No decision about me, without me

November 27th, 2011

The slogan, ‘No decision about me, without me’, was originally a demand formulated by the emerging patient movement. The current government adopted the ‘no decision’ slogan in its 2010 White Paper, Equity and Excellence: Liberating the NHS

The government wants to place patients’ needs, wishes and preferences at the heart of clinical decision-making.

Why shared decision-making is important?

  • Shared decision-making is viewed as an ethical imperative by the professional regulatory bodies which expect clinicians to work in partnership with patients, informing and involving them whenever possible.
  • There is also compelling evidence that patients who are active participants in managing their health and health care have better outcomes than patients who are passive recipients of care.
  • Shared decision-making is also important for commissioners because it reduces unwarranted variation in clinical practice. Shared decision-making is the principal mechanism for ensuring that patients get the care they need and is the essential underpinning for truly patient-centred care delivery.

Making shared decision-making a reality: No decision about me, without me aims to clarify shared decision-making and what skills and resources are required to implement it and it also outlines what action is needed to make this vision a reality.

The principle of shared decision-making in the context of a clinical consultation is that it should:

  • support patients to articulate their understanding of their condition and of what they hope treatment (or self-management support) will achieve
  • inform patients about their condition, about the treatment or support options available, and about the benefits and risks of each
  • ensure that patients and clinicians arrive at a decision based on mutual understanding of this information
  • Record and implement the decision reached.

The paper outlines the importance of communication skills and sets out how clinicians might approach consultations to arrive at shared decisions. It also suggests that tools that help patients in making decisions are just as important as guidelines for clinicians. In fact, the government officially launched a set of innovative online tools that can help patients make informed decisions about their healthcare.

Health and Social Care Bill 2011

April 17th, 2011

Health and Social Care Bill 2011

The Health and Social Care Bill was introduced into Parliament on 19 January 2011. The Bill took forward the areas of Equity and Excellence: Liberating the NHS (July 2010) and the subsequent Government response Liberating the NHS: legislative framework and next steps (December 2010), which required primary legislation.

The Health and social care Bill proposed to implement a radical reorganisation of the NHS which aimed to devolve responsibility to clinicians, cut management costs, and reduce political involvement in the health system. The Bill was criticised for a number of reasons. The 3-month “listening exercise”, delaying progress of the bill through Parliament, was launched in April 2011 in response to widespread concerns about the impact of the bill. A NHS Future Forum was set up to lead the exercise.  The government presented a revised bill in the parliament based on the NHS future forum recommendations. The Bill went through the Commons in Sep 2011 and is currently in the Lords.

The original Bill presented in Parliament on 19th Jan 2011 contained provisions covering the following key themes:

  • Establish an independent NHS Commissioning Board responsible for the operational management of NHS (i.e. allocate resources and provide commissioning guidance). However, the Secretary of State would still account to parliament for the performance of the NHS and the Bill included wide-ranging powers for him/her to intervene in the system.
  • Increasing GPs’ powers to commission services on behalf of their patients. This involves giving groups of GP practices – GP consortia – ‘real’ budgets to buy care on behalf of their local communities from ‘any willing provider’. This was aimed to improve clinical involvement in commissioning and addresses the current weakness in the commissioning arrangements, with PCTs lacking the knowledge and skills to challenge providers about the quality and efficiency of their services.
  • Developing Monitor, the body that currently regulates NHS foundation trusts, into an economic regulator with three key functions: promoting competition, setting prices, and ensuring continuity of essential services.  The Bill gave Monitor wide-ranging powers to impose licence conditions to prevent anti-competitive behaviour, apply sanctions to enforce competition law and refer malfunctioning markets to the Competition Commission. This mirrored the approach taken in the utility sector and aimed to open up the NHS to challenge by the Office of Fair Trading and the Competition Commission.
  • Cutting the number of health bodies to help meet the Government’s commitment to cut NHS administration costs by a third, including abolishing Primary Care Trusts and Strategic Health Authorities.
  • Ensuring all NHS trusts achieve foundation trust status by April 2014
  • Extending the role of local authorities in the health system by creating Health and Wellbeing Boards (HWBs) and giving them responsibility for public health. The aim was to strengthen democratic legitimacy and ensure that commissioning is joined up across the NHS, social care and public health. HWBs will be responsible for producing joint strategic needs assessments and developing a joint health and well-being strategy for their local area. The core members of HWBs will be GP consortia, the Director of Adult Social Services, Director of Children’s Services, Director of Public Heath, and the local Health Watch.

