of confidence in approaching their first consultant positions. Our Regional Anaesthesia course continues to build and innovate within this exciting learning framework, taking specialist medical education to new heights. We are investing heavily in developing and refining our course to ensure it meets each trainee’s specialist educational needs.

There is a consensus that Modernisation of Medical Careers (MMC) and the European Working Time Directive (EWTD) has had an adverse impact upon UK medical training2. More than 70% of trainees have a perception that the EWTD has or will have

a negative effect on their training and experience. 74% feel less prepared for a consultant post. This has served as an impetus for students to seek additional opportunities and for the UEA to help balance this demand with specialist-training programme.

The Norwich Medical School’s MSc course in RA is a paradigm shift in philosophy and delivery. Utilising problem based learning (PBL); trainees apply a mature learning strategy for reading contextually around - and discussing, in depth, complex real-life scenarios. Trainees are encouraged to drive their own learning, exploiting opportunities to develop procedural skills outside of their own units and accessing up-to-the-minute educational tools and methods – including mobile technologies - to ensure uninterrupted access to the course.

With no equivalent formal UK degree course, the aim of the UEA Mastership programme has been to better prepare, assess and endorse an Anaesthetic trainee for consultant specialist practice with a subspecialty interest in RA. The new consultant needs to be competent as a leader, have an in depth knowledge of audit, service delivery and management in addition to having excellent practical skills in Regional Anaesthesia. Confidence in each of these areas can be gained through fully participating with the RA MSc course.

UK anaesthetic trainees work within a fragmented shift system and, more so now than ever, the “time factor” is their biggest obstacle to professional progression. The MSc format, delivered through a Virtual Learning Environment (VLE) provides 24/7 access to learning, with real-time peer-driven discussion, e-tutor supervision and formative assessment that flexibly caters for varied shift patterns week on week.

The course offers unprecedented flexibility, enabling both students and their tutors to study and deliver the course asynchronously. The VLE serves as a record for each student’s input as well as a central repository for course material, assessment tools, bibliographies, discussions, tutor interaction, news and library access.

Our online learning community approach not only provides structured learning and assessment, but also access to a large specialist faculty, where communication with e-tutors, as well as access to up-to-date literature resources is available continually. This degree course has strived to deliver all the advantages of a modern 21st century training scheme and has been structured to compliment ‘real-world’ professional development.

To meet the needs of the modern Regional Anaesthetist, delivery of theory, practice and transferrable skills can be achieved at different levels. The student may decide to which level they wish to train; from a PGCert upon successful completion of 3 modules, through a PGDip requiring completion of the 6 compulsory Modules and Practical examination, to a Masters level qualification, with successful completion of 6 modules together with dissertation within one year.

For a course to deliver effectively at this level engagement is required by the students. Unlike a traditional course however, participation of around 10 hours per week occurs at any time over the week, day or night at times that best suit the students; waiting to enter theatre, over coffee, at home after a shift, in the morning before work or on a Sunday afternoon. Although each student participates asynchronously, most engagement is not through programmed ‘stand-alone’ e-learning activities or packages. Participation is with the students’ peer-group where the role of the computer is to provide the vehicle for linking trainees together.

35 hours of e-Tutor mediated discussions of case presentations provides the support that students need to stay on track, however,

The MSc in Regional Anaesthesia, a new innovative Training Scheme

UK Anaesthetic trainees have traditionally used the esrA diploma as a route to qualification in the regional Anaesthesia (rA) subspecialty. Until recently, there has been no advanced-level qualification to recognise the training of doctors wishing to specialise in the field, which, given it’s rising popularity amongst trainees1 and increasing demand for out-patient throughput, is overdue.

Optimising Modern RA Training



in traditional PBL style, the MSc avoids a didactic lecture-based approach so our tutors are careful not to direct the discussions, but instead observe and redirect as required.

