Health CommitteeWritten evidence from The Royal College of Anaesthetists (ETWP 15)

Executive Summary

Importance of and need for support to trainers to deliver training and conduct roles outside their parent Trusts to the benefit of the wider NHS.

Increased conflict between the delivery of service and the delivery of training and the requirement for this to be addressed.

Importance of Quality Assurance, the role of the Colleges and accountability of Deaneries.

The requirement for coherent workforce planning linked to a consultant delivered service with full stakeholder engagement.

Introduction

1. Anaesthesia is the largest single hospital specialty in the NHS. The Royal College of Anaesthetists (RCoA) is the professional body responsible for the specialty of anaesthesia throughout the UK, and ensures the quality of patient care through the maintenance of standards in anaesthesia, critical care and pain medicine.

2. The RCoA is responsible for the Anaesthetic Curriculum and in fulfilling its role in maintaining standards in anaesthetic, pain and critical care training through working closely with the Deaneries and the General Medical Council (GMC) in accordance with the Quality Improvement Framework (QIF)1 and the Standards for Training as stated in The Trainee Doctor.2 The RCoA is also responsible for the delivery of the Fellowship Examinations of the Royal College of Anaesthetists (FRCA) which are a mandatory part of the anaesthetic training programme. Details of the FRCA examinations can be found on our website.3

Training

1. The Training Programme. The Anaesthetic Training Programme is a seven year training programme divided into Basic (two years), Intermediate (two years), Higher (two years) and Advanced (one year) levels of training. Successful completion results in a Certificate of Completion of Training. The CCT in anaesthetics can be found at the following link4 and a summary of the programme can be found here.5

2. Training Numbers. There are approximately 4,500 anaesthetic trainees in the UK Training Programme which is delivered by Deaneries and Local Education Providers (LEPs).

3. The Curriculum. The 2010 Anaesthetic Training Programme has been approved by the GMC and is delivered by all LEPs. In addition some trainees remain on the 2007 Anaesthetic Training Programme, also approved by the GMC. The training programmes and curricula can be found at the following link.6

Training Related

4. Support to Trainers. There is significant pressure from Trust managers on trainers and those who work to provide good quality training and improve training standards Trusts are increasingly reluctant to allow trainers the requisite time in job plans necessary for training delivery and the work required to meet and further improve the standards for training and assessment. These concerns have been raised in the College’s Annual Specialty Report (ASR) to the GMC. A copy of which is available on request. The College continues to canvass the GMC, DH and Trusts to recognise the importance of trainers and assessors and the need for their work to be appropriately recognised however to resolve the issue a more formal process of recognition needs to be agreed.

5. Support to College Representatives. College Representatives such as Regional Advisers, College Tutors and examiners are often unsupported by their Trusts. College activities, including examining and external QA visits to other Deaneries are often undertaken during personal leave time. Regional Advisors, College Tutors and in some cases Educational Supervisors in both anaesthesia and Pain Medicine are having difficulty fulfilling their training and quality commitments as Trusts are restricting professional leave to perform these key tasks. Representatives are regularly expected to pay back clinical time. For example, a leading first wave foundation trust recently unilaterally reduced Supporting Professional Activity (SPA) time in consultant contracts to six hours per week (1.5 SPA) and further specified that none of it would be allowed to be used for national duties which henceforth must come entirely from Annual Leave and Study Leave entitlement. Although CEOs are outwardly supportive of work for the wider NHS this is not reflected in the approach on the shop floor by CDs and MDs, as a result of the increasing pressures on service delivery in the current financial maelstrom. Solutions are required to enable this essential work to continue as doctors will increasingly feel unable to commit to additional work outside of their Trust, resulting in the non-sustainability of externality and other essential training related activities which benefit the future development of NHS workforce.

6. Training vs Service. Concerns were identified in the ASR regarding the impact of service on training. Anecdotal evidence from trainers and College Representative supports this:

Education may become a “Cinderella activity” delivered on a goodwill basis by overly committed trainers in unpaid time.

As a result of WTR and the consequent gaps in rotas, trainees are undertaking an excess number of on-call commitments, particularly in ICM at the expense of their anaesthesia training. ST trainees are not getting sufficient emergency theatre work.

There is also concern that the planned reduction of training numbers will impact on service and exacerbate the problems listed above, this was expressed during visits to Schools of Anaesthesia and Specialty Training Committees conducted by the College in 2011.

7. Improving Quality. The role of the Colleges in maintaining and improving quality of training is essential and is emphasised in The Trainee Doctor. Formalising the role and involvement of Colleges within the QIF is essential. Deaneries must recognise the importance of informing Colleges of training issues pertinent to the appropriate specialty. This might be best coordinated by Health Education England (HEE) in order to make the procedure and reporting chains more accountable.