The Bill was criticised because of the following:

  1. The primary criticism was about the bill’s intention to amend one of the founding pillars of the NHS to read “any willing provider” rather than the current language guaranteeing a needed service exclusively via the NHS and its direct affiliates and partners. These critics noted that the NHS is not allowed to have any bias based on profit or competition; rather it is committed by law exclusively to medical objectivity and patient care, and the changing of the language of the NHS tenets to include “any willing provider” is thinly-veiled code to allow the private sector inside the NHS, disrupting its inner workings or even potentially opening up local NHS operations to the possibility of forced closure because the private industry has out-competed them and corralled them into bankruptcy.

Summary: The Bill signalled a significant shift towards a more competitive market for health care. While increased competition need to be supported in areas where it demonstrates benefits to patients, the Bill appeared to move towards promoting competition at the expense of collaboration and integration

2. GP-led commissioning (GP consortia) was as an opportunity to improve patient care. However, there was considerable disparity in the capability of local health economies to take on the commissioning role and hence the deadline of April 2013 for GP consortia to be established was felt to be too tight. The winding down of primary care trusts (PCTs) and strategic health authorities (SHAs) without providing time for GP consortia to be established caused anxieties regarding services failing or patient care suffering.

Further, the Bill included few requirements on the governance of consortia. The critics pointed out that the consortia governance structure should be clarified to include a wide range of health professionals (including hospitals specialists) and involve the public in their work.

3. The critics also opposed that all NHS trusts should be forced to become foundation trusts by 1 April 2014, given the unacceptable outcomes that have resulted in a small number of cases where the financial imperatives required to achieve FT status have been pursued at the expense of good-quality patient care . It was feared that intensifying the pressure to achieve foundation trust status may lead to distorted priorities and drive trusts to place the achievement of this target above all others, including safe patient care.

4. Bill gave health and wellbeing boards insufficient powers to fulfil their remit in joining up local commissioning.

Revised Bill addressed a number of issues in the original bill and is currently in the Lords. The Government hopes that the Bill will be passed in the Lords and would go for Royal assent before the end of 2011

Key changes in the revised Bill:

  1. Competition: There is emphasis now on integration rather than competition with Monitor’s powers now focused on preventing anti-competitive behaviour rather than promoting competition. The Bill signals a more nuanced approach to competition by ruling out competition on price (evidence suggests that price competition reduces quality and increases transaction costs) and a commitment to phase in ‘any qualified provider’ from April 2012 (this should reduce the risk of fragmentation of services).

2. Commissioning: Wider clinical involvement in commissioning, strengthen governance arrangements for local commissioning groups and adopt a more flexible approach to implementing clinical commissioning.

GP consortia will be re-named clinical commissioning groups and will be required to obtain a wide range of clinical advice and consult a number of bodies in developing their commissioning plans. Existing clinical networks (groups of experts working in specialist areas such as cancer) will be strengthened and new clinical senates established to bring together a wide range of health and social care professionals.

Changes made to the governance of clinical commissioning groups: Clinical commissioning groups will also be required to include a nurse and a hospital specialist on their governing body besides two lay members (one to champion patient and public involvement and one to lead on governance).

The April 2013 deadline for establishing GP consortia has been relaxed – clinical commissioning groups will be established either in full or in shadow form by this date, but take on their new responsibilities only when they are ready and willing to do so.

3. The government has relaxed the April 2014 deadline for the remaining NHS trusts to become foundation trusts, although it stresses that the majority will still be expected to meet this deadline.

