The Royal College of Anaesthetists www.rcoa.ac.uk | [email protected]

BULLETIN Issue 95 | January 2016

Consent: Who are we protecting? Mapping the anaesthetic pathway through the shape of training The 2nd Sprint National Anaesthesia Project: Epidemiology of Critical Care provision after Surgery UK Anaesthetic Workforce and Census 2015 Is there a need for anaesthetic career courses? Seeing the bigger picture: training in obesity and bariatric anaesthesia

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BULLETIN of The Royal College of Anaesthetists

Churchill House  35 Red Lion Square  London WC1R 4SG 020 7092 1500  www.rcoa.ac.uk  [email protected]  [email protected] Registered Charity No 1013887   Registered Charity in Scotland No SC037737   VAT Registration No GB 927 2364 18

Follow @RCoANews

4

The President’s Statement

6

Guest Editorial

9

Find us on Facebook

28

Organising in-situ simulation – one trainee’s description of a valuable learning opportunity

31

51

Senior Fellows Club Report

52

Letters to the Editor

54

Revalidation for anaesthetists

Mind maps for the Final FRCA

Programme of events 2016

10

33

Report of meetings of Council

Patient Perspective

12

The Faculty of Intensive Care Medicine (FICM)

13

The Faculty of Pain Medicine (FPM)

13

Pain in Secure Environments Project

14

Anaesthesia Clinical Services Accreditation (ACSA)

15

National Institute of Academic Anaesthesia (NIAA)

Is there a need for anaesthetic career courses?

36

Lessons from a national training survey in neuroanaesthesia

39

42

Seeing the bigger picture: training in obesity and bariatric anaesthesia

45

Health Services Research Centre (HSRC)

20

48

UK Anaesthetic Workforce and Census 2015

25

Consent: who are we protecting?

66

Notices and advertisements

Striving for THRIVE: Proceedings from the inaugural THRIVE Research Consortium

Anaesthetic Impact Calculator: a smart phone app to derive the environmental and financial cost of inhalational anaesthesia

18

64

The sweet life: ‘la dolce vita’

50

As We Were

The Royal College of Anaesthetists is grateful for the contribution to the production of the Bulletin by Laerdal Medical Ltd and Dräger Medical UK Ltd.

The views and opinions expressed in the Bulletin are solely those of the individual authors, and do not necessarily represent the view of The Royal College of Anaesthetists.

Page 3 | Bulletin 95 | January 2016

A medical College traditionally has a number of well-recognised roles: training, education, professional standards and the promotion of quality. Colleges used to regulate, particularly in training, but this is now the role of the deaneries. Much of this, if not all of the regulation across the NHS is process driven. We see the consequences, when centres of excellence, such as Bart’s and the Royal London and Addenbrooke’s, are deemed grossly inadequate, their management sacked and ‘special measures’ imposed. Last time I looked their outcomes, across a broad sweep of their core work, were anything but grossly inadequate. This is not so much a problem with the regulators as with the metrics they are assessing and the political imperative driving them. Quality in health care should not be aspirational and the government rightly demands this. They also demand the delivery of healthcare at a cost well below that of our economic peers. The Kings Fund is not alone in spotting the problems here and questioning how quality might more effectively be addressed. Both Rob Thompson and Bob Evans describe their experience of ASCA as reviewers and we have previously heard what it is like to be on the receiving end of it. This is a constructive, self-assessed and peer-reviewed quality improvement programme and surely points the way forward for quality review. Two years ago ‘Shape of Training’ was a hot issue. Supposedly a review of training intended to develop a workforce fit for the 21st century, the emphasis on shortening training seemed to many a rather obvious attempt to produce a sub-consultant grade focussed entirely on service delivery. Nigel Penfold and Russell Ampofo’s update describes the current position. You will see that the College has demonstrated that we already have a training scheme fit for purpose. What you will also notice is that we are proposing the introduction of an ACCStype model for all entering the specialty, thereby preparing us to deliver perioperative medicine, and to better manage the ageing population with multiple co-morbidities. The President briefly mentions a College initiative designed to improve awareness of and recruitment into anaesthesia, aimed at undergraduates. This is gathering

momentum and will be described in more detail in a future edition. Dr’s McCormick, Baker, Sheils and Pandit describe a course aimed at increasing awareness at foundation level. Although it might appear that they are preaching to the converted, it is difficult to argue with their conclusion of the need for more of the same.

President Liam Brennan Vice-Presidents Richard Marks Jeremy Langton Editorial Board Simon Fletcher, Editor Richard Marks, Vice-President Janice Fazackerley, Council Member David Rowbotham, Faculty of Pain Medicine

The College Winter Symposium included a session focussed on staying out of trouble (medico-legally) and dealing with disasters once they have occurred. Consent is topical, and many of you will have despaired at the introduction of US-style paperwork outlining every possible complication. A lack of appropriate informed consent is increasing the focus of medical litigation.

Monty Mythen, Faculty of Intensive Care Medicine

To that end, please read Mevan Gooneratne and Andy McLeod’s article addressing this issue. It is a thoroughly informed and insightful piece, right up-to-date, advising on a safe path through this potential minefield, where informed consent should be specifically for the patient’s benefit and not the doctor’s protection.

Mandie Kelly, RCoA Website and Publications Officer

Many of you will have provided the information published here detailing the UK anaesthetic workforce. 100% of anaesthetic departments responded. One-fifth of permanent staff are SAS doctors or similar and they are thus an essential part of most departments. There are significant numbers of ‘declared’ unfilled posts and the actual number is likely to be considerably larger. This data is powerful when resisting HEE’s desire to shift resources to GP training, although gaps here are much greater. Age demographics point to troubles in 10-15 years. The next edition of the Bulletin will focus on anaesthetic and intensive care research.

Simon Fletcher, Editor

Ewen Forrest, Lead Regional Advisor Oliver Pratt, Lead College Tutor Lorraine Hart, Lay Committee Charlie McLaughlan, RCoA Director of Clinical Quality Sonia Larsen, RCoA Director of Communications

Anamika Trivedi, RCoA Website and Publications Officer

© 2016 Bulletin of The Royal College of Anaesthetists All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, of The Royal College of Anaesthetists. Fellows, Members and Trainees are asked to send notification of their changes of address direct to the College Membership Department ([email protected]) so that their copy of the Bulletin is not misdirected. Articles for submission, together with any declaration of interest, should be sent to the Editor via email to: [email protected]. All contributions will receive an acknowledgement and the Editor reserves the right to edit articles for reasons of space or clarity.

ISSN (print): 2040-8846 ISSN (online): 2040-8854

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The President’s Statement

At the turn of the year ‘Honesty is the best policy’ Benjamin Franklin (1706–1790)

Liam Brennan President

I hope that you have been able to get some time away from the pressures of work to enjoy the Christmas and New Year celebrations with your friends and family. It is my turn to be on call over some of the festive period, to take care of the paediatric service in Cambridge. I would like to take this opportunity to say thank you to all of my colleagues at Addenbrooke’s for their encouragement and support since I took office as President last September. It is traditional at this time of year to reflect on the past 12 months, perhaps to make some New Year’s resolutions, and to look forward to the challenges ahead. 2015 has been, by everyone’s assessment, a very tough year for all of us involved with delivering healthcare. Cost pressures have escalated in all parts of the UK; in England, providers are in deficit to the tune of £1 billion at the end of the first three months of this financial year, with a quarter of

Foundation Trusts, including my own, facing regulatory intervention. The regulators themselves are not immune, with the CQC expecting their budget to be reduced by 25–40% next year. The relentless demand for clinical care has exceeded the capacity to deliver; waiting times have started to lengthen and providers are challenged by political expectations to achieve the requirements of initiatives such as Seven Day Services (however they are defined). As Chris Ham, the Chief Executive of the King’s Fund, has stated in a recent BMJ editorial, with a growing and ageing population and rising demands for care, the additional £8 billion of NHS funding for England by 2020–21 is unlikely to be sufficient. If this government line is maintained, ministers will need to ‘spell out the consequences for patient care and to be honest with the public about what it will mean.’ Add to this the unprecedented climate of conflict and uncertainty engendered by the current consultant and trainee contract situation in England, and it is with some trepidation that we set off into 2016.

Boots on the ground Maintaining a skilled and motivated workforce in sufficient numbers is clearly essential to delivering high quality perioperative care. At the time of writing, the pressures on workforce numbers for 2016 are a little less acute than we had feared, although there are still parts of the UK where it remains more challenging to recruit to the specialty. The College, in collaboration with the Faculty of Intensive Care Medicine (FICM), have lobbied successfully in all four UK nations to maintain training numbers, despite the political pressure to divert resources to

other specialties (particularly general practice). However, in financially challenging times, particularly in parts of the country with longstanding recruitment difficulties, some healthcare organisations are looking to alternative staffing models across many specialties, including anaesthesia, to satisfy service needs. Physicians’ Assistants (Anaesthesia) (PA(A)s) are an established group of healthcare professionals, currently numbering about 150 across the UK. Analogous groups in other specialties are much larger, and the Royal College of Physicians of London (RCPL) has recently established a Faculty of Physician Associates. A large recruitment drive for Physicians’ Associates has occurred for medical specialties in some parts of the UK, which has been paralleled by a growing interest in training and recruiting PA(A)s by some anaesthetic departments. The issue of nonphysician anaesthetists continues to polarise opinion within our specialty. Statutory regulation (currently not in place), scope of practice, currency of qualifications, supervision, life-long learning requirements and the impact on training opportunities for medically trained anaesthetists are some of the areas of concern that have been expressed. The College believes that the way forward is to facilitate the debate on the future direction of this part of the perioperative workforce, along with key stakeholders including our Fellows and Members, PA(A)s and their professional association, the AAGBI, anaesthetic specialty societies, potential regulatory authorities and NHS Employers. Look

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The President’s Statement out for opportunities to contribute your views during 2016.

Another lost tribe? The recent College workforce census highlighted that SAS grade doctors make up over 21% of the anaesthesia workforce, which is higher than many other secondary care specialties. SAS grades are a heterogeneous group, ranging from those who may only recently have left core training or arrived from overseas with a varied training portfolio, to very experienced associate specialists engaged in complex, subspecialty practice. However, all too often a one-size-fits-all strategy is applied to how SAS grades are regarded. This affects all aspects of their professional lives, including access to life-long learning, SPA allocation, opportunities to re-engage with specialty training, and furthering equivalence applications. In addition, SAS contractual issues are often complex and do not always conform to national terms and conditions of service. The College believes that it must do more for these members of our specialty and, along with our SAS members of Council, we are exploring how we can better work in collaboration with colleagues from the AAGBI so as to meet the varied needs of SAS colleagues in our specialty. This edition includes an analysis of the workforce census, and provides a national picture of the workforce challenges across the devolved nations.

Getting the early years right Disseminating the skills that we anaesthetists have to all doctors involved with acute care, encouraging interest and recruitment to our specialty, and training the consultant anaesthetists of tomorrow is core business for the College. Exposure to anaesthesia, intensive care, pain management and perioperative medicine in UK undergraduate curricula varies considerably between medical schools,

both in length and content. We are currently developing an undergraduate theme as part of our perioperative medicine training strategy; we will progress this further to give adequate coverage to all relevant aspects of practice, and will extend this to include the foundation curriculum. In due course we will present our views to the Medical Schools Council and the General Medical Council, with whom the authority rests to reform the relevant curricula. The Shape of Training saga continues, and at the time of writing we have recently submitted the College’s response to the generic competencies mapping exercise. Nigel Penfold and Russell Ampofo tell us more elsewhere in this edition of the Bulletin. This work stream, coordinated by the Academy of Medical Royal Colleges, attempts to gain the profession’s view on which aspects of specialty curricula may usefully be shared by some or all other specialties. This College’s view, supported by a survey of our trainers, is that there is most value in enhancing generic competencies in the early years of training. This perspective is shared by several other Colleges and Faculties, namely the Royal College of Emergency Medicine, FICM and the RCPL, who all agree that the Acute Care Common Stem model – which has been a great success since its introduction – provides an excellent common introduction to acute specialty training. We are still some way from seeing Professor Greenaway’s vision turned into action, not least due to the fact that his proposals have not been costed; at a time of financial stringency, this is clearly going to be a major impediment to progress.