Students also attend a Training and Theoretical Assessment Day at the end of each module, which introduces the new topics and provides an opportunity for trainees to air problems and ask questions. These sessions are also important in providing time to interact face-to-face with their fellow students and tutors and for tutors to get a visual ‘feel’ for the cohort they will be teaching.

In addition to direct engagement with the VLE, students are required to have regular assessments of practical skills in the form of DOPS assessments with their chosen local Educational Supervisors. RA-UK’s commitment to this programme ensures that the UEA is able to provide the infrastructure to deliver the “Practical Training Arm”. Students are expected to develop ‘Practical Portfolios’ within their specific regions in the UK. Local Educational Supervisors and Regional Assessors provide the support and mediation, should any student fall short on their DOPS assessments.

Assessment is a key component of the MSc RA course and takes place throughout each module with a suite of formative assessment tasks. At the end of each module, a summative assessment take place at the AAGBI comprising of MCQ and EMQ style questions relating to the module topics covered. The University’s stringent assessment criteria require all students to achieve a minimum level of online participation – measured by registration of their posting within the forums. These formative tests provide students with a means to measure their own progress at the end of each topic block. Whilst depth of knowledge can be appraised by the formative MEQ and MCQ, this is supplemented by appraisal of clinical application of this knowledge by use of the Script Concordance Test.3

Assessment of clinical and communication skills takes place at the end of 2 years (or 6 completed modules) at the OSCE examination. Student examinations include critical analysis of portfolios and reflective diaries for the Practical Arm where students are required to pass the required DOPS evaluations for upper and lower limb blocks.

This e-learning/practical skills course has strong support from an experienced and motivated faculty of tutors recruited by the University of East Anglia, RA-UK, the AAGBI and the RCoA.

The education programme is very much aligned with the future direction of education and training strategy of the key stakeholders. This model of training has caught the imagination of clinical educationalists in other specialities and currently the Mastership programmes cover Oncoplastic Breast Surgery (in its 3rd year), Coloproctology, Orthopaedics and Hepatobiliary. In addition, this UK initiative has stimulated interest from European and Asian institutions leading to invitations to develop collaborative e-learning programmes in a number of countries and specialties.

Feedback has been encouraging, suggesting that new initiatives such as this are welcomed by trainees and by their faculty. Trainees seeking consultant positions value the opportunity to be formally qualified in the field and that the qualification represents increased opportunities for skills-development, in-depth exploration of relevant topics, and exposure to current literature and evidence-driven debate within the forums. Trainees leave the course having considered complex cases in depth whilst developing critical reasoning skills and overall knowledge. Faculty also benefit from their involvement with the course. Curriculum design, literature review, mentoring and e-tutoring within forums helps to promote continuing professional development within the field of RA as well as providing networking links within the sub-speciality.

drs stef oosthuysen, James stimpson, Mike hudspith and Nat haslamConsultant Anaesthetists

Mr Andrew simpson Chief web designer and e-learning technologist

References1. Group of Anaesthetists in Training. The GAT Handbook 2011-2012: Regional

section [accessed 15 April 2013]. Available from: http://www.aagbi.org/sites/default/files/AAGBI_GAT_handbook_2011revised.pdf

2. Medical Education England. Impact of the European Working Time Directive on the Quality of Training: Literature Review; 2010 [accessed 15 April 2013]. Available from: http://www.mee.nhs.uk/pdf/LiteratureReviewFINAL.pdf

3. Charlin B, Roy L, Brailovsky C, Goulet F, Van Der Vleuten C. The Script Concordance Test, a tool to assess the reflective physician. Teaching Learning in Medicine: An International Journal. 2000; 12(4): 189-195

for more information on the Msc in regional Anaesthesia and how to apply, please visit: www.uea.ac.uk/med/course/PGT/obs/howtoapply

August 2013

Digested Intra-operative monitoring – many alarms with minor impact.de Man FR, Greuters S, Boer C, Veerman DP, Loer SA.