4. The role of health and wellbeing boards has been strengthened in a number of ways. They will be given a stronger role in the development of local commissioning plans, more responsibility for promoting joint commissioning and health and social care integration, and a lead role in local public involvement. They will also be able to refer commissioning plans back to clinical commissioning groups or the NHS Commissioning Board if they are not satisfied it takes proper account of the local health and wellbeing strategy.

CfWI ‘Recommendation for medical specialty training 2011’ report.

April 16th, 2011

CfWI ‘Recommendation for medical specialty training 2011’ report.

The Centre for Workforce Intelligence (CfWI) has carried out a piece of work to analyse and inform on the numbers of doctors going into medical specialty training following on from foundation training. The work, commissioned by DH, in consultation with SHAs and Medical Education England (MEE), makes recommendations on numbers for the 2011 intake.

The report:

  • contains an overall analysis of numbers going into medical specialist training
  • contains more detailed analyses for each specialty
  • identifies which medical specialties are at risk of over supply as well as identifying the geographical balance.

This report is the first of a number of reports looking at the shape and size of the overall workforce needed for the NHS of the future. As one of the first pieces of work carried out by the CfWI in its current form, and within a constricted time span, the underpinning research is necessarily limited, but the report makes reliable recommendations and identifies emerging messages.

Ref: http://www.cfwi.org.uk/intelligence/projects/recommendation-for-medical-specialty-training-2011

Collins Review- Foundation for Excellence: An Evaluation of the Foundation Programme

April 16th, 2011

Collins Review (published Oct 2010)

Foundation for Excellence: An Evaluation of the Foundation Programme

The report was commissioned by Medical Education England (MEE) to formally evaluate the Foundation programme. The Terms of Reference for the Evaluation were to assess how successfully the Foundation Programme is delivering against its original objectives, as well as against the future needs of the National Health Service and of trainees. The Evaluation was to recommend changes to the Foundation Programme to ensure that the first two postgraduate years deliver against future needs.

Recommendations:

Issue 1: Lack of a clearly articulated purpose for the Programme

By the end of 2011, the GMC should define, in a revised edition of The New Doctor, the outcomes required to complete the second year (F2) of the Foundation Programme.

Issue 2: Misgivings about the selection of trainees into the programme

A standardised and uniform process should be developed for the recruitment, selection and appointment of Foundation doctors by 2012, taking into account the guidance provided by the GMC in Tomorrow’s Doctors and The New Doctor.

Issue 3: Confusion over the role of the trainee

MEE should work with its members and partners to develop a consensus statement on the role of the trainee by 2012. NHS Trusts and the HR departments which draw up service rotas must have a detailed understanding of the role of Foundation doctors.

Issue 4: Questions about GMC registration of trainees and medical student

The GMC should review the timing of full registration. It should also review the merits of marking on the Medical Register the successful completion of the Foundation Programme.

Issue 5: Dissension over the length of the Programme and its rotations

The length of the Programme should remain at two years for the present, and be reviewed in 2015.  In the meantime F2 must demonstrate that it is a step-up in experience from F1 and be able to prove its overall value beyond doubt.

Issue 6: Perceived deficiencies in careers information and advice

Define good practice for the provision of careers information and advice.

Issue 7: Lack of flexibility in the Programme

Greater flexibility should be available within a single programme, allowing F1 trainees to have greater input into the allocation of their F2 specialty placements and rotations.

Issue 8: Gaps in the curriculum

The Foundation Programme curriculum should be revised to give greater emphasis to the total patient, long-term conditions and the increasing role of community care. It should also reflect the changing ways of working, in particular the need for team-working skills within a multi-professional environment.

Issue 9: Maldistribution of placements by specialty

The successful completion of the Foundation Programme should normally require trainees to complete a rotation in a community placement, e.g. community paediatrics, general practice or psychiatry.  The distribution of specialty posts in the Foundation Programme is predominantly in two specialties and this must be reviewed by 2013 to ensure broader based beginnings, to share the supervision of trainees among a wider number of supervisors and to ensure closer matching with current and future workforce requirements.

