Consultant Medical Interview

On 17 March 2009 the Healthcare Commission published its report into the severe failings in emergency care provided by Mid Staffordshire NHS Foundation Trust between 2005 and 2008.

Robert Francis QC led an inquiry following these concerns. The inquiry report made many recommendations and all of them were accepted by the Department of Health and the Trust Board.

Summary:

The report concluded that the trust did not have a grip on operational and organisational issues, with no effective system for the admission and management of patients admitted as emergencies. Nor did it have a system to monitor outcomes for patients, so it failed to identify high mortality rates among patients admitted as emergencies. This was a serious failing.

When the high rate was drawn to the attention of the trust, it mainly looked to problems with data as an explanation, rather than considering problems in the care provided. The trust’s board and senior leaders did not develop an open, learning culture, inform themselves sufficiently about the quality of care, or appear willing to challenge themselves in the light of adverse information.

The clinical management of many patients admitted as emergencies fell short of an acceptable standard in at least one aspect of basic care. Some patients, who might have been expected to make a full recovery from their condition at the time of admission, did not have their condition adequately diagnosed or treated.  The trust was poor at identifying and investigating such incidents.

In the trust’s drive to become a foundation trust, it appears to have lost sight of its real priorities. The trust was galvanised into radical action by the imperative to save money and did not properly consider the effect of reductions in staff on the quality of care. It took a decision to significantly reduce staff without adequately assessing the consequences. Its strategic focus was on financial and business matters at a time when the quality of care of its patients admitted as emergencies was well below acceptable standards.

Based on the above findings, the inquiry reported a number of lessons relevant to the whole NHS. These include the need for:

• Trusts to be able to get access to timely and reliable information on comparative mortality and other outcomes, and for trusts to conduct objective and robust reviews of mortality rates and individual cases, rather than assuming errors in data.

• Trusts to identify when the quality of care provided to patients admitted as emergencies falls below acceptable standards and to ensure that a focus on elective work and targets is not to the detriment of emergency admissions. Care must be provided to an acceptable standard 24 hours a day, seven days a week.

• Trusts to ensure that a preoccupation with finances and strategic objectives does not cause insufficient focus on the quality of patients’ care.

• Trusts to ensure that systems for governance that appear to be persuasive on paper actually work in practice, and information presented to boards on performance (including complaints and incidents) is not so summarised that it fails to convey the experience of patients or enable nonexecutives to scrutinise and challenge on issues relating to patients’ care.

• Senior clinical staff to be personally involved in the management of vulnerable patients and in the training of junior members of staff, who manage so much of the hour-by-hour care of patients.

• Trusts to identify and resolve shortcomings in the quality of nursing care relating to hygiene, provision of medication, nutrition and hydration, use of equipment, and compassion, empathy and communication.

• Good handovers when reorganisations and mergers occur in the NHS.

• PCTs to ensure that they have effective mechanisms to find out about the experience of patients and the quality of care in the services that they commission.

Ref:http://www.nhshistory.net/midstaffs.pdf

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.

The Collins Review of Foundation Training has been published. The main recommendations are that the length of the Foundation Programme should remain unchanged at two years, but this should be reviewed in 2015 when the impact of the General Medical Council (GMC) recommendations in Tomorrow’s Doctors will be clearer, and that action should be taken to strengthen supervision for Trainees, many of whom have had to act beyond their level of competency. The review also recommended that trainers should be supported in providing the supervision for the trainees.

Other recommendations included:

1. Standardised recruitment system for selection into training
2. Need to define the balance between service and educational needs. It is essential that, in addition to delivering patient care, Trainees receive protected time with which to complete their Training. Failure to do so could lead to a generation of inadequately trained doctors and, in turn, compromise patient safety.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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

Progress on the Collins Review:

The Academy of Medical Royal Colleges has revised the foundation programme curriculum for trainees who start in 2012 to deal with some of the concerns raised by John Collins’s review of the programme in 2010.

The updated curriculum aims to meet the purpose of the foundation programme and includes high level descriptors, differentiating between F1 and F2 outcomes, after the review by Professor Collins and Medical Education England said that the programme “lacks a clearly articulated and generally accepted purpose.”

Greater emphasis is given to long term conditions, in response to comments that the syllabus was too biased toward the acutely ill patient; and the “total patient” and the increasing role of community care are also given more precedence.

Formal assessment during foundation training will take place in supervised learning events evenly spread throughout each placement, instead of workplace based assessment. The Collins report described the current arrangements for assessment of foundation trainees as “excessive, onerous and not valued” and recommended that the number of times that foundation doctors are assessed should be cut.

What do you know about Revalidation?