A silver lining Finally, to end on a positive note, a year from now in 2017 the College will celebrate 25 years since gaining its

Royal Charter. This is a momentous occasion for any organisation, but for such a young specialty the growth in our stature in recent years has been truly remarkable. As the third-largest Medical Royal College, our Fellows and Members (who number over 17,500) engage with more than two-thirds of inpatients, and our influence on patient experience and outcome extends far beyond the operating theatre doors. We are planning a series of events to mark our Silver Jubilee, and I would like to hear your ideas of what they might include. If you have any suggestions on this matter or wish to express your views on any of the other issues I have raised, then I would like to hear from you at [email protected] I wish you all a happy and successful 2016!

References 1

Ham, C. The three crises facing the NHS in England. BMJ 2015;351:h5495.

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Guest Editorial

Mapping the anaesthetic pathway through the shape of training

Nigel Penfold Chair of Training Committee, RCoA

Russell Ampofo Director of Training and Examinations, RCoA

The last time we commented on the Shape of Training (SoT) Review was back in the 2014 guest editorial of the Bulletin discussing the key messages and recommendations outlined in the review. At that time there were sharp intakes of breath from all concerned about what Greenaway’s proposals and outline principles could mean for anaesthetic and intensive care training and what could be feasibly implemented from the review. Some intakes were with optimism about the long-term benefits that the review would bring for training and the wider medical workforce, with aspirations to develop well-rounded doctors and a flexible training system which enables trainees to make informed career decisions when needed. Other intakes were slightly deeper, with a scent of cynicism at the potential prospect of unilateral decisions being swiftly imposed on training and other issues, for example, point of registration. Also at that time the Academy of Medical Royal Colleges (AoMRC) held a workshop for colleges to feedback on what had been published, with an accompanying statement released from the UK Medical Steering Group outlining the following: where training is fit-for-purpose and working well, these processes should remain; where changes to training are required, these should be consistent to the principles outlined in the review; groups should be established in each country to take account of the specific challenges faced by each country. Among the actions indicated within the statement was that colleges undertake a mapping exercise, coordinated via the AoMRC, to explore how more generic training could be developed to meet the current and future needs of patients. However we then entered into the election season and, with that, political purdah, meaning that organisations were not keen to commit to any announcements or make any decisions that could be radically altered by a change of Government.

Fast forward a few months to June 2015 (and a majority Conservative government), and the AoMRC added more detail by announcing that it would continue with its pledge to map medical curricula to the ‘Shape principles’, and therefore to ensure that training produces doctors who are well equipped in terms of their knowledge, capability, experience, attitudes and behaviour to meet the changing needs of the patient population, with the flexibility to continue to meet those needs as they may evolve. Along with the mapping request were 23 accompanying questions, designed to guide each respondent through the full range of issues.

Context There will undoubtedly be a need to train doctors who are able to respond to service requirements now and in the future, whatever those challenges may be. We know that the needs of patients are becoming more complex and more multi-faceted, requiring decision making in more uncertain environments, and

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Guest Editorial that the population is living longer. We are experiencing continuing increases in demand for anaesthetic and pain services right across primary and secondary care, with patients requiring more individualised care for their needs. As services continue to reconfigure new ways of working and new service models are being developed across the UK, the training programmes that we put in place must equip doctors to operate in and lead complex change within the NHS. Raising the profile of perioperative medicine will facilitate the interface of primary and secondary care services, and further embed the interactions of multidisciplinary teams within the hospital.

College response We were keen to ensure we worked collaboratively in order to develop our position and response to the mapping exercise. We initially met with the Faculties of Pain Medicine and Intensive Care Medicine to discuss our shared approach and understand where there was agreement. We then also held meetings with the Joint Royal College of Physicians Training Board (JRCPTB) and the Royal College of Emergency Medicine (RCEM)

to understand their positions, particularly in relation to adopting the Acute Care Common Stem (ACCS) model as a solution to broad-based training and its utility within their proposed training models. We also circulated the mapping questions and initial thoughts to internal committees, Regional Advisers, College Tutors and the Lay Committee. We would like to thank all those who contributed to the consultation process.

Broad-based training The review has an aspiration to encourage more broad-based and generic training at earlier stages of training. We feel that moving more towards an ACCS-type programme which continues to share training with emergency medicine, acute medicine, intensive care medicine and anaesthesia at core level, would meet the direction of travel for SoT. However we appreciate that the current ACCS model would still require some work to ensure it maintains the desired flexibility to truly share competences across specialties, and that some regions may not be able to implement ACCS for all immediately. However, overall ACCS would provide a useful vehicle that could develop a

well-rounded doctor and could lead into specialty training for each of the four related specialties.

Length and content of training Quite fortuitously, we carried out a review of the CCT curriculum in 2014, which concluded that the current training curriculum is broadly fit for purpose to develop an anaesthetist ready for independent practice, and furthermore strongly recommended that training time could not, and should not, be shortened. Dr Devlin’s work in this area (see the two articles in Bulletin November 2014) was helpful in bringing together and analysing over 3,000 responses to provide evidence confirming which positive elements of the current training programme should remain and what other areas could be improved. The curriculum enables the acquisition of learning and experience in handling both emergency and acutely ill patients, and also in decision making about their ongoing care. We have signalled that we would also like to preserve content around teaching and training, management, leadership, academia, research and improvement science, safe and reliable systems, including capabilities outlined

Figure 1 Mapping exercise diagram outlining RCoA vision of future training

Flexible, broad-based training Selection

Broad and generic specialty training Selection

Single CST ICM

Post CST CST

Dual CST

2 years Foundation Training

3 years

5 years

ACTS

Anaesthetic Specialty Training

At least six months each of: • Acute medicine • Emergency Medicine • Anaesthesia • Intensive Care Medicine 12 months of base specialty

ST3 – ST7

Intermediate, higher and advanced training which includes: Neuro, cardiothoracic, general duties, intensive care medicine, paediatrics, trauma and stabilisation, obstetrics, pain

Life-long learning

Page 8 | Bulletin 95 | January 2016

Guest Editorial within the GMC’s Generic Professional Capabilities consultation and embedded within Good Medical Practice.

Credentialing Credentialing remains a hot topic debate amongst Colleges. The mapping exercise attempted to differentiate between preand post-CCT credentials, whereas the GMC consultation on the same subject asked more detailed questions about the concept of ‘tiered’ credential, regulation and ‘authoritative bodies’ who could propose and submit frameworks for credentials, potentially moving us closer to what sounded like an open market for developing modules of training. We have been clear that the SoT Steering Group’s work on credentialing, should not go on in isolation from the GMC’s. There are however potential benefits to credentialing such as developing skills such as sedation skills and stabilisation of the critically ill patient within other specialties. The full RCoA submission to the mapping exercise can be found on the website (www.rcoa.ac.uk/node/20979), but our proposal can be seen from Figure 1 showing: ■■

Further work undertaken to improve the quality of foundation training.

■■

Introduction of an ACCS-type broadbased core training programme, which preserves sharing of training between Anaesthesia, Emergency Medicine, Acute Medicine and ICM.

■■

The maintaining of the current broad specialty training from ST3 to ST7.

Next steps Following our submission, the AoMRC held a seminar of Royal Colleges in October to discuss their submissions directly with members of the UK Steering Group. The meeting was positive and revealed much common ground between specialties, however, quite unsurprising was the fact that no specialty in the room felt that their training programme

should be shortened in duration. The lay and patient view in the room was strong and pragmatic when they proposed that Colleges should try harder to align the format and structure of their curriculum – maybe a potential consequence as a result of implementing the GMC’s generic capabilities. The steering group will be developing a statement in early 2016, shortly to be accompanied by a suite of recommendations to ministers on next steps. Of course we continue to advocate the need for work to be commissioned on the costings and implementation of the SoT proposals. There will almost certainly be some destabilisation of the system unless there is a managed and phased implementation, and we will work through some of these issues with our regional colleagues to continue delivering high quality training.

References 1

Shape of Training: Medical steering group statement. Shape of Training, 2015. (http://bit.ly/1vby5zO).

2

RCoA responses to GMC consultations. RCoA, 2015. (www.rcoa.ac.uk/node/20831)

3

Shape of Training. RCoA (www.rcoa.ac.uk/shape-of-training)

Page 9 | Bulletin 95 | January 2016

Revalidation for anaesthetists

[email protected]  www.rcoa.ac.uk/revalidation

‘Snapshots’ from the report on Quality Assurance of the RCoA CPD Approval Scheme Chris Kennedy CPD and Revalidation Co-ordinator

At this time each year this Bulletin article includes extracts from the quality assurance report for the CPD approval scheme at the College, which is produced for the CPD Board to cover a number of its Terms of Reference, including reviewing the applications received for CPD approval and the subsequent decisions made by the CPD Assessors. During the period from 1 November 2014 to 31 October 2015, details of 1,017 events were submitted to the College for CPD approval, an increase of 85 on the number of applications in the previous 12-month period. The majority of applications received were for events targeted at a ‘national’ audience and most were being held in London, closely followed by the East of England and the North West regions. Of the applications received, 861 were unconditionally approved for the CPD credits applied for, whilst 117 were only approved when further information had been supplied by the event provider; for example, clarification of the programme timings or ‘mini biographies’ of the event faculty, demonstrating their experience to deliver the subject matter. A total of 39 applications were not approved for CPD, which was a slight increase on the number from the previous 12 months, with reasons including that the event content was not appropriate for career-grade doctors or that the events did not come under the category of ‘external’ CPD. The evaluation process only applies to ‘external’ CPD events, because at these

the delegates will have opportunities to meet and share ideas and examples of good practice with doctors from outside their own trust or board. The event evaluations were completed by 71 CPD Assessors – including seven members of the CPD Board, and during this period we were pleased to welcome six Fellows of the College as new CPD Assessors. The College is extremely grateful for the support and expertise of the CPD Assessors in this important role, and applications for new CPD Assessors are very welcome. As part of the quality assurance report, summary delegate feedback was examined from over 100 CPD-approved events. It was noted that the events which received the highest delegate ratings tended to be those which featured a practical component, and it was encouraging to see that many of the event feedback forms included questions prompting individual reflection. Some issues which were identified will be followed up by the College CPD & Revalidation Team; for example, where concerns had been raised about an event’s timekeeping or where the learning outcomes could be more clearly defined. The quality assurance report also details some of the CPD resources which are available at the College. The CPD Online Diary continues to go from strength to strength, and during 2015 the milestone figures of 7,000 and then 7,500 registered users were passed. The CPD web app continues to be a popular resource, and in the first 13 months

since its September 2014 launch it had received in excess of 19,000 visits. Event providers may be interested to know that the CPD Online Diary currently features an option whereby users can review the ‘performance’ of an event they have attended against its stated learning outcomes. Completion of this brief review is not mandatory although some users of the CPD Online Diary do still complete it, and it generates some meaningful data which can be provided, on request, to the appropriate event provider. Other available CPD resources include online learning via the British Journal of Anaesthesia and BJA Education and webcasts – free video recordings of lectures (including lecture slides) from selected College events. The quality assurance report also provides an update on the development of the CPD Framework, which will incorporate many of the features requested in an earlier College Survey on CPD and Revalidation. The full quality assurance report is available in the CPD section of our website at www.rcoa.ac.uk/cpd, or for any further information please contact [email protected].