Issue 10: Shortcomings in technology-enhanced learning

The importance of learning resources including skills labs and simulated patient environments is reaffirmed. Concerted efforts need to be made across the different organisations involved to co-invest in facilitating innovations in the delivery of education and training.

Issue 11: Equipping and approval of trainers is necessary

A framework for the approval of trainers involved in teaching and assessing trainees is a high priority and the professional standards developed and published by the Academy of Medical Educators provides a useful resource for this.

Issue 12: Assessment is excessive, onerous and not valued

The range of assessment tools and the number of times assessment must be repeated in the Foundation Programme should be reviewed, with a view to reducing these to the minimum required by 2013. The opportunity to avoid repetitive assessments, by improved transfer of information between undergraduate and postgraduate schools, should be actively explored.

Feedback from patients who have been in contact with the Foundation doctor should be part of assessment by 2013 and the GMC should be invited to oversee research to identify best practice in this regard.

All Foundation Programme assessments should be conducted and signed off by resourced and trained assessors by 2013. Assessors should undergo regular review of their performance for this role.

Issue 13: Variability in the deployment and supervision of trainees

Methods must be developed to ensure that all health professionals and employers understand the objectives of the Foundation Programme, become quickly conversant with the prior clinical experience and level of competence of individual F1 and F2 trainees, and support the standard that no Foundation doctor will be required to practise beyond their level of competence or without appropriate supervision.

Issue 14: Variability in the quality of education and learning

The Postgraduate Deans, the GMC and NHS Trusts must clarify the appropriate balance between service and education during F1 and F2 and ensure that the effective monitoring of this balance is being achieved by 2012. Clear pathways must be available for trainees to obtain satisfactory resolution if the appropriate balance is being eroded.

Issue 15: Lack of pastoral support for trainees

Good practice with regard to pastoral care needs to be defined

Issue 16: Inadequate transfer of information about trainees

In the interests of patient safety and in order to help trainees to address issues which have been identified, the transfer of relevant information about medical students and trainees across the continuum of education and training must take place (within carefully defined limits) by 2012.

Ref: http://www.mee.nhs.uk/pdf/401339_MEE_FoundationExcellence_acc_FINAL.pdf

Health Priorities for Scotland

April 16th, 2011

The Royal College of Physicians of Edinburgh’s Health Priorities for Scotland manifesto sets out 12 key priorities that we believe should be the health goals of an incoming Scottish Government to ensure safe, patient-centred medical care of the highest quality and improved public health. These priorities focus on the three areas of patient safety, quality care and public health, and were informed by a survey of College Fellows and Members. While these priorities will initially be advocated to the Scottish Government, many of these are equally applicable to the NHS in England and will form the basis of much of our policy work during the next terms of the Scottish and UK Governments.

The key priorities include:

·   Addressing the ongoing erosion of the balance between training and service needs by protecting training time for both Trainees and their supervisors to ensure that Trainees are adequately trained and patient safety is maintained.

·   Ensuring timely patient access to consultant-delivered care through more flexible working patterns and improved workforce planning.

Other recommendations include:

·   Better access to diagnostic services and alternatives to hospital admission to improve acute care.

·    Improved continuity of care through several measures, including a modest relaxation of European Working Time Regulations.

·    A strategy to improve the quality of audit data available to consultants.

·   The introduction of minimum pricing to reduce alcohol consumption.

Ref: http://www.rcpe.ac.uk/policy/health_priorities.php

Service Line Reporting (SLR)

April 16th, 2011

What do you mean by Service Line Reporting (SLR)?

SLR means departments are accountable for their income and expenditure. This means that departments will be charged for all the resources it uses i.e. every blood test, every imaging or every cross specialty consult.

The idea is to use resources efficiently to ensure expenditure of departments do not exceed its income.