On 16 November 2009 the GMC introduced the licence to practise. To practise medicine in the UK all doctors are required by law to hold both registration and a licence to practise. Licensing is the first step towards the introduction of revalidation.  Licences will require periodic renewal by revalidation.

Revalidation is the process by which doctors will have to demonstrate to the GMC, normally every five years, that they are up to date and fit to practise and complying with the relevant professional standards.

Revalidation is expected to begin in late 2012.

How will revalidation work?

Revalidation a step to step guide:

• Licensed doctors will be required to link to a Responsible Officer (new statutory post). The responsible Officer will usually be a senior, licensed doctor like the medical director in the healthcare organisation where the doctor works.
• Licensed doctors will need to maintain a portfolio of supporting information drawn from their practice which demonstrates how they are continuing to meet the principles and values set out in Good Medical Practice Framework for appraisal and revalidation.

• Licensed doctors will be expected to participate in a process of annual appraisal based on their portfolio of supporting information.
• The Responsible Officer will make a recommendation to the GMC about a doctor’s fitness to practise, normally every five years.  The recommendation will be based on the outcome of a licensed doctor’s annual appraisals over the course of five years, combined with information drawn from the clinical governance system of the organisation in which the licensed doctor works.
• The GMC’s decision to revalidate a licensed doctor will be informed by the Responsible Officer’s recommendation.

What are the key pieces of evidence a doctor will need to supply for revalidation?

Key pieces of evidence a doctor will need to supply for revalidation include:

• Evidence of continuous professional development
• Evidence of quality improvement activity
• Significant Events
• Colleague Feedback (multisource feedback)
• Patient feedback (where relevant)
• Review of complaints and compliments

Do you feel Revalidation will resolve the issues they are meant to address?

The purpose of revalidation is to provide greater assurance to patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise.

Revalidation aims to:

• Provide a focus for doctors’ efforts to maintain and improve their practice
• Encourage the organisations in which doctors work to support their doctors to improve their practice and, where necessary, to identify and respond appropriately to emerging concerns about doctors at an early stage
• Encourage patients to provide feedback about the medical care they have received from a doctor, to be considered in their annual appraisals

In these ways, revalidation will contribute to the ongoing improvement in the quality of medical care delivered to patients throughout the UK. The principles of revalidation are sound. The process is likely to be effective as long as the trusts and doctors engage in the process.

Some people think that revalidation/appraisals are a waste of time and just a paperwork/box-ticking exercise. Do you feel it is a useful process?

The revalidation process requires the hospital and the consultant to reflect on their practice and the organisation and to identify possible improvements. As such it is a desirable process. However, it requires commitment from both the trust and the consultant. The trust need to provide training to its appraisers and appraisees and provide adequate time for it in the job plan. It also needs to support the consultant in achieving the objectives set in the PDP. Obviously, the consultant needs to be committed to the process for it to be effective.

What can you tell me about appraisals?

Appraisal is a formal process aimed to give doctors regular feedback on past performance, to chart their continuing progress and to identify education and development needs. It is part of a doctor’s career development.

The key principles of professionalism set out in Good Medical Practice will be used to create a framework for annual appraisals. The evidence for appraisal will be collected under 4 domains:

• General information – providing context about what you do in all aspects of your work
• Keeping up to date – maintaining and enhancing the quality of your professional work
• Review of your practice – evaluating the quality of your professional work
• Feedback on your practice – how others perceive the quality of your professional work

The doctor and appraiser will agree a written overview of the appraisal, which should include a summary of achievement in the previous year, objectives for the next year, key elements of a personal development plan, actions expected of the organisation, a standard summary of the appraisal and a joint declaration that the appraisal has been carried out properly.

Personal development plan (PDP) – This is an outcome of the appraisal process listing the key development objectives of the appraisee for the following year as agreed with the appraiser.

What is the difference between Assessment and Appraisal?

Appraisal is a formal process to provide feedback on doctors’ performance, chart their continuing professional development, and identify their developmental needs.

Assessment is a formal process which examines performance.  In other words, assessment is ticking boxes set by others, whereas appraisal is ticking boxes that you have helped to set yourself. Revalidation will include both appraisal and assessment.

Who is the main beneficiary in an Appraisal or revalidation?

• It increases public confidence in doctors by reassuring the public that doctors are up to date and fit to practice.
• It leads to the personal and professional development of the individual and the NHS benefit as a whole.

What about appraisal of doctors in training?

Specialist training and progress through the grade are noted in the Record of In Training Assessment (RITA) or ARCP, and are subject to assessment and development review.

Ref: http://www.gmc-uk.org/doctors/revalidation/9546.asp

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.