Page 10 | Bulletin 95 | January 2016

Patient Perspective

[email protected]  www.rcoa.ac.uk/laycom

An Inspector Calls Rob Thompson Chair, Lay Committee

I suppose it is nothing new to criticise a Government Inspector. After all, Nikolai Gogol, a Russian novelist, was poking a stick in the 1840s in his play ‘The Government Inspector.’ He satirised the arrogance of a supposed national inspector and the ineptitude of the local officials as they all rushed around making mistake after mistake. And I suppose it is nothing new to question the current arrangements in the NHS. After all, the Care Quality Commission does seem to be on the end of a lot of critical comments, from both within the NHS and outside it. So if I write a few more negative words I don’t suppose it will make much of a difference. However, having recently been part of an Anaesthesia Clinical Services Accreditation (ACSA) visit, it does seem to me that there is a different way of assuring patients and the public more generally that the NHS and independent sector can provide a high standard of care through the mechanism of quality improvement and peer review. I write this as Addenbrooke’s Hospital in Cambridge has failed to meet the CQC standards, with very public fallout and the (inevitable) resignation of the Chief Executive. What are the good folks of Cambridge to make of it all? Do they cancel their next appointment and travel to...where? After all, the CQC has determined that three quarters of trusts in the country seem to have safety issues. At the same time, Bootham Park Hospital in York, which has been providing mental health care for over two hundred years, was closed literally overnight. With no provision for acute mental health care in York, patients were taken out of the area for inpatient treatment. There was widespread confusion and

worry among the 400 outpatients served by Bootham Park – some of whom had appointments there on a daily basis – about where and when their next appointments will be. The jobs of the hospital’s 300 staff are also in jeopardy. Is this the right way? Can’t we do this better? Obviously it is right that patients and the public (as tax-payers) are assured that their local hospital and community services are up to scratch. In a publicly funded service, which has been ‘ringfenced’ against deep public spending cuts, they also want to know that the money is well spent. However, I am not convinced that the expensive and time-consuming arrangements that are currently in place help to address these basic questions. Nor am I sure that the consequences of such inspections provide any confidence that things will be put right. Respected NHS policy commentators such as Chris Ham of the King’s Fund, have written about the need to transform the NHS, which depends much less on bold strokes and big gestures by politicians than on engaging doctors, nurses and other staff in improvement programmes. Ham writes that NHS reform has relied too much on external stimuli, such as targets and performance management, inspection and regulation, competition and choice, and too little on bringing about improvement ‘from within.’ I take ‘from within’ to include involving those people directly involved in providing care to patients. I think it requires using a wide range of the ‘quality improvement’ techniques pioneered by the likes of W. F. Deming (indeed, a recent King’s Fund article urged Trusts to ‘Do Deming or die’). And it means an end to the regulatory

framework which many have said is not working. I suppose it was with these thoughts swishing around in my head that I undertook my first ACSA visit. My first impression was a pile of paperwork – made manageable by an assumption that we were not able to cover all of the ACSA standards, but that the team would focus on those issues that the hospital may be challenged by. Good use of technology also made the task much easier. Credit must go to the College’s team for preparing the local hospital and developing the iPads, which even I could use. Secondly, the anaesthetic team were welcoming and (whilst anxious) were keen to demonstrate the value and achievements of their services. They had spent a lot time preparing the necessary documents and proof of meeting all the standards; only when they thought they were ready had they put themselves forward. Thirdly the two-day visit was busy but do-able. This was a District General Hospital (more complex sites may need more time – closer to three days) and my overall impression was that this was acceptable for both the hospital staff and the reviewer. It was penetrating and challenging, but without questions for questions’ sake. Fourthly, the process was seen as a positive intervention. The local team said that they had found the preparation daunting, and had actually delayed invitation until some new equipment had been purchased. However, they reported that the upcoming ACSA visit had made the business case for the investment more compelling and successful.

Page 11 | Bulletin 95 | January 2016

Patient Perspective

[email protected]  www.rcoa.ac.uk/laycom

Most importantly, there was a sense of learning and development ‘from within.’ Constructive critique by the reviewers was welcomed, and the team seemed to want to learn and develop. Equally, the local team were keen to promote their work – and the review team wanted to glean ideas and best practice to promulgate elsewhere. A clinician recently quipped, ‘with regulation, it’s a bit like driving down the motorway using the rear-view mirror – it’s about what’s past and the most you can hope for is that you don’t crash!’ Well, that doesn’t seem much of a learning and improvement experience to me.

But am I just seeing ACSA through rose-tinted spectacles? Well, it was my first visit, and they did seem a wellrun, cohesive department aiming to do their best. Other visits may be a more disappointing process – and there may well be many departments who really do need a lot of support and attention. But overall, it seemed a constructive, challenging and productive process. I wonder if the latest CQC visitors and visited can say the same? Of course, ACSA only covers anaesthetic services, and this is but one part of a hospital. But some Colleges cover their own areas of specialty. And what if other

Colleges translated their standards into a similar process? Think of the potential development. Consider the possible buy in ‘from within.’ Salivate on the likely savings, especially as CQC’s budget has grown rapidly to over £200m (plus all the local costs picked up by the visited Trusts). There are also the wider ‘corporate services’, which are not addressed. I suppose the Department of Health Clinical Commissioning Groups, Monitor, Healthwatch, National Institute for Health and Care Excellence, NHS Litigation Authority, Medicines and Healthcare Products Regulatory Agency, Health and Safety Executive and several others are all there waiting in the wings. So, a cry for change? Very definitely. A call in the dark? Very likely.

Figure 1 Lay Committee – work themes

National Audit Projects

Focusing our work Training and Curriculum

PCPIE

Exams

NIAA

Becoming an Anaesthetist

Research and Audit

rative Medi

Patient Info

Working in Partnership AoMRC

PSC

* Perio p

e cn

sia

* Co m m s

I * Anaest

Education and PPA

he

National Advisory Boards

*Q

oe

NELA

Safety

Being an Anaesthetist

CPD

RCS

FPM and FICM

Consultations

Equivalence GPAS

We are keen to support and – where appropriate, challenge – the growing agenda faced by the College. So we have shaped our work around four themes, shown in Figure 1, and we are gradually developing the team to respond in a constructive and coherent way. Please let me know what you think of this approach ([email protected]) and how we may work together in this critical time for the College and the NHS.

ACSA/ QMSC

Revalidation

It is the development of ACSA and other dimensions of the College’s work which have led to a focusing of our work in the Lay Committee.

Page 12 | Bulletin 95 | January 2016

[email protected]  www.ficm.ac.uk

FICM Workforce Andy Rhodes Chair, FICM Workforce Advisory Group

The Workforce Advisory Group (WAG) of the Faculty of Intensive Care Medicine (FICM) is tasked with advising the Council on current and future workforce issues. Making an accurate assessment of future workforce requirements is highly complex, and involves making predictions of future changes well in advance of them actually happening. Usually the factors that drive changes in these areas occur reasonably slowly. More recently, however, a number of pressures are coinciding to provoke a potential crisis. The demand for intensive care medicine (ICM) is increasing year on year. This is in part due to the increasing size of our population, but is also due to the increasing proportion of elderly patients who are more likely to need this level of care and have chronic co-morbid diseases such as diabetes or obesity. The Intensive Care National Audit and Research Centre (ICNARC) have modelled this increasing demand, and have advised the FICM WAG that we should expect to see a 4% increase per year in demand for intensive care beds. This overall figure masks a more pressing need for increased level 2 capacity with a less pressing need for level 3. The Centre for Workforce Intelligence (CfWI) has reported in 2015 on their estimates of the future supply of trained Intensivists. In their estimates they have taken into account new entries into the consultant grade via completion of training or Certificate of Eligibility for Specialist Registration (CESR) and also routes of attrition through early retirement, shift to other work (e.g. management, academia or another primary specialty) or changes to working patterns or shifts. They estimate

that the 6,100 WTE in anaesthesia and ICM may need to increase to as many as 11,800 by 2033. At the same time they estimate that the likely increase in consultants, in reality, during that time is likely to be nearer to the 8,000 mark. This clearly suggests that there may be a mismatch between the supply and demand of Intensivists that can cope with the future requirements. Whilst these predictions are mainly based around changes in the demographics of the population that we serve, there are a number of factors that are currently making these assumptions even more pressing. Recent changes to the training programmes in ICM (splitting out to a single CCT), changes to the junior doctors (and soon the consultant) contract, changes to the pension rules and likely retirement age will all have an influence on future workforce requirements. Somehow we need to be able to attract more young doctors into our specialties and at the same time provide working conditions that facilitate working for longer than many had previously expected. This will require imaginative working patterns, use of novel innovative technologies (for instance telemedicine) and other types of middle-grade cover, for instance an expansion of the Advanced Critical Care Practitioners (ACCP) grade. Whichever way you look at these figures, there is a growing problem. Whilst our problem is not as acute as some other specialties at the moment, it is important that we do not lose focus, as correction of some of these deficits takes a long time. Health Education England are currently prioritising increased training slots to a number of stressed specialties – in particular

general practice, emergency medicine, psychiatry and radiology. ICM is not on that list, although we are lobbying hard for this to be changed.

Page 13 | Bulletin 95 | January 2016

[email protected]  www.fpm.ac.uk

Pain in Secure Environments Project Mike Basler Course Lead for Pain in Secure Environments

The prisoner is not the one who has committed a crime, but the one who clings to his crime and lives it over and over. Henry Miller

Robust epidemiological work informs us that wherever you find poverty, mental health issues and trauma in all forms, then you are likely to find pain. You are also likely to find crime. Where there is prescription medication abuse there will always be illicit drug abuse. It was therefore only a matter of time before the pathways of prison health and the management of chronic pain should cross. It goes without saying that prison populations are different from normal health care groups. Current figures indicate that at any one time there are approximately 80,000 people in prison, with 160,000 others on remand. The health care needs of this population are both significant and complex. Typically they are young male subjects with mental health issues and personality disorders, as well as alcohol, smoking and substance abuse problems. An itinerant population with poor utilization of health care and sparse medical histories, will have many with significant untreated physical as well as mental pathology. Data shows that two-thirds of all prisoners have used one illicit drug in the year prior to incarceration and that 30% of all the people treated for substance misuse in England are in prison. Psychoactive/ CNS drugs account for 30% of all prisons prescriptions, with analgesics not far behind at 15%. Due to issues of drug diversion, medicines like

many other things (including batteries from TENS machines) are a tradable commodity. This and the need for effective and safe therapy has become part of the catalyst for change in prison pain management. Many well-known pain medications including Opiates and Pregabalin, are drugs of abuse in prisons. Not only does this expose prisoners and society to risk, but it also could limit the effective use of these agents in those that need. It is also clear to those in this environment that these are complex issues that mean that guidelines are of limited use and that education is paramount. Prison medication regimes are also unique. An initial decision will be made to allow some medicines to be kept ‘in possession’, but the majority of medication will be given in sight and supervised and the ‘medicine queue’ will form. Prisoners will travel between a variety of sites and agencies, and it is unlikely that the medication will be guaranteed to follow. Pain relief is often caught up between operational issues and genuine concerns for the wider community. Access to physiotherapy is limited but gyms are available. Mental health services are present but the needs are complex and the pathology is often chronic. The setting of the prison is one of the few areas that allows the observation of chronic pain patients and this can help the clinician obtain a clear picture of a patient’s true functional capacity. Initial work centered on the development of the Managing Pain in Secure Settings document – a collaborative work between the Faculty of Pain Medicine (FPM), the Royal College of General Practitioners

(RCGP), the British Pain Society (BPS) and the Department of Health. This dovetailed in with the Pain and Substance Misuse document that had already been produced by the BPS. Thereafter, Dr Cathy Stannard and Mr Kieran Lynch undertook roadshows to disseminate good practice. It was from this project that the Pain in Secure Environments (PISE) training days developed. So far we have had two highly successful days with over 40 participants from a variety of disciplines working in prisons. The days involve lectures, and case studies, and a successful feature of the day, according to feedback, is the collaborative and occasionally provocative discussion between both participants and facilitators. Not only is there much to debate but the cross-fertilization of knowledge is important for all both inside and outside prisons. Facilitators with a broad understanding of key issues are always welcome and there are plans to run several further PISE days in the immediate future. Nelson Mandela stated, ‘no one truly knows a nation till they have been inside their jails.’ Pain medicine and substance misuse have become unfortunate bedfellows in some countries. The PISE project, with several others, is a step in the right direction to ensure safer environments, consistency of practice and ultimately better pain relief for a vulnerable group of individuals. Would the man from Robben Island approve?