Watchout: Some departments may underuse resources (to balance books) to the detriment of patients. Proper governance structures and outcome data will be needed to avoid any patient consequences.

Information Governance (IG)

April 16th, 2011

What is information governance (IG)?

Information Governance is the way by which the NHS handles all organisational information – in particular the personal and sensitive information of patients and employees. It allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care.

It provides a framework to bringing together the requirements, standards and best practice that apply to the handling of information. It has four fundamental aims:

  • To support the provision of high quality care by promoting the effective and appropriate use of information;
  • To encourage responsible staff to work closely together, preventing duplication of effort and enabling more efficient use of resources;
  • To develop support arrangements and provide staff with appropriate tools and support to enable them to discharge their responsibilities to consistently high standards;
  • To enable organisations to understand their own performance and manage improvement in a systematic and effective way.

IG has come about because of concerns about public sector data protection. A board-level Senior Information Risk Owner (SIRO) is required in each organisation for IG.

More info

How do SIRO and Caldicott Guardian differ?

SIRO and Caldicott Guardian should work together.  However,

SIRO

  • Is accountable
  • Fosters a culture for protecting and using data
  • Provides a focal point for managing information risks and incidents
  • Is concerned with the management of all information assets

The Caldicott Guardian

  • Is advisory
  • Is the conscience of the organisation
  • Provides a focal point for patient confidentiality & information sharing issues
  • Is concerned with the management of patient information

NHS White Paper July 2010

August 13th, 2010

Health secretary Andrew Lansley’s white paper on Monday 12 July reflects the Government’s wish to put clinicians and patients at the heart of the NHS, cut bureaucracy and put more power in the hands of frontline staff.

The white paper will have implications for all health organisations in the NHS, particularly PCTs and SHAs, which will be phased out under the proposals.

In the short term, however, SHAs and PCTs will have a role to play in the quality, innovation, productivity and prevention (QIPP) programme. This will continue with even greater urgency, but with a stronger focus on general practice leadership.

Empowering clinicians and GPs

GPs will be handed the majority of the commissioning budget and local authorities will be handed control of local health improvement budgets. Professionals will be free to focus on improving health outcomes so that these are “among the best in the world”.

NHS pay

Under the proposals all NHS trusts will become foundation trusts by 2014 and will have the same rights to set pay locally as Foundation Trusts do now. Pay decisions will be led by employers rather than imposed by the Government and it is recognised that many providers will want to continue to use national contracts as a basis for their local terms and conditions.

In the short term, during the two-year pay freeze, the Government will ask the pay review bodies to make recommendations for staff earning under £21,000 and will consult with employers and trade unions on long-term arrangements.

Healthcare skills planning

Healthcare employers and their staff will determine workforce development and training needs and these decisions will determine education commissioning.  The NHS Commissioning Board will provide national oversight of healthcare providers’ funding plans for training and education and GP consortia will provide this oversight at a local level.

Government consultation

The white paper is the start of an extensive consultation that will take place over the coming weeks. The Department of Health will shortly be publishing a number of consultation documents.