Alarms are still a problem!Edworthy J.

“By 2017, no individuals will be harmed by adverse alarm events.”

Spinal haematoma after removal of a thoracic epidural catheter in a patient with coagulopathy resulting from unexpected vitamin K deficiency. Ladha A, Alam A, Idestrup C, Sawyer J, Choi S.

As clinicians we all know that alarms are an annoyingly imperfect part of theatre life. de Man et al., observing intermediate surgery, found a median one alarm per three minutes during anaesthesia maintenance and one per minute during induction and emergence; only 5% of alarms required immediate clinical action, whereas two thirds were irrelevant. But even so, alarms must be a ‘good thing’, mustn’t they? The thought provoking editorial that accompanies de Man et al.’s study by Professor Edworthy suggests that we need to delve more deeply into this assumption – as evidenced by the quotation above that she cites from the U.S. Association for the Advancement of Medical Instrumentation, who list alarms as one of the top ten patient safety hazards! There are problems related to failure of alarms to do their job of alerting the clinician to a threatening situation. More interestingly is the phenomenon of alarm fatigue, when false alarms lead to the clinician ignoring both false and true alarms (the classic ‘cry wolf ’ story), and alarm competition, when loud high pitched alarms compete and are difficult to localise.

There is a plethora of research in the area. Acoustic quality of alarms can be improved to aid spatial localisation of the source. Alarm delays and limits can be juggled, although there is a risk that false alarms are reduced at the expense of delayed detection of true physiological derangement. Improved instrumentation (and attention to the alarm-patient interface) can improve signal:noise

ratios. There are also published standards, although Professor Edworthy suggests that these are not wholly debate-free. In particular, the International Electrotechnical Commission specifies melodies to be used for particular alarm types, but melodies are difficult to learn.

Is there a solution? A large part of this lies in the hands of the manufacturers. Alarms can carry information as well as providing an alert. For instance, an elegant simulator-based research study showed that arterial oxygen desaturation was discovered quicker with a variable tone to the pulse signal compared to a fixed tone (Craven & McIndoe. Br J Anaesth 1999;83:747). But clinicians must also be prepared to work with what they currently have. Knowing the system defaults or actively programming limits, rather than just switching off ‘the noise’ is highly desirable. And the opposite approach of leaving audible alarms sounding may be tolerated by some clinicians, but at the likely expense of distracting other members of the team.

Declaration of interests: I became hypersensitised to ventilator alarms as an ITU Registrar, when the on-call room was sited above the Unit and regular prolonged tracheal suctioning was performed by the nurses without switching off the full-volume disconnect alarms.

These authors describe a frightening case of a healthy woman who had a laparotomy for removal of gastric tumour with a T7/T8 epidural for post-operative analgesia. The catheter was removed on the fifth post-operative day, 23 hours after a dose of enoxaparin and three hours before the next dose. The day after catheter removal she developed rapid-onset back pain progressing to paraplegia. MRI showed an extramedullary space occupying lesion. Her INR

was 2.54 and PTT 48.6 s. Surgical decompression was performed expeditiously and fortunately she had almost complete neurological recovery one year afterwards. The only risk factors for vitamin K deficiency that the authors could identify were possible mild nutritional deficiency together with the pre-operative antibiotics. What would the professional outcome have been if the authors had bent the rules as we often have to do?

M.Kinsella, Editor, Anaesthesia

Par

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David Blumenthal, Jennifer Dixon

health-care reforms in the UsA and england: areas for useful learning Lancet (2012); 380:1352–57

introductionBoth the UK and the USA, despite apparently very different systems, have an urgent need to control healthcare expenditure whilst improving quality. The authors explore similarities between the systems and suggest ways in which these countries could learn from each other’s experiences.

financial MeasuresIn the US there is no binding overall budget for federal spending on healthcare, leaving authorities legally obliged to pay all costs of eligible beneficiaries. Independent bodies model trends in expenditure and advise on a sustainable growth rate formula for predicting prospective payments.