ROYAL C O

OF AN AE EGE LL

CC

A

[email protected]  www.rcoa.ac.uk/acsa

TISTS HE ST

Page 14 | Bulletin 95 | January 2016

R E D I TAT I O

N

A Reviewer’s review Bob Evans Lay Committee member and ACSA Reviewer

Do you want to make a difference to anaesthesia services in the UK? Do you enjoy working in a team on intensive projects producing real benefits? If so, whether you are a clinician or a lay person, then you should consider being an ACSA Reviewer.

and early hospital visits, the standards have been the subject of updating and review, again with the opportunity for lay involvement at every point. Annual events for reviewers are positive events and I have been able to attend and relate experiences of a lay reviewer to others.

The Anaesthesia Clinical Services Accreditation (ACSA) scheme is gathering momentum since its inauguration in 2013. A considerable number of clinical directors and trust chief executives are keen to engage with the process. Some will do so because their services are already effective and they seek formal recognition of their excellence. Others may do so to provide a clear framework for a selfassessment and programme of service improvements. As more departments are awarded accreditation, neighbouring trusts do not wish to be left behind.

Once a department has decided to pursue accreditation, it has to undertake a period of self-assessment. This process is valuable for the clinical lead in that it provides time-out to analyse performance as well as an opportunity to engage staff. I remember from my own job experience that such processes can contribute towards team building as well as driving up improvement.

Under the exemplary leadership of past Vice-President Dr Peter Venn, current ACSA lead Dr Simon Fletcher, and College Deputy Chief Executive and Director of Clinical Quality, Mr Charlie McLaughlan, the ACSA process has developed on a sound foundation with a comprehensive set of standards. These in turn draw on recommendations in the Guidelines for the Provision of Anaesthetic Services (GPAS) and both sets are reviewed annually. The rigour of the process is recognised by other national bodies, including the Care Quality Commission (CQC). A particularly rewarding aspect of ACSA work for a lay person is that involvement can take place across the board. I have contributed to sessions which first set out the ACSA standards and their five domains. Following pilot studies

When the self-assessment is completed, a review team comprising a lead clinician, a second anaesthetist, a lay reviewer and an administrative reviewer is appointed. Preparations for the on-site visit begin. The ACSA review team will discuss which particular standards will be observed on the basis of the self-assessment. The lay reviewer will normally focus on the Patient Experience domain. The overall objective will be to review compliance with the standards. The on-site visit itself is the culmination of much effort, both for the department staff and the review team. It is a very intensive period involving careful observation and considered questioning. There can be no indication on site of the likely result of the visit, but despite the formality and objectivity of the process, it is interesting to relate to the staff of different hospitals. It is especially rewarding to see how the self-assessment has already brought about improvement and how the whole process has helped

reinforce staff engagement and team spirit, not only in the anaesthesia department, but in the trust as a whole. The work of the Lay Committee is embedded in the ethos of the Royal College of Anaesthetists. This is evident nowhere more than in the ACSA process. It is a privilege for me to be a part of this, and I am grateful for the opportunity to contribute. Come and join me! For further information on ACSA please contact the ACSA team at [email protected].

NIAA

Page 15 | Bulletin 95 | January 2016

National Institute of Academic Anaesthesia

[email protected]  www.niaa.org.uk

Chronic pain after caesarean section Katie Warnaby, Senior Research Scientist, University of Oxford Nicola Beale, Consultant Anaesthetist, Oxford University Hospitals NHS Trust Robin Russell, Consultant Anaesthetist, Oxford University Hospitals NHS Trust Jane Quinlan, Consultant in Anaesthesia and Pain Management, Oxford University Hospitals NHS Trust

This project was supported by an OAA Project Grant via the National Institute of Academic Anaesthesia in 2010. To access an archive of progress reports from successful studies funded via the NIAA go to: www.niaa.org.uk/NIAA_Research_Projects.

Chronic pain after surgery is a recognised clinical phenomenon that has generated considerable research interest over the last two decades. In 1998, a survey of over 5,000 patients attending pain clinics found that 23% of patients identified previous surgery as the initiating factor for their current chronic pain.1 This early work highlighted the potential extent of the problem, and recent data suggest that the prevalence of chronic postsurgical pain (CPSP) in the general population may be even higher, e.g. up to 40% in Norway.2 What is yet to be fully established though, is why some patients make the conversion from acute to chronic pain whereas others do not. Ultimately, if we can identify patients with the highest risk preoperatively, we can intervene with targeted treatment regimens for vulnerable patients to prevent the development of long-term pain.

What is CPSP? It is well known that an individual’s experience of chronic pain is determined by a number of psychological, social, environmental, genetic and biochemical factors. Recent work in the pain research field has highlighted the importance of resilience or vulnerability to chronic pain. Genetics (genotype/gender), environmental factors (stressful life events/injury at critical moments) and their interaction (personality traits such as anxiety, catastrophizing and

pessimism) potentially prime the central nervous system to induce changes in neuromodulatory pathways that increase the risk of developing chronic pain.3 Recent guidance from the International Association for the Study of Pain (IASP) brings the definition of CPSP in line with that of chronic pain, as pain that persists for more than three months after surgery (i.e. pain extending beyond the normal tissuehealing time). Additionally for CPSP, all other causes of pain (e.g. infection, recurring malignancy) or pain from a pre-existing painful condition must be excluded.4 Prospective and longitudinal investigation of CPSP therefore offers insight into why some individuals are vulnerable to the development of chronic pain.

What makes some people more vulnerable than others? The reported incidence of CPSP varies widely from 9-70% across the surgical cohorts investigated in previous studies5, with low rates associated with operations such as hip replacement, and high rates following thoracic or breast cancer surgery. It was initially suggested that the main contributor to CPSP was neuropathic pain due to nerve damage during surgery, with secondary contributions from inflammatorymediated tissue injury.6 Systematic reviews have since shown that there is an increased likelihood of neuropathic pain for operations where CPSP is most

prevalent, namely thoracotomy and breast cancer related surgery where the incidence of neuropathic pain is around 67%.7 However, it is clear that this does not explain the whole situation across all surgical cohorts, as only 43% of individuals have pain that is neuropathic in nature.8 Various risk factors have been independently associated with the development of CPSP, including preexisting pain, psychological factors, surgical technique and genetics.6,9 However, very few studies have investigated all factors within one study population. Subsequently, in recent years, there has been a move within the research community to develop standardised datasets with core outcomes10 that ultimately allow big data analysis approaches. Five core risk-factor domains have been identified: patient demographics (e.g. younger age, lower socio-economic class), surgical-related factors (e.g. longer duration, invasive technique (i.e. open vs laparoscopic)), clinical factors (e.g. number of co-morbidities) as well as pain and psychological factors. Interestingly depression, psychological vulnerability and late return to work have shown probable correlation with CPSP across all surgical cohorts.5 However, one of the most marked risk factors is the presence of preoperative pain (either unrelated or at the site of surgery) and the presence of severe acute pain in the first seven days after surgery.

NIAA

Page 16 | Bulletin 95 | January 2016

National Institute of Academic Anaesthesia

[email protected]  www.niaa.org.uk In terms of outcome following surgery, it is not just the presence or severity of CPSP that needs to be addressed but the effect on quality of life, as this has the biggest personal and public health impact. Furthermore, it is important to investigate fully the characteristics of the pain experienced: for example, the pain location, its sporadicity, whether it has neuropathic qualities, and its trajectory in the days and months following surgery. All of these variables may enable identification of certain individual phenotypes of CPSP that require different interventions to prevent chronification.

Does CPSP occur after caesarean section? Caesarean section (CS) is one of the most commonly performed surgical procedures in the UK, with a quarter of women now giving birth surgically. The incidence of CPSP has been variously reported as 30 kg/m2) and morbid obesity (BMI > 40kg/m2) in the UK are increasing at epidemic proportions. Since 1993, obesity has increased from 13.2% Sarah Stobbs ST6, South East Scotland School of Anaesthesia

Nick Kennedy Consultant Anaesthetist, Musgrove Park Hospital, Taunton

to 24.4% in men and in women from 16.4% to 25.1%.3 In 2012, 42% of men and 32% of women were overweight (BMI ≥ 25kg/m2). Forecast reports estimate that by 2050, the prevalence of obesity will rise to 60% of males and 50% of females.3 In 2014, the National Child Measurement Programme in England reported 33.5% of 10-year-olds were overweight or obese: this is increasing every year.4 Trainees will be encountering these patients both as children today and as adults in the future (Figure 1). The complex co-morbidities associated with obesity are multisystem (Table 1) and are often the reason for surgery, e.g. orthopaedic

Figure 1  Prevalence of underweight, healthy weight, overweight and obese children by NCMP in year 6, 2006/07 to 2013/14

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Table 1  Co-morbidities associated with obesity System

Example

Respiratory

Obstructive sleep apnoea Asthma Reduced functional residual capacity

Cardiovascular

Hypertension Ischaemic heart disease Right and left heart failure

Gastro-intestinal

Fatty liver Cholelithiasis

Orthopaedic

Osteoarthritis Reduced mobility

Haematological

Venous thromboembolism

Neoplasia

Pancreatic, colorectal, breast cancers

Psychological

Depression Anxiety

joint replacements, cholecystectomy. Difficulty with all aspects of the anaesthetic is universal. Out-of-hours, obstetric obesity can also present difficulties for the resident trainee. During pregnancy, 4.99% of women have a BMI >35 kg/m2 (approximately 38,478 pregnancies per year) and 2.01% of women have a BMI >40 kg/m2. The latest Centre for Maternal and Child Enquiries (CMACE) report of maternal obesity demonstrated an increased caesarean section (CS) rate of 37% in women with BMI >35kg/m2 (compared to 25% national average). This increased further to 46% in women with BMI ≥50 kg/m2. Obstetric complications also increase, such as preeclampsia and stillbirth. 38% of women with BMI ≥35 kg/m2 suffer post partum haemorrhage (PPH), four times higher than the general obstetric population. PPH risk increases by 2.6% for each BMI unit increment over 35. Obesity increases the frequency and difficulty of anaesthetic intervention, including the risk of difficult intubation, difficult facemask ventilation and failed regional anaesthesia. General anaesthesia was administered in 7.7% of all CS in obese parturients, compared to 5.5% in the general obstetric population.5 The British Association of Day Surgery advises that obesity should no longer contraindicate day surgery, as long

as appropriate care is provided by an experienced team.6 Obese patients have much to benefit from the day case enhanced recovery ethos. Providing optimal care to this patient group is therefore increasingly important.