NHS five year plan 2010-2015

June 14th, 2010

The NHS five year plan 2010-2015
NHS 2010-2015: from good to great. Preventative, people-centred, productive
This sets out the NHS five year plan in the context of a new financial era and it is intended to give people working in the NHS a clear sense of direction and time to plan for the challenges ahead. Key aspects of the plan are:
Implementing our vision: a preventative, people-centred, productive NHS
• It is stated that change will be on an unprecedented scale for patients and staff and hard choices about resources and priorities will have to be made, delivering £15-20 billion efficiency savings over three years from April 2011 (£10billion by 2012/13). Savings are identified in the following areas:
o Productive NHS workforce – £3.5 billion
o Reduced management cost, back office support and procurement – £1.8 billion
o Care closer to home and self care for people with long term conditions – £2.7 billion
o Tighter control of the pay bill
• Reference is made to six challenges; ever higher patient expectations; an ageing society, the dawn of the information; the changing nature of disease; advances in treatments and a changing workforce.
• There is emphasis on reform and that this can only be achieved through clinical leadership and a change in current roles for NHS staff. There is commitment to support staff to make the changes necessary to shape services around the needs of patients – more care closer to people’s homes that are better integrated around people’s needs.
The deal for patient and the public
• The legally binding entitlements to staff, patients and the public are now set out in the NHS Constitution. There are 25 rights in the Constitution and a further 2 have been proposed:
o You have the right to access services within maximum waiting times.
o You have the right to an NHS Health Check every five years if you are eligible for one.
• There is acknowledgement that there should now be a shift from ‘diagnose and treat’ to ‘predict and prevent’ and that personalised care can only be realised by tailoring provision with services and organisations working together across traditional boundaries. Changing behaviours will continue through schemes such as Change4Life, NHS Stop Smoking Service and Total Place pilots.
• The introduction of NHS health checks is set to save thousands of lives by preventing
stroke and heart attacks.
• More screening and earlier diagnosis of cancers is planned through increased GP access and modern laboratory medicine.
• The following priority areas for achieving High Quality Services have been identified:
o further reductions in MRSA
o cancer care
o care for stroke patients
o care for those at risk of heart disease
o care for pregnant women.
• For the three interdependent areas of quality, as per Lord Darzi’s vision organisations will be required to:
o Safety. Focus on a wider set of safety challenges, safer care for patients, zero
tolerance of preventable infections
o Effective. Reduce the number of patients who die from VTE and increase prevention of pressure ulcers.
o Patient experience. Expand the measurement of patient satisfaction and for those to be included in Quality Accounts. There will also be a greater
proportion of provider income linked to patient experience and satisfaction – potentially up to 10%)
• There is clear requirement to have more choice for patients and to transform the care for groups of people with the following long term conditions; diabetes, heart failure, respiratory disease (including COPD), cancer as a chronic disease and dementia.
• More local care is seen to be delivered by GPs and community services rather than having to be seen in an urgent or emergency setting.

The deal for staff
• The focus is clinical leadership, collaborative working, reuniting doctors and nurses, managers and politicians and staff flexibility.
• Change needs to be fast moving as good practice cannot be allowed to spread at its own pace. An evidence base of around 70 examples of best available evidence will be used to escalate improvements. Organisations will be supported nationally but locally led. The Trust will be able to drive this through NETS and Service Improvement.
• With regards to pay, future pay awards will need to strike the balance between rewarding existing staff for increased quality and productivity and the need to maintain security of employment by retraining and redeploying staff to meet additional demand. A sustained pay restraint is required. It is recommended that consultants and very senior managers receive no increase in 2010/11 and GP practice income increases are restricted and they need to make at least 1% cash releasing efficiency savings.
• Work is ongoing exploring the pros and cons of offering frontline staff an employment guarantee locally or regionally in return for flexibility, mobility and sustained pay restraint. This may involve staff working in a different place or even a different organisation. The Trust will need to align training plans to support delivery of local clinical visions and new ways of working in support of retraining and redeployment of staff, utilising the new Staff Passport.
How the system will support NHS staff and organisations to deliver
The key levers include:
• Payment systems support improved quality and efficiency
o 0% maximum uplift for next four years (hospitals)
o Increases in payment linked to quality goals
o Incentivising the shift of care out of hospital settings
o Withdrawal of payments when care does not meet minimum standards
• Helping staff through change
o Empower and enable NHS staff to lead change
o NHS will be given the first opportunity to improve
o Commissioners will have a legal duty to secure best services.
• Strengthening regulation, dealing with failure
• Creating leaner, stronger commissioners
o Freedoms and incentives to high performing commissioners
o Poor performers to demonstrate clear and rapid improvement
o Improve information on management costs
o Significantly reduce management costs in PCTs and SHAs (30% over next four years)
o Permit reconfiguration where it leads to greater coterminosity between PCTs and LAs
• Integrating services, supporting high performing organisations
o Reduce variation in quality among primary care providers and practice based commissioners.
o Increase integration of services
o Alignment of incentives so organisations work better together
o Reform of provider services
o Reduce overheads and transaction costs
o Offer rewards and freedoms for high performers
o High performing FTs to expand their services
o Make it easier for high performing trusts to take over poorly performing organisations.
• Streamlining the reconfiguration process
o Further simplification
o Better engagement.
• Driving innovation
o £220 million Regional Innovation Fund
o Development of NHS Evidence
o NHS Life Sciences Innovation Delivery Board to support adoption of clinically and cost effective innovations