In contrast, the UK has no independent body to model projected costs and calculations behind quoted figures are far from transparent. The Department of Health and the Treasury agree an upper limit of total NHS expenditure as part of 3-year spending reviews. Consequently services are cut when resources are scarce, with a risk of overt rationing in the long term.

Prospective payment systems have long been in use in the US, and recently introduced in the UK (national tariffs). Both countries are now considering bundled payments to cover pre-admission and post-discharge services as well as inpatient care. Value-based purchasing initiatives to reward better care and penalise poor performance feature in the payment reforms of both systems.

Provider-led accountable care organisations in the US will share in both the savings and losses achieved in delivering care, while planned reforms in the UK under the Health and Social Care Act1 will see primary care providers commission community and many acute services on a basis of quality and efficiency.

organisationThe elimination of Primary Care Trusts and Strategic Health Authorities in 2013 will pave the way for a central commissioning board to advise and supervise clinical commissioning groups in the UK. The reformed regulator, Monitor, will be responsible for tackling anticompetitive behaviour and setting national tariffs for inpatient care.

In the US the new Payment Advisory Board and Center for Medicare and Medicaid Innovation are intended respectively to report to congress on containment of costs within set limits and to identify and assess new models of care and payment innovation to provide higher quality at lower cost. A greater focus on primary care is planned, recognising the benefits of the UK’s long term emphasis on community-based services.

information TechnologyElectronic records have been in use in UK primary care for some time, yet hospital systems and integration between inpatient and outpatient records have been slow to emerge. The nature of the NHS provides a unique opportunity to collect almost whole-population data. This should be used to introduce national standards, link data from multiple sources and develop clinical outcome measures against which the NHS could be held accountable.

The HITECH Act2 to digitise US health information is intended to encourage exchange of information including sharing it with patients.

conclusionSimilar initiatives are being introduced in both countries to address ever-increasing healthcare costs in a time of national austerity. Developed nations should share experience with respect to interventions made to improve cost-effectiveness.

dr Joanne smith,ST6 Anaesthetics,

Northern School of Anaesthesia

References1. Department of Health. Health and Social Care Bill 2011. January, 2012.

http://www.dh.gov.uk/health/2012/06/act-explained/(accessed Sept 7,2012).

2. Blumenthal D. Launching HITECH. N Engl J Med 2010;362: 382–85.

The effect of the european working Time directive on anaesthetic working patterns and training

Paul RG, Bunker N, Fauvel NJ & Cox M (2012) Anaesthesia 67 pp 951–956

This study analysed rotas from corresponding 6 month periods of 1999 and 2009 to assess what impact the European Working Time Directive (EWTD) has had on training opportunities for trainees within numbered training posts at a single site. Previous work has demonstrated a perception that training had suffered as a result of the EWTD.

For a 6-month period in 1999 theatre activity was recorded as part of a separate project. This data was compared against an identical 6-month period from 2009. Importantly, both these data sets represented actual work, rather than the published rota, as the authors make the point that when boots are short on the ground, it is usually training time that suffers. All obstetric work was included in the study but both ICU and out of hours work were excluded.

The work demonstrates a 52% increase in total number of theatre sessions and an associated 60-70% increase in all grades of staff. It is unclear if this represents absolute numbers or whole-time equivalents.

There was significantly reduced number of ‘study leave’ days or ‘off’ days for the core trainee group (ST1-2) in 2009 compared to 1999. There were significant reductions in ‘solo’ lists for all trainees and a significant increase in the number of training lists for ST1-2, although not for ST3-7 in 2009 compared to 1999. There has been an overall reduction of 27% in the number of theatre sessions for ST3-7 but this has come out of solo rather than supervised lists.

The authors acknowledge that out of hours (OOH) commitments for ST1-2 trainees have changed, thus freeing them up for more day work.