A surgical solution? Our society’s demographics are changing, and with it there is an increasing acceptance of bariatric surgery to treat morbid obesity. It is becoming a recommended treatment for type II diabetes:2 being associated with significant and sustainable disease remission – especially within 5 years of diagnosis.7 Bariatric surgery can also significantly improve or cure comorbidities such as hypertension, high cholesterol, sleep apnoea, gastrooesophageal reflux disease, liver disease, and arthritis. Surgical techniques have developed from original techniques with high complication rates, such as jejunoileal bypass; to procedures now almost always performed laparoscopically, including gastric bypass sleeve gastrectomy and adjustable gastric banding. The UK mortality rate is 0.1%, and complications are low.8 UK-based estimates suggest that the health consequences of obesity cost the economy £5 billion per year, and that this will double by 2050.9 Bariatric surgery has proved to be clinically

and cost effective, and has been recommended by NICE in those who are BMI>40 or BMI 35-40 with remediable co-morbidity (including diabetes and hypertension). Additional benefits of surgery include reduced future NHS and improved comorbidities: all of which will increase demand for bariatric surgery. Undiagnosed obstructive sleep apnoea is frequently identified and treated at surgical pre-assessment – as well as improving anaesthetic safety, this can improve productivity and reduce road traffic accidents. National reports highlight the requirement for improved anaesthetic care in obese patients. Obese patients were vastly over-represented in NAP4 case reports: this highlighted inappropriate use of supraglottic airway devices, under-appreciation of obesityrelated airway difficulty and underdiagnosis of obstructive sleep apnoea.10 Accidental awareness under general anaesthetic was also reported as greater in the obese patient in NAP5. This has been potentially attributed to dosing errors, airway management issues and an anaesthetic ‘gap’ between anaesthetic room and theatre. The NCEPOD report into bariatric surgery in the UK recommended greater experience and improved multidisciplinary preoperative assessment.

Training experiences Bariatric surgery and obesity fellowships are geography-dependent, and out-ofprogramme experience may therefore be the only opportunity to gain an important transferable skill set (Table 2). A recent survey suggested that trainees feel that some higher level subspecialty training will be of limited future relevance.11 A period of training in bariatrics and obesity will certainly benefit all anaesthetists. Many do not perform anaesthesia for bariatric surgery, and may therefore incorrectly assume that it will not concern them. However, surgical complications may have to be managed in the NHS, in non-bariatric units, and it is therefore useful to have an

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Table 2  Advantages of a bariatric surgery attachment Knowledge of surgical procedures Appreciation of non-surgical management, including gastric balloon placement and supervised dieting regimes Experience of obesity pre-assessment and risk stratification Awareness of equipment, staffing and infrastructure requirements for a bariatric service Transferable skills: management of sleep apnoea, ventilation strategies, non-opioid analgesic options such as IV lidocaine, management of difficult airways and difficult regional anaesthesia Challenges common myths, e.g. RSI in obesity, drug dosing Competence and confidence in managing high-risk obese patients and the ability to lead this in a department as a consultant

understanding of the procedures performed and what complications can arise. In addition, patients can subsequently present for unrelated surgery with gastric bands or balloons in situ, requiring specific consideration of nutritional status and regurgitation risk. We believe that obesity and bariatric anaesthesia is becomingly increasingly part of NHS practice and therefore should become a more significant part of the anaesthetic training curriculum – with formal inclusion of relevant anaesthetic techniques and specific competencies that could be completed by all exposed to the obese patient. For those interested, it would be beneficial to add bariatric and obesity anaesthesia as an optional unit in training. Appointment of obesity leads in hospitals, as recommended by the AAGBI, would give more focus on the subject on a day-to-day basis in training. Other opportunities to develop a subspecialty interest and to meet training needs include ‘taster’ attachments to bariatric units and attendance at national and international meetings. The Society for Obesity and Bariatric Anaesthesia (SOBA) is an AAGBI specialist society with more than 200 members. The SOBA website (www.sobauk.co.uk) includes guidelines and information about educational days and events, as well as contact details for available fellowships and taster opportunities.

Declarations of interest VH is a trainee representative for SOBA. NK is the past Chairman of SOBA.

References 1

Response to the Shape of Training Review. RCoA (www.rcoa.ac.uk/node/12026).

2

NICE guideline: CG189. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults. NICE 2014.

3

Health and Social Care Information Centre. Statistics on Obesity, Physical Activity and Diet: England 2014. Health and Social Care Information Centre. National Child Measurement Programme: England, 2013/14 school year. (http://bit.ly/1ETARLi). (Figure re-used with permission).

4

Centre for Maternal and Child Enquiries. Maternal obesity in the UK: findings from a national project: Executive Summary and Key Recommendations 2010. (http://bit.ly/1bEXgAX).

5

Peri-operative management of the morbidly obese patient. AAGBI, 2007. (http://bit.ly/1lJYTDX).

6

Brethauer SA et al. Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg 2013;58(4):628-636.

7

Welbourn R et al. National Bariatric Surgery Registry Report 2014. British Obesity and Metabolic Society Surgery 2014. (www.nbsr.co.uk).

8

Tackling obesities: future choices – project report (2nd edition). Government Office for Science 2007. (http://bit.ly/1Gd9RGI).

9

4th National Audit Project: Major Complications of Airway Management in the UK. RCoA 2011. (www.rcoa.ac.uk/nap4)

10 Devlin, A. Curriculum review project update. RCoA Bulletin 2014;88:28-29.

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Anaesthetic Impact Calculator: a smart phone app to derive the environmental and financial cost of inhalational anaesthesia Sustainable development The term sustainable development (SD), first coined by Gro Harlem Brundtland in 1987,1 refers to development which meets the needs of the present without compromising the ability of future generations to meet their own needs. SD is a visionary paradigm2 representing the convergence of the three pillars of social equity, economic development and environmental protection. Few disagree, yet despite this, the concept remains elusive, implementation has proven difficult and importantly, atmospheric CO2 continues to rise. Kevin Scott Sleekwater Software

Charlotte Jenkins Medical Student, Southampton University

Sustainable anaesthesia Extending SD to anaesthesia, practically then, we should reduce resource use and at the same time minimise the environmental impact whilst remaining socially equitable. In other words both lean and green. Pharmacists and our clinical directors remind us that isoflurane is less costly than sevoflurane. Environmentalists inform us that volatile anaesthetics are greenhouse gases; sevoflurane has the least global warming effect and desflurane the greatest. But how costly and how much warming? We describe here an easy to use, free Android app that calculates both the cost (in one’s chosen currency) and the CO2e (kg CO2 equivalent) per hour of one’s inhalational anaesthetic.

A few definitions The Global Warming Potential (GWP100) of a greenhouse gas (GHG) is the atmospheric warming effect that the GHG exerts over 100 years. By definition the GWP for CO2 is unity. The GWP of anaesthetic agents are: nitrous oxide 310, sevoflurane 130, isoflurane 510 and sevoflurane 2540.

JM Tom Pierce Environmental Advisor to the President, RCoA

The carbon dioxide equivalence (CO2e) is the amount of CO2 that has the same warming effect as the particular GHG over 100 years. It is the product of the mass released and the GWP. For example, the 3.4 kg nitrous oxide (N2O) contained in a size E cylinder has a CO2e of 3.4 x 310 = 1054 kg and a 240 ml bottle of desflurane (mass 352g) 0.352 x 2540 = 894 kg.

Embedded carbon vs atmospheric effects For most drugs, procurement, including the extraction of raw materials, refining, manufacturing, packaging and distribution, are the most energy dependent part of the life of the drug and where most carbon can be thought to be ‘embedded’. As inhalational agents persist in the atmosphere, sometimes for decades, the longer the tropospheric life time the greater the proportion of the GHG effect that is due to the agent rather than the procurement process. The relative atmospheric effects are 5, 15 and 47 times greater than to procurement for sevoflurane, isoflurane and desflurane respectively,3 reflecting their progressively longer tropospheric life.

Calculations and assumptions If the fresh gas flow (FGF) and the vapouriser setting are known, then it is possible to calculate the mass of inhalational agent and N2O used per unit time. However certain assumptions need to be made: ■■

The vapouriser output is the same as the chosen vapouriser setting.

■■

Volatile anaesthetic gases behave as ideal gases and 1 mol occupies 24.4l at SATP.

■■

The ideal gas equation can be applied to describe the volume occupied by a molar mass at 15oC. This temperature was chosen as it is the temperature at which BOC describe cylinder contents of gas.

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Converting to smart phone app A rough prototype was created for Android to prove the concept and to check that the formulas from the Excel spreadsheet described above could be converted reliably into code. The prototype was published to the Google Play store as a private Alpha.

The screen appearance of the Anaesthetic Impact Calculator. The FGF is set by either sliding over the rotameters or rotating the flow controllers. The vapourisers are set by swiping the vapouriser control. In the example, isoflurane is the leanest but sevoflurane is the greenest.

The CO2e is derived from the product of mass and the GWP100. The mass of vapour is obtained from the FGF and vapour concentration to calculate the equivalent number of moles. The mass is obtained from the product of moles and molecular weight (MW).The MW of N2O is 44, isoflurane 184.5, sevoflurane 200 and desflurane 168. Allowance

has been made for 4% metabolism of sevoflurane. All other agents are considered to be minimally metabolised and exhaled unchanged. The carbon intensity for oxygen manufacture has been taken as 200 ml CO2 per litre of oxygen supplied – a guesstimate.

Costs and prices Whilst prices may vary according to local contracts the following are representative NHS costs. Vapour

Cost

Notes

Oxygen

0.004 pence per litre

Supplied at £4.40 per 105 l from liquid oxygen to pipeline*

Nitrous oxide

0.23 pence per litre

Supplied at £20 per 9000l size G cylinder*

Isoflurane

£10 per 250 ml

Density 1.496g/cm3 (20C) Mass 0.374 kg / bottle

Sevoflurane

£80 per 250 ml

Density1.517g/cm (20C) Mass 0.379 kg /bottle

Desflurane

£75 per 240 ml

Density 1.465g/cm3 (20C) Mass 0.352 kg/bottle

3

* Michael Winer BOC Personal Communication

The mass of volatile used divided by the density gives the volume of liquid agent used, from which the cost can be calculated. The GWP and costs for each agent and the vapouriser setting and FGF for one’s anaesthetic have been combined into an Excel sheet: this can be found at http://bit.ly/1MDTtjI and the instructions for use at http://bit.ly/1NniimV

The application was developed using Unity (www.unity.com). Unity allowed us to develop a fully graphical skeuomorphic user interface to resemble a real anaesthesia machine. Unity also supports a range of operating systems so that the final application can run on Android, iOS or Windows. Unity is free for small companies. Graphics for the user interface were developed from a photograph of a GE anaesthesia work station. Each part of the UI was drawn in Inkscape (http://www.inkscape.org) and exported as a png image. Each rotameter control knob is a separate graphic, and they are imported into Unity as 2D sprites. C# code scripts were attached to each sprite, so that they would animate and react to user input. For example, the rotameters can be used as sliders or the rotameters knobs can be spun to change settings. As each sprite changes, a central C# script performs the calculation for the cost and CO2e for each volatile agent and updates the numbers shown. Once the initial code was complete, the application was published as a private Alpha on Google Play and the Windows version emailed privately as a zipfile. This allowed regular feedback on changes. In real life you will use a single inhaled agent, and the application originally mimicked this. Since we wanted to highlight the relative costs and CO2e for each agent, the application was altered so that multiple agents can be selected, with each agent having its own inhaled concentration. The graphic also illustrates the effect of changes in FGF. The app allows the user to adapt the inhalational cost to suit their local costs or currency. Should new data become available redefining the GWP of

Page 47 | Bulletin 95 | January 2016

inhalational agents those values can be altered too in a settings screen. The app is available as a download here: http://bit.ly/1XEoRWU or search for Anaesthetic Impact Calculator on Google Play.