Temple report summary: Time for change

June 14th, 2010

Temple report- Time for Training: A Review of the impact of the European Working Time Directive on the quality of training
The report Time for Training was commissioned by Medical Education England at the request of the former secretary of state for health Alan Johnson. The report was instigated in response to the concern raised by many specialties, but by surgeons in particular, that after the introduction of the EWTD it was impossible to ensure doctors in training acquired a sufficient number of hours of supervised and hands-on experience to bring them up to an adequate standard. The report was published on June 9, 2010
The report looked at the impact of the 48-hour week on the quality of the training that is necessary to ensure the continuing supply of a world class workforce which is able to deliver high quality services to patients.

Problems with EWTD implementation:
• The reduced hours have necessitated a move to shift patterns of work in many
Specialties (Any doctor working to a rota that requires them to work different duty times at certain points on the rota can be considered to be a shift worker). Shift working has decreased training opportunities and impacted on trainee experience by reduction in trainer and trainee interaction and lack of continuity of patient care. Although with the reduction in hours there should be less sleep deprivation and better work–life balance for trainees, but shift patterns have possibly decreased the quality of life, as work periods, although shorter, are more frequent, less regular and more antisocial.
• The move to resident shift systems to accommodate the 48-hour week means that more trainee doctors are required to cover the out of hours care if the structure of service cover remains the same. This increased requirement for doctors results in an increase in the number of rota gaps. Recruitment challenges due to changes in immigration law have compounded the difficulty in fillings gaps. Rota gaps result in trainees being moved from their daytime, more elective training often at very short notice to fill service gaps. These are usually out of hours where there is minimal supervision and therefore less training opportunity. This results in the trainee missing out on the planned training that day and often the next due to compensatory rest. Although many rotas are compliant with 48 hours on paper, rotas have gaps.
• Rigid, poorly designed rotas result in trainees being unsupported and unsupervised.
• The impact of EWTD is greatest in specialties with high emergency and/or out of hours workloads

Recommendations
The report recommends that high quality training can be delivered in 48 hours. Any current problems will not be solved by either increasing hours or lengthening training programmes, says the report, which shows that despite an increase in consultant numbers of more than 60% over the past ten years, hospitals remain too reliant on junior doctors to provide out of hours services. There is a total of over 15,000 hours available to trainees working a 48-hour week in a seven-year training programme, but these are not all being used effectively for training.

It recommends the following to achieve high quality training within EWTD:
Implement a consultant delivered service: Consultants must be more directly responsible for the delivery of 24/7 care. The roles of consultants need to be developed for them to be more directly involved in out of hours care.

Service delivery must explicitly support training: Services must be designed and configured to deliver high quality patient care and training. Reconfiguration or redesign of elective and emergency services and an effective Hospital at Night programme are two of the ways in which healthcare can be changed to support training and safe services

Make every moment count
• Training must be planned and focused for the trainees’ needs
• Trainers and trainees must use the learning opportunities in every clinical situation
• Handovers can be an effective learning experience when supervised by senior staff, preferably consultants
• The co-ordinated, integrated use of simulation and technology can provide a safe, controlled environment and accelerate learning

Recognise, develop and reward trainers
Consultants formally and directly involved in training should be identified. • They must be trained, accredited and supported.

Training excellence requires regular planning and monitoring
Commissioner levers should be strengthened to incentivise training, ensure accountability and reward high quality and innovation