Workforce Related

8. RCoA 2010–11 Census. The RCoA conducted a census of all departments of anaesthesia, intensive care and pain medicine from October 2010 to April 2011.7 There are 6,849 consultants UK wide (5,639 in England) of which 209 (107) are less than full time, 1,784 (1,553) non-consultant, non-training grades which includes post CCT (fully trained) doctors not yet in a consultant post. There are 244 (197) consultant posts vacant and 281 (236) SAS/SD grades.

9. Recruitment of Newly Qualified Doctors. A total of 522 Anaesthetic training posts were advertised at CT1 for 2011 (entry level for specialist training), this includes two streams which comprise of two or three years of core training, and the fill rate was over 90%. 314 posts were advertised at ST3 (entry into intermediate training) for 2011. This is a year on year cut of 5% from 2010. Trainee numbers broadly match the requirements for new consultant posts but do not take account of the current vacant posts and more detailed modelling is required in conjunction with the Centre for Workforce Intelligence (CfWI) to ascertain accurate trainee numbers which will sustain service needs for the future. Anecdotal evidence suggests that the current reduction in training posts is affecting service delivery and putting a greater burden on specialty doctors to provide service. Specialty doctors currently provide approximately 25% of service. Trainees are integral to service and there is considerable reliance on them.

10. Consultant Delivered Service and Workforce Changes. Time for Training; A Review of the Impact of the European Working Times Directive on the Quality of Training by Professor Sir John Temple advocates a number of key recommendations, principally a consultant delivered service, service delivery implicitly supporting training and focused appropriate training.8 The College fully support the recommendations made in the report. These recommendations still remain an aspiration and it is hoped that further work will be done to implement these. The College has conducted a considerable amount of work on the impact of WTR and this was provided to Professor Temple for the report. Further details on WTR are on the College website.9

11. Feminisation of the Workforce. Feminisation of the workforce will impact on consultant numbers due to the increased requirement for LTFT both in training and at consultant level. Entrants to medical school this year were predominantly female (100% of CT1 anaesthesia trainees in Northern Ireland this year were female) and this trend is likely to increase. Unintended consequences of a move to resident on-call commitments for consultants will have an effect on LTFT doctors and may make anaesthesia a less attractive specialty for women as a result.

12. RCoA Workforce Planning. The College is committed to a coherent and deliverable workforce planning strategy, has engaged with principle stakeholders and is working with them to provide deliverable solutions for anaesthesia, critical care and pain medicine workforce challenges (Appendix A). Anaesthesia numbers are linked to other acute specialties and so any increases in the surgical workforce will require a representative increase in anaesthetists. However, the converse is not true as anaesthetists provide a significant number of other services outside of the provision of anaesthesia to facilitate surgery.

December 2011

Appendix A
December 2011

RCOA WORKFORCE PLANNING STRATEGY GROUP—OBJECTIVES AND TASKS

Aim

The RCoA, FICM and FPM are committed to developing a workforce which can deliver the best care to patients to ensure optimal outcomes and facilitate quality improvements.

Principles

Ensure that decisions are not made in isolation.

UK wide focus.

Engagement with FICM and FPM.

Focus on primary specialty (anaesthesia and ICM) and avoid specialty areas with the exception of pain medicine initially.

Cooperation with key workforce agencies including Devolved nations, CfWI, GMC, DH (JWG, WAPPIG).

Involvement and consideration of all grades; consultant, SAS/SD/trust, trainee and non-medical grades.

OBJECTIVES/TASKS

Objective/Task

Description

Deep Dive

Work with CfWI and use identified pilot sites to look at anaesthesia, critical care and pain medicine working practices to provide scenarios for further modelling of the workforce.

Agree proposed scenarios for pilot.

Coordinate with Prof Stds in using data from accreditation pilot to answer some of the key workforce questions.

Workforce Numbers

Work with DH on anaesthesia workforce numbers to ascertain output and requirement.

Data Capture and Analysis

Agree with CfWI a more pragmatic approach to data capture and analysis to inform decision making.

Workforce Tracking

Discuss with GMC the availability of ARCP outcome data in order to inform trainee numbers within the specialties and the progress from core to higher specialty training and beyond.

Request from the GMC a definitive list of those in UK training related to training posts and agree governance to allow information sharing.

Workforce Structure

Work with DH, CfWI, GMC to consider workforce structure to include the future of SAS/SD grades and a variety of other grades including trust fellows etc and their role.

1 http://www.gmc-uk.org/Quality_Improvement_Framework.pdf_39623044.pdf

2 http://www.gmc-uk.org/Trainee_Doctor.pdf_39274940.pdf

3 http://www.rcoa.ac.uk/index.asp?PageID=1148

4 http://www.rcoa.ac.uk/index.asp?PageID=1479

5 http://www.rcoa.ac.uk/docs/TrainingProgramme2010.pdf

6 http://www.rcoa.ac.uk/index.asp?PageID=1479

7 http://www.rcoa.ac.uk/docs/2010_CensusSummary.pdf

8 http://www.mee.nhs.uk/pdf/JCEWTD_Final%20report.pdf

9 http://www.rcoa.ac.uk/index.asp?PageID=1008

Prepared 22nd May 2012