What the app does not account for No account has been taken of the carbon intensity of procurement of inhalational agents or the impact of running air compression, purification and delivery plants. Whilst a contribution for the carbon intensity of oxygen manufacture has been included, the cost of pipeline oxygen is negligible and has been ignored. Cylinder supply of oxygen costs 0.38 pence/litre from a size E cylinder and if this is the oxygen source then allowance needs to be made. The app does not describe the ozone depleting effect of exhaled and scavenged nitrous oxide.

The next steps The Excel® calculations are simple mathematics and, given the appropriate anaesthesia work station, could be incorporated into the software to present these data automatically. This is currently the only mobile ‘phone app of its type and, given the constraints that exist when using an Apple platform, only available currently on an Android platform. The authors understand that an iOS version is being developed at Yale University. By the time this article is published, we expect our version will be available in iOS and free to Apple users. Published in late September 2015, this is new technology; the impact on behaviour, FGF and vapour use has yet to be evaluated. It is not known whether being cognisant of the environmental and/or financial impact make anaesthesia greener or leaner. The authors are keen to develop the app to include a TIVA component, though this will require cooperation from industry in order to provide details of the embedded CO2 within drug procurement processes. Thus

far. Feedback from users has been overwhelmingly positive.

Cost of app development The app software development costs were borne by one of the author (JMTP).

Further reading For a more extensive description of atmospheric science and anaesthesia please consult Reference 4.

References 1

Report of the World Commission on Environment and Development: Our Common Future (http://bit.ly/1bZJgwk) (accessed 15 October 2015)

2

Sustainable Development: From Brundtland to Rio. (http://bit.ly/1jGKLo4) (accessed 14 October 2015)

3

Sherman J et al. Life cycle greenhouse gas emissions of anesthetic drugs. Anesth Analg 2012;114(5):1086-90.

4

Campbell M, Pierce JM Tom. Atmospheric science anaesthesia and the environment. BJA Education 2015;15:173-179.

Page 48 | Bulletin 95 | January 2016

The sweet life: ‘la dolce vita’ The Italian Trainee in London: My story with a little Italian Lesson!

Our contract allows Italian registrars to spend up to 18 months in another European Union public hospital, in order to obtain expertise in a specific area whilst maintaining a salary from Italy. I have always been interested in major trauma both from an anaesthetic and intensive care point of view, from the role in ED during initial stabilisation, to that in theatre and again in ITU.

Flavio Severgnini The Royal London Hospital

The Italian trauma network, which resulted in the foundation of Italian Trauma Centres and their integration with the pre-hospital emergency system, is a recent development. Indeed in some respects it is still a ‘work in progress,’ with many regional variations in practice. So at the beginning of 2013 I made contact with the Royal London Hospital, one of the four main major trauma centres in London and the base of the famous HEMS, to try to arrange an educational period in UK. I think you call it an OOPE (Outof-programme-experience). I joined the General Medical Council with ease (thanks to the European Union agreements), but then had to face the language, system and bureaucracy to arrange the experience, which struck me as being as difficult to navigate as the Italian system! At the end of December 2013, thanks to contact with Dr Breda O’Neill at the Royal London via an Italian contact Dr Elisa Bertoja from University College London Hospital, I finally obtained an honorary contract within the anaesthetic department at the Royal London Hospital (RLH) for six months, with a view to extension. So, within one month I left my flat in Milan, packed all my belongings into 15 big boxes and flew to London. First of all, I had to find a place to stay, and after searching the internet, I found a flat located in the Bromley-by-Bow area, with a nice Italian flat mate! I faced massive bureaucracy opening a UK bank account – ‘MAMMA MIA!’ (I couldn’t use my Italian one regardless of my EU status). I also had to arrange a mobile phone contract, GP, and so on.

“I think you call it an OOPE”

On the 4 February 2014, I had my first day and ‘induction’ at the RLH. That day was rainy (I hadn’t realised yet that this is normal in the UK) and there was a tube strike! So I had to

run about 4 km (sorry I’m still not able to use miles), from my home to the hospital, in the rain. I was 30 minutes late and soaked when I arrived at induction. Not a good way to start? But I was so happy ‘FELICE’ as I had finally made it to my new hospital in the UK. The biggest problem at the beginning was the language. I have studied English and I thought I was quite good, but when I arrived I realised that it was much more difficult than expected, and even if I knew the correct grammar, the pronunciation was completely different! I could understand maybe one third of what I was hearing. I remember on that first day, the security man asked me almost eight times ‘What’s your date of birth?’ so that he could issue my ID badge. It sounds to me like ‘deitofborf’.. What? ‘CHE COSA?’ And to make things more complicated pronunciation is very different depending on which part of UK (or outside UK) you come from… The simple word ‘blood’ may sound to me as ‘blood but even bluud, blaad…’ Help! ‘AIUTO’! Fortunately, NHS staff are accustomed to diversity and multi-ethnicity and they didn’t have any problem repeating 3-4-5 times until I got it, often acting as if nothing had happened when I made some blunders. Maybe the odd ‘giggle’, which I eventually joined in with, but at the beginning it was very hard for me. From the clinical point of view, anaesthetic practice in Italy and the UK is very similar. The same drugs, same instruments and same equipment, same anaesthetic machines, same standards… This made it easier for me! But, the Registrar role in the UK is completely different from Italy. In Italy, a Registrar is a sort of student until the end of the specialty school. He or she has to be supervised by a Consultant

Page 49 | Bulletin 95 | January 2016

the whole time. They can’t be in theatre or covering ITU shifts alone, they can’t admit or discharge patients, they can’t write down any clinical notes, they can’t even prescribe paracetamol without a consultant countersignature! Furthermore in Italy, the head of the department is a very strong figure that decides and plans all the work and makes clinical decisions that everyone else has to accept (particularly in ITU). Unlike in the UK, every Consultant makes his/her own clinical decisions and the heads of the department have a managing and organisational role, as much as a clinical one. In the UK, registrars act in a completely different way: senior registrars are alone in theatres and registrars are alone during the night and weekend with the consultant on call from home. This is unthinkable in Italy! ‘IMPENSABILE!’ So my autonomy level had to increase very quickly in the UK. Here no one countersigns my decisions, or is behind me every single minute, even if I have a mentor consultant assigned all of the time. Another big difference is protocols. In UK there is a protocol or a guideline for nearly everything. Many ‘MOLTISSIMI’ protocols, from how to wash your hands to how manage haemorrhagic shock in trauma. This is an advantage for the newcomer and is helpful ‘UTILE’ to avoid big mistakes thus providing safer patient care. In Italy, it is often left to good sense and experience, but probably this generates more errors and we could do with more ‘PROTOCOLLI’. However, following a protocol all the time does take out that ‘mental flexibility’ that is often very helpful in our job. And in this, Italians excel… finding creative solutions for strange problems. Solutions that often work! Sorted!’ ‘RISOLTO!’ In Italy, we don’t have ODPs. Usually, a theatre nurse helps you during induction and emergence, but most of the time you have to do everything by yourself... from preparing the tube and laryngoscope to the monitoring of the patient.

Flavio and the theatre team

For me, interacting and communicating with someone else that is helping me is not easy, even now, and requires a big effort and an increase in confidence. If I know the ODP and I trust ‘CONFIDENZA’ them I’m very happy to have them now! Continuing with differences (‘DIFFERENZE’), the working pace is hugely different. In the UK working days and hours are well defined and the same for annual leave and days off. In Italy, registrars (and consultants too!) don’t have a set rota, and usually they work even 60 hours per week. Often they can’t obtain annual leave when they want, and often they can’t even use all of their annual leave that they are entitled to. When sickness or unexpected leave occurs, working doctors must cover the shifts of their absent colleagues. An amazing thing that British people take into serious consideration is the patient pathway and the safety system. Guidelines and protocols, revisions, debriefings, M&M’s and educational meetings regularly take place in UK hospitals in order to improve patient care. In Italy, this doesn’t happen so systematically. For example, after a patient death in theatre the best we can expect is an informal discussion with the team members. In the UK the ‘improvement process’ takes place every single day. By the way, do you know another funny thing that I have noticed here?

Managers! How many managers do you need to run a hospital? Here there is a bed manager, site manager, ward manager, staff manager, nurse manager... Wow! Unbelievable! (INCREDIBLE!) And sorry to say (SCUSATEMI!), but this doesn’t result in a more efficient system. Maybe I shouldn’t say this considering the profound crisis that is affecting the Italian health system, but I’m absolutely sure that the crisis in Italy is not due to an inefficient system, but most of all to the squandering of resources and political incompetence. Even in the ED things are very different. First of all, in Italy the ED Doctor doesn’t exist. The Italian School in Accident and Emergency medicine started just a couple of years ago. In most of the Italian EDs there is an internal medicine doctor, a surgeon, and an anaesthetist/critical care doctor. And always ‘SEMPRE’, in all life threatening situations, high risk or seriously injured patients, the team leader is the anaesthetist. Here at the Royal London, the anaesthetist is one of the members of the team, and most of the time the team leader is the ED Doctor. So being in the team from a different perspective and letting someone else (not an anaesthetist!) make decisions for the patient was quite strange for me. The last big difference is the salary. The Italian salary for a registrar is about 1700 Euros a month pre-tax without any possibility of being paid for extra shifts

Page 50 | Bulletin 95 | January 2016

or doing private practice for agencies. And I can assure you that the cost of the life in Milan is similar to that in London. What am I missing most from Italy? No doubt: the food (‘CIBO’)! In London there are many good Italian restaurants but the ‘everyday food’ is awful. The hospital canteen is very different from what I’m used to… Sometime I miss the sun (‘SOLE’) and warmth too… but my first summer here (‘ESTATE’) the world turned upsidedown: in Italy it was very rainy: instead in London we had a nice summer! After the first six months here, my honorary contract was extended, and I’m still working at the RLH. I’m rotating through all different theatres, I’m covering ITU shifts and ‘anaesthetic coordinator’ shifts. I have had invaluable experience managing trauma patients, and I think I’ve attended more than 30 ‘code reds’. (In Italy we call it CODICE ROSSO). My English is more fluent, and I’m perfectly integrated into the hospital system thanks to my fabulous colleagues, who have tried to make me feel comfortable. I have made new friends, and now I can say that London is actually my city. I am exploring the UK and I still have so much to discover ‘SCOPIRE ’! I’m finishing my training and starting as a locum consultant at the London even if I still have an unrealised ambition to work in Australia. Let the Dolce Vita continue and see where it takes me! Let’s wait and see ‘STAREMO A VEDERE...’ With thanks to Annie Hunningher, Alastair Mulcahy and Breda O’Neill for their help.