The overall conclusion is that the EWTD has not adversely impacted on supervised training time.

The work is a useful addition to the debate around EWTD in that it is not based on perceptions from cross sectional surveys, rather it is a quantitative analysis of training time.

However, the work assesses only the time spent supervised, not whether the supervision is useful training. A supervised knee arthroscopy list may be very useful to an ST1, less so to an ST7. The authors also acknowledge that there is a debate around whether solo time is potentially very useful for senior trainees. Immediately supervised practice is but one facet of a multitude of prerequisites for thorough training.

dr Thomas duncan, ST6 Anaesthesia,

Oxford Deanery

dr Nicholas love, ST6 Anaesthesia & Intensive Care Medicine,

Oxford Deanery

Sutton M, Nikolova S, Boaden R, Lester H, McDonald R and Roland M

reduced Mortality with hospital Pay for Performance in england New England Journal of Medicine 2012;367:1821-8

The trend in modern healthcare towards pay-for-performance exists despite little evidence to support it1. The Advancing Quality programme was the first of its type to be undertaken in England. Undertaken in all North West National Health Service hospitals this provided an opportunity to compare outcomes to the rest of England.

The Advancing Quality programme required quality measures across 5 clinical areas: acute myocardial infarction, coronary artery bypass grafting (CABG), heart failure, hip and knee surgery, and pneumonia. Hospitals with quality scores in the top and second quartile received financial rewards in the first year. In the following 6 months level of achievement and the increase in achievements were also rewarded.

MethodRetrospective data was examined from national Hospital Episode Statistics2 over the 18 months prior to introduction and the 18 months of operation. At this point a national programme withholding payments was introduced.

30 day mortality of 3 of the 5 clinical areas were examined: acute myocardial infarction, heart failure and pneumonia. CABG (low number of hospitals performing procedure) and hip and knee surgery (elective mortality under 1%) were excluded. Six unrelated diagnoses that were not part of the programme were examined to provide a control group. In the statistical analysis effect on mortality was examined through pre and post introduction mortality with a series of difference in difference analyses.

resultsThe study sample included 410,384 pneumonia, 201,003 heart failure and 245,187 acute myocardial infarction patients while 241,009 had conditions not in the programme.

The risk adjusted mortality decreased for all conditions during the study period. Conditions not in the programme showed a similar reduction in mortality in both geographical groups. For conditions in the programme there was a statistically significant decrease in the North West compared to the rest of England (-1.8% versus –0.9%). In individual conditions there was a greater reduction in mortality in the North West. However, pneumonia (P<0.001) was the only significant reduction, heart failure (P=0.30) and acute myocardial infarction (P=0.23) were not.

discussionThe authors found a statistically significant decrease in mortality within a pay-for-performance programme. Geographical location allowing regular face to face meetings of hospitals taking part was highlighted as one potential explanation. Large bonuses may have explained substantial investments in specialist nurses and systems such as improved data collection and feedback. The global inclusion of all hospitals in one area also prevented self-selection of high achieving hospitals. The possibility of a substantial effect on mortality cannot be excluded and further research on implementation is required. The discussion did not further explore why only one condition showed a significant reduction in mortality.

References1. Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An

overview of reviews evaluating the effectiveness of financial incentives in changing health care professional behaviours and patient outcomes. Cochrane Database Syst Rev 2011;7:CD009255

2. Hospital Episode Statistics home page (http://www.hesonline.nhs.uk)

dr sam Burnside, ST6 Northern Deanery


it’s That Time Again! calling all talented anaesthetists!As we have discovered during the history of the Annual Congress Charity Art Exhibition, anaesthetists are really creative folk and many of us pursue hobbies that result in fantastic art, photography or other craft. If this applies to you or one of your family, or you know someone in your department who is creative, then why not come and share your work with delegates at our Annual Congress in Dublin. Not only does it make you feel great to have your work appreciated, it is all in aid of two very good causes.

The AAGBI Overseas Anaesthesia Fund (OAF)

The OAF was set up in 2006 by the International Relations Committee (IRC) to enable members to donate directly to the provision of assistance for anaesthetists in the developing world. This includes financial contributions to travel expenses for members undertaking teaching and funding for Primary Trauma Care courses in six African countries to improve survival rates in young adults. The fund also provides educational material in the form of CD-ROMs, books and journals to 50 different countries.

Year on year, the AAGBI provides financial support and the OAF exists to help do more.

The Royal Medical Benevolent Fund (RMBF)

The Royal Medical Benevolent Fund offers help to colleagues and their families in need. Widows, orphans and families can benefit from financial support and/or specialist advice. Not only the elderly or very young occasionally need a helping hand, young doctors and their families can be vulnerable in the first few years of NHS practice, particularly if they have been working for relief agencies in the Third World. They have little to fall back on if they are unable to work due to chronic illness or accident. The RMBF is particularly good at offering practical help designed to get colleagues or family back on their feet whenever possible, enabling them to retain their independence. The Fund also provides support for refugee doctors retraining to practise medicine in the UK.

Last year, in Bournemouth, the AAGBI Art Exhibition raised just under £1000 for these two charities, by means of sale of donated exhibits, greetings cards, and a prize raffle.

Please help us continue that success. You can post your work to the venue in Dublin if you are unable to attend or bring it yourself at the beginning of Congress. It would greatly assist us if you register your work in advance, regardless of transport method as it will enable us to plan the exhibition and provide a catalogue of contributors for visitors’ use during the exhibition. You are also more likely to get a plum site for your exhibits if you are registered in advance! A registration form can be found on the Annual Congress website explaining everything - www.annualcongress.org/content/social-events.

In recent years the exhibition has been extended to include all manner of art and craft other than the mainstay painting and photography. We have had jewellery, needlework, knitting, beading, sculpture, pots - there seems to be no end to the creativity of anaesthetists and their families!

Please come along and support the Art Exhibition in Dublin in September. You can do this in so many ways. You can:

• Contribute by exhibiting some of your art or craft • Donate for sale any you can bear to part with• Buy a stunning work of art created by a colleague for a

fraction of the market cost• Vote for your favourite – prizes awarded at the end of

conference• Buy lots of raffle tickets in a prize draw for two very good

causes• Buy beautiful greetings cards• Just simply visit and enjoy the talents of your colleagues

This year in Dublin, set in a land of beautiful scenery and a culture of world class art and craft, we are relying a great deal on local contributions since transport across the Irish Sea might prove more limiting for contributors who have to travel by air.

The Scots were magnificent in Edinburgh 2011. Undoubtedly the Irish can give them a good run for their money!

And for those flying to Dublin: please try and find a small space in your luggage for something special.

come on! Get cracking and join in! You’ll enjoy yourselves, we promise!

stephanie Greenwell and di dickson

DUBLIN

To sign up, view the scientific programme or explore sponsorship & exhibition opportunities visit:www.annualcongress.org

Book your places for the AAGBI Annual Congress at the

Convention Centre Dublin, Ireland’s new world class, purpose-

built international conference and event venue, situated only 20

minutes from the airport. Indulge yourself in the programme we

have lined up for you, network with anaesthetists and industry

representatives and take this opportunity to enjoy the history

and culture of Dublin at the same time! Annual Congress Dinner & DanceThe much anticipated AAGBI Annual Dinner and Dance will be held in the historic and impressive Guinness Storehouse, a seven storied building which brings to life the history of the famous Guinness brand.

Keynote Lectures: Perioperative risk and testing – Is it worth it or should we assume the worst? Prof Mike Irwin, Hong Kong Long term perioperative outcomesProf Dan Sessler, Cleveland, USA

Plus many more informative talks, workshops

& interactive sessions

ANews_AC2013.indd 1 30/05/2013 13:52

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