ASWEWERE

by Dr David Zuck, History of Anaesthesia Society

Page 51 | Bulletin 95 | January 2016

Senior Fellows Club Report Chaired by Ian Calder, 15 October 2015 Over one hundred and twenty members were present. Ian Calder has taken over as Chairman from Kwee Matheson. Liam Brennan, our new President updated us on current issues. The (non) negotiations over new contracts and ‘seven day working’ make for interesting times. Liam was his usual cheerful self, but such are the difficulties besetting the NHS that somehow I kept hearing Nat King Cole singing ‘there may be trouble ahead’. We wished our President luck. Dr Brennan introduced us to our new Chief Executive, Tom Grinyer, who has moved from the RCP. Anne Thornberry updated us on ‘The Lives of The Fellows’ project. Anne pointed out that we are lagging behind other Colleges in documenting the careers of our distinguished predecessors. Details of how to go about making a contribution can be found on the College website, and Anne can be contacted at [email protected]

Dr Anne Thornberry

The main business of the day was a lecture on ‘The Legacy of the Anaesthetic Events at Pearl Harbour’, given by Dr John Crowhurst of Adelaide. John had been told during his first anaesthetic job, that thiopentone caused more deaths at Pearl Harbour than Japanese bombs and torpedoes, and this myth has persisted – a show of hands revealed that most of us had been similarly misinformed. Anaesthesia in 1941 was a Cinderella subject, in which surgeons had taken little

Dr John Crowhurst

interest. There were only nine certified anesthesiologists in the USA in 1939, and not one physician anaesthetist at Pearl Harbour. Experience in the management of severe trauma was very limited, possibly because there were still relatively few road traffic accidents; a massive disaster like Pearl (1,000 casualties requiring anaesthesia in 24 hours) was unprecedented. The medical facilities were overwhelmed, and although inexperienced anaesthetists did remarkably well, it was recognised that the medical services lacked the skills required to treat victims of major trauma. The consequences of attempting to anaesthetise unresuscitated patients were clearly demonstrated. Inexpert administration of thiopentone did cause cardiovascular depression, and probably a number of deaths, as did spinal anaesthesia, ‘the ideal form of euthanasia in war surgery’ according to a British observer. The subsequent growth of the specialty of anesthesiology in the USA was ‘phenomenal’, and the UK and Australasian Colleges of Surgery set up Faculties of Anaesthesia. I doubt whether many, or even any, of us had realised the seminal nature of the dreadful events of December 7th 1941. We owe the casualties of Pearl Harbour a very great deal, their legacy

has been enormous improvements in our management of trauma, and an understanding of the vital nature of the specialty of Anaesthesia. Dr Crowhurst has performed an important, and overdue, service in drawing our attention to this.

Future meetings Tuesday 14 June 2016 at the RCoA, ‘Horatio Nelson: his Wounds, the Seventh Commandment and the Festival of Priapus’ by Dr Simon Harris. Thursday 3 November 2016 at York Railway Museum, Howard Driver of the North Yorks Mountain Rescue Association.

Page 52 | Bulletin 95 | January 2016

Letters TO THE

Editor

is one of The Royal College of Anaesthetists (RCOA) auditable standards3 and The National Patient Safety Agency (NPSA)4 did issue an alert in 2010 regarding the same. b

Placenta Site: This needs to be highlighted at the time of team briefing especially when it is low lying or anterior or in cases of placenta praevia at the time of caesarean section (LSCS). This enables the theatre team to prepare for obstetric haemorrhage, which still contributes significantly to morbidity and mortality in obstetric units throughout UK5.

c

Hydration: This is relevant to most lists. This enables the theatre team to liaise with ward staff, who can continue to administer clear fluids to patients at least two hours before surgery6. We have found this a very useful addition especially in paediatric population; geriatric cases listed as on trauma lists and on day-case surgical list. Further it maintains communication between the theatre team and ward staff.

d

Bone Cement: This is to be recommended by The Association of Anaesthetists of Great Britain and Ireland (AAGBI) for orthopaedics and trauma theatres. This is to alert the team about the risk of bone cement implantation syndrome (BCIS), which can affect almost 20% of patients having a cemented hemi-arthroplasty. This allows roles to be assigned during the team brief in order to be prepared to manage BCIS especially when it’s severe.

e

Research: We have now included this at the team brief to make sure that the theatre team are aware of the timing of any blood samples, or any other research intervention, that needs to be carried out. It also ensures that the appropriate equipment that is needed for the intervention/research is available in a timely fashion.

[email protected] | www.rcoa.ac.uk/letters Dear Editor We read McGlennan and colleagues’ article about the development of perioperative medicine with interest1. In 2011 the NCEPOD report highlighted a mortality rate of 10-15% in high-risk patients, and called for improved and more coordinated perioperative care to improve surgical patient outcomes2. The RCoA Perioperative Vision document may be lacking in details, but it is just the first step in a conversation about how as a profession, we can provide better joined-up patient care. Anaesthesia has consistently championed patient safety, and isn’t that what perioperative medicine is at its core? We would challenge the authors to consider who else is better placed to oversee and lead the changes in this pathway. In our trust, we are currently developing a comprehensive Perioperative Medicine service. Our aims are to identify highrisk patients preoperatively and follow them through their perioperative journey, implementing bespoke patient treatment plans and providing POM team follow up. This work will be based on best evidence, expert opinion and local consultation. Collaboration with the patient, GPs, MDT and, of course, the surgeons will be fundamental to this service. We believe this will be the first of its kind in the UK and have received external funding from the Health Foundation for evaluation. We agree with the authors that the solutions are complex and need greater thought, but nothing will improve if we stick to hiding behind our theatre doors and being satisfied only by giving a good anaesthetic. Nor will a ‘tweak’ in the

curriculum suffice. We must embrace this wholeheartedly or not at all. Far from being a covert retirement home for the ‘jaded intensivist’, we believe that perioperative medicine offers anaesthetists an exciting opportunity to improve patient outcomes and experience, and to break down the silos that exist within the wider surgical team. S. Saha, N. Stevenson, J. Paterson, S. Bampoe, M. Cole, P. Odor, J. Tomlinson J. Wight, J. Whittle. Perioperative Medicine Fellows University College London Hospital References 1

McGlennan A et al. Anaesthesia’s existential crisis. RCoA Bulletin 2015:93:20-22.

2

Findlay GP et al. Knowing the risk: a review of the perioperative care of surgical patients. National Confidential Enquiry into Patient Outcome and Death, 2011.

Dear Editor

Should the NHS WHO surgical safety checklist be updated? We would like to congratulate the authors on the excellent suggestions they make via modifications of WHO surgical safety checklist1, 2. Our trust has already incorporated some changes suggested by them but we would like to suggest a few more modifications that could be adapted, that would promote patient safety, enhance quality of care, increase patient satisfaction, improve theatre team performance and decrease critical incidents. 1. At the pre-operative ‘team brief ’: a

Pregnancy testing for nonobstetric surgery: This should be discussed all times a woman of child bearing is on the list. This

2. At the time of ‘sign in’ and ‘sign out’ Personal Possessions: Belongings of patient brought to theatre especially

Page 53 | Bulletin 95 | January 2016

glasses, dentures and hearing aids needs to be appropriately documented both at sign in and at sign out. This also should be part of the handover in recovery. It is one of the most common causes of litigation and trusts have been fined recently for inappropriate handling and loosing personal possessions of patients. As per NHS Protect, all NHS organisations have a duty to ensure the secure management of patient’s property during their admission, stay, transfer and discharge from healthcare services and facilities8. We hope that anaesthetists as perioperative physicians adapt and update the WHO checklists as necessary and make the patients journey from the ward to the operating room and back to the ward a safe and a pleasant one. Kind regards Dr Dipali Verma, ST6 Anaesthetics Dr Kailash Bhatia, Consultant Anaesthetist Central Manchester University Hospitals and St. Mary’s Hospital, Manchester

References 1

Should the NHS WHO surgical safety checklist be updated? Bulletin 2015;92:26.

2

Letter to the editor - Should the NHS WHO surgical safety checklist be updated? Bulletin 2015;93:59.

3

Raising the Standard: a compendium of audit recipes. 3rd Edition. RCoA 2012.

4

Rapid Response Alert NPSA/2010/RRR011: Checking pregnancy before surgery. NPSA, London 2010.

5

MBRRACE-UK. Saving Lives, Improving Mothers Care. Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012.

6

Preoperative fasting for adults to prevent perioperative complications. Cochrane Database of Systematic Reviews 2003, Issue 4. Art No: CD004423.

7

Safety guideline: reducing the risk from cemented arthroplasty for hip fracture. AAGBI 2015.

8

NHS Business Services Authority. Guidance for NHS organisation on the secure management of patient’s property July 2012.

Dear Editor, It is clear from recent statements and interviews made by Rt Hon Jeremy Hunt that he intends to increase hours considered as social to include evenings and weekends. The implications for anaesthetic elective care delivery and on training of junior anaesthetists must be taken seriously and into consideration by the Royal College and the GMC. If hospitals consider a need for more anaesthetic trainees working evenings and weekends, we will inevitably see fewer juniors working shifts in the week. An obvious disadvantage to this will be the reduced exposure to elective work and the direct consultant supervision. Not only this, but elective care itself will be affected, with longer waiting lists, as hospitals cannot staff theatre lists. One positive thing to take from this is that junior trainees consider themselves to be extremely well supported by statements made by the Royal Colleges and the Association of Anaesthetists of Great Britain and Ireland over the past few months. It is with this support that I, as well as my peers, continue to deliver the care and compassion we always have, irrespective of the hour or day a patient needs our help. Dr Jessica Bowen CT2 Anaesthesia Scunthorpe Hospital

Page 54 | Bulletin 95 | January 2016 ›› 9 February 2016

›› 10 March 2016

AFTER THE FINAL FRCA – MAKING THE MOST OF TRAINING YEARS 5 TO 7 RCoA, London £165

AIRWAY WORKSHOP Hotel Marriott, Cardiff £260 (£195 for RCoA registered trainees)

›› 9 February 2016

Programme of events 2016 020 7092 1673 [email protected] www.rcoa.ac.uk/events

Find us on Facebook Follow @RCoA_Events

›› 14 January 2016

GASAGAIN (GIVING ANAESTHESIA SAFELY AGAIN) COURSE RCoA, London £240 ›› 18–22 January 2016

FINAL FRCA REVISION COURSE RCoA, London £395 ›› 3–5 February 2016

RECENT ADVANCES IN ANAESTHESIA, CRITICAL CARE AND PAIN MANAGEMENT RCoA, London £490 ›› 8 February 2016

FPM ACUTE PAIN STUDY DAY RCoA, London *£175 (£140 for trainees) ›› 9 February 2016

FPM NEUROMODULATION/NSUKI STUDY DAY RCoA, London *£175 (£140 for trainees) JOINT RATE

* A joint rate of £330 (£255 for trainees) is available for those attending both the FPM Acute Pain Study Day and FPM Neuromodulation/NSUKI Study Day

INTEGRATING CARE THROUGHOUT THE PATIENT’S SURGICAL JOURNEY The King’s Fund, London See King’s Fund website for fee details. ›› 10–11 February 2016

ANAESTHETISTS AS EDUCATORS: TEACHING AND TRAINING IN THE WORKPLACE RCoA, London £425 (£320 for RCoA registered trainees) ›› 12 February 2016

CPD STUDY DAY: CARE OF THE PATIENT UNDERGOING MAJOR COLORECTAL SURGERY RCoA, London £200 (£150 for RCoA registered trainees) ›› 24 February 2016

QUALITY IMPROVEMENT AND PATIENT SAFETY: IMPROVEMENT SCIENCE IN ANAESTHESIA TRAINING RCoA, London £150 ›› 25 February 2016

HSRC QuARC MEETING RCoA, London By invitation only ›› 25 February 2016

AIRWAY WORKSHOP RCoA, London £260 (£195 for RCoA registered trainees) ›› 26 February 2016

ULTRASOUND WORKSHOP RCoA, London £240 (£180 for RCoA registered trainees) ›› 2 March 2016

CPD STUDY DAY: ANAESTHESIA AND ACUTE CARE IN AUSTERE ENVIRONMENTS RCoA, London £200 (£150 for RCoA registered trainees) ›› 9–10 March 2016

ANNIVERSARY MEETING – INNOVATING AND IMPROVING WITHIN PERIOPERATIVE MEDICINE The Mermaid Conference Centre, London £395 (£295 for RCoA registered trainees)

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/EVENTS

›› 17 March 2016

RCOA & DAS AIRWAY LEAD DAY RCoA, London £125 ›› 17 March 2016

LEADERSHIP AND MANAGEMENT: LEADING AND MANAGING CHANGE; SUCCESS WITH SERVICE DEVELOPMENT RCoA, London £220 ›› 18 March 2016

FPM EXAM TUTORIAL RCoA, London £95 ›› 21 March 2016

BJA/NIAA RESEARCH METHODOLOGY WORKSHOP RCoA, London £150 ›› 23 March 2016

CPD STUDY DAY The Teacher Building, Glasgow £200 (£150 for RCoA registered trainees) ›› 23 March 2016

GASAGAIN (GIVING ANAESTHESIA SAFELY AGAIN) COURSE RCoA, London £240 ›› 6 April 2016

AIRWAY WORKSHOP RCoA, London £260 (£195 for RCoA registered trainees) ›› 14 April 2016

NIAA ANNUAL SCIENTIFIC MEETING RCoA, London £45 ›› 18 April 2016

CPD STUDY DAY: PREHOSPITAL MEDICINE AND MOTORSPORT RCoA, London £200 (£150 for RCoA registered trainees) ›› 22 April 2016

CLINICAL DIRECTORS MEETING (JOINT WITH THE AAGBI) RCoA, London By invitation only ›› 28–29 April 2016

UK TRAINING IN EMERGENCY AIRWAY MANAGEMENT (TEAM) COURSE Wrexham Maelor Hospital £450

Page 55 | Bulletin 95 | January 2016 ›› 3–4 May 2016

CPD STUDY DAYS RCoA, London £355 (£265 for RCoA registered trainees) ›› 5–6 May 2016

CARDIAC DISEASE AND ANAESTHESIA SYMPOSIUM RCoA, London £415 (£315 for RCoA registered trainees)

GASAGAIN (GIVING ANAESTHESIA SAFELY AGAIN) COURSE 14 JANUARY 2016 RCoA, LONDON £240 Organisers: Dr J Horn and Dr A Hunningher

›› 9–11 May 2016

5

UPDATES IN ANAESTHESIA, CRITICAL CARE AND PAIN MANAGEMENT Marriott City Centre, Liverpool £490 ›› 11 May 2016

AIRWAY MANAGEMENT: TRAINING THE TRAINER S RCoA, London £260 (£195 for RCoA registered trainees) ›› 24–25 May 2016

INTRODUCTION TO LEADERSHIP AND MANAGEMENT: THE ESSENTIALS RCoA, London £395 ›› 25 May 2016

ETHICS AND LAW FOR ANAESTHETISTS RCoA, London £200 (£150 for RCoA registered trainees)

CPD CREDITS

Future dates: 23 March 2016 (RCoA, London) 5 July 2016 (Education Centre, Royal Bournemouth Hospital) This course provides strategies for managing a return to work. Simulation scenarios to refresh skills are enhanced with a series of short relevant lectures on the latest in the world of anaesthesia. Workshops and scenario topics include: ›› A&E ›› Airway ›› ICU ›› Communication ›› Paediatric ›› Obstetrics ›› Theatre

›› 26 May 2016

ADVANCED AIRWAY WORKSHOP G&V Royal Mile Hotel, Edinburgh £260 (£195 for RCoA registered trainees) ›› 7–8 June 2016

RCOA SUMMER SYMPOSIUM IMPROVING PATIENT OUTCOMES IN ANAESTHESIA AND PERIOPERATIVE MEDICINE Hilton Brighton Metropole £395 (£295 for RCoA registered trainees) ›› 8 June 2016

ANAESTHETISTS AS EDUCATORS: AN INTRODUCTION RCoA, London £220 (£165 for RCoA registered trainees) ›› 9–10 June 2016

COLLEGE TUTORS MEETING Hilton Brighton Metropole By invitation only ›› 13–14 June 2016

UK TRAINING IN EMERGENCY AIRWAY MANAGEMENT (TEAM) COURSE Solihull Hospital £450

AIRWAY WORKSHOP 25 FEBRUARY 2016 RCoA, LONDON Future dates: 10 March 2016 (Hotel Marriott, Cardiff) 6 April 2016 (RCoA, London) 15 June 2016 (RCoA, London)

£260 (£195 for RCoA registered trainees) Organisers: Dr R Bhagrath and Dr T Turley 5

CPD CREDITS

The airway workshop provides an opportunity to gain hands-on practice with airway equipment and teaching in core airway skills from experienced consultants. Appropriate for all grades of anaesthetist-trainees, speciality doctors and consultants. Workshop stations: ›› Fibreoptic handling skills (2A01) ›› Supraglottic airways (1C02) ›› Rescue techniques (2B02) ›› Awake fibreoptic intubation (2A01) ›› Video laryngoscopy (1C01, 1C02, 2A01) ›› Extubation (1C01, 1C02)

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/EVENTS

Page 56 | Bulletin 95 | January 2016

CPD STUDY DAY: CARE OF THE PATIENT UNDERGOING MAJOR COLORECTAL SURGERY

AFTER THE FINAL FRCA: MAKING THE MOST OF TRAINING YEARS 5 TO 7 9 FEBRUARY 2016 RCoA, LONDON

Joint meeting with the Association of Surgeons of Great Britain and Ireland and Association of Coloproctology of Great Britain and Ireland

12 FEBRUARY 2016 RCoA, LONDON

5

CPD CREDITS

£200 (£150 for RCoA registered trainees) Organisers: Dr J Williams and Mr J Lund 9.10 am Registration

£165 Organiser: Dr P Kumar

SESSION 1

›› Pre-operative risk assessment of the colorectal patient (2A03)

5

Dr R Moonesinghe, London

CPD CREDITS

›› Surgeon specific mortality data; are we becoming more risk

RECENTLY PASSED THE FINAL FRCA? A one day event that will explore how to make the most of your learning experiences in years ST5-7. Recently appointed consultants will speak about building your career in various subspecialties of anaesthetics like paediatrics, neuroanaesthesia, regional, cardiothoracics and intensive care. Experienced anaesthetic consultants will provide practical information on non clinical work and other ways to improve your CV to make yourself competitive for consultant jobs. 9.30 am Registration HOW I BECAME A SPECIALIST ›› Obstetrics

Dr P Sultan, London ›› ICM

Dr G Pugh, Cardiff ›› Paediatrics

Dr C Sheppey, London ›› PHEM

Dr N Hussain, Birmingham ›› Regional/Orthopaedics

Dr S Patel, London ›› Cardiothoracic

Dr A Ranjan, Bristol ›› Pain

Dr S Balasubramanian, Coventry ›› Perioperative medicine

Dr R Santhirapala, London

›› How to manage training as

LTFT trainee

Dr E Plunkett, Birmingham ›› Higher degrees

Dr K Clayton, Coventry ›› How to enhance your CV

Dr A Goodwin, Bath ›› Management and

leadership opportunities for trainees Dr M Wittenberg, London

›› Changes in training

Dr N Penfold, Suffolk ›› OOPT, Year abroad,

Fellowships, Locum Consultancy Dr R Self, London

›› Job application, shortlisting

and interview Dr A Goodwin, Bath

›› Q&A panel – all speakers

4.45 pm Close

averse? (1I05, 3A03) Professor S Westaby, Oxford ›› Prehabilitation before major surgery (2A07) Dr C Snowden, Newcastle

SESSION 2 ›› Iron transfusion or blood transfusion for the anaemic patient (2A05) Mr A Acheson, Nottingham ›› Optimising the colorectal patient with significant cardiac disease (1A01) Dr A Vohra, Manchester ›› Robotic surgery: what will be the impact on surgical and anaesthetic practice? (2A12) Professor A Parvaiz, Portsmouth SESSION 3 ›› Why doesn’t goal-directed fluid therapy work? (1A03, 2A04) Dr R Struthers, Plymouth ›› Reducing the incidence of wound infection (2A07) Mr T Pinkney, Birmingham ›› Optimal analgesic strategies following major abdominal surgery (1D02, 2E01) Dr J Cashman, London SESSION 4 ›› Perioperative medicine: the pathway to better surgical care (2A07, 2A12) Dr J Dhesi, London ›› Current trials in perioperative medicine (3J03)

Dr M Edwards, London ›› Debate: the perioperative medicine team should be

anaesthetist led? For: Speaker TBC Against: Dr S Gold, Bath

4.35 pm Close

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/EVENTS

Page 57 | Bulletin 95 | January 2016

QUALITY IMPROVEMENT AND PATIENT SAFETY: IMPROVEMENT SCIENCE IN ANAESTHESIA TRAINING 24 FEBRUARY 2016 RCoA, LONDON £150 Organiser: Dr J Colvin 5

CPD CREDITS

A meeting to support the introduction of Quality Improvement and Improvement Science to the anaesthesia training curriculum. The aim of the day is to build knowledge, insight, enthusiasm, and confidence amongst the training community to support the introduction and spread of systematic quality improvement using proven Improvement science methodology. Building on our feedback from last year’s successful event, the emphasis of the day will be hands-on practical experience. This event is great value for money as delegates will receive a full day of training at a reduced rate. This event is primarily suitable for QuARCs, Consultant Anaesthetists (particularly Regional Advisers), Deputy Regional Advisers, College Tutors and Senior Trainees; however all are welcome. 9.10 am Registration LECTURES INCLUDE: ›› AoMRC quality improvement – Training for better outcomes

Dr E Vaux, Reading ›› QI delivery in action – inspiration and enthusiasm

Dr R Paterson, Edinburgh ›› Curricular development and PRISM

Dr E Innes, Robertsbridge Dr C Johnston, Surrey ›› The importance of embedding QI – a personal view

Speaker TBC WORKSHOPS INCLUDE: ›› Developing a QI Project

Dr E Haxby, Dr S Webb, Dr M Wittenberg and Dr T Reynolds ›› Measurement for Improvement

Mr T Stephens and Dr L Jordan ›› Delivering QI Training

Dr C Johnston and Dr E Vaux 4.30 pm Close

ULTRASOUND WORKSHOP 26 FEBRUARY 2016 RCoA, LONDON £240 (£180 for RCoA registered trainees) CPD Matrix codes covered: 3A08, 3A09, 3B00 Organisers: Dr A Gaur and Dr R Diwan 5

CPD CREDITS

With a focus on clinical scenarios, group discussion and hands-on skill practice, the ultrasound workshop will cover a number of topics using experienced small group teachers to improve knowledge and competencies in ultrasound guided regional anaesthesia. 8.45 am Registration

›› Lower limb – sciatic/popliteal

Workshop stations: ›› Upper limb – above clavicle ›› Upper limb – below clavicle and pecs block ›› Lower limb – femoral and subsartorial sephahous

›› Epidural/spinal

›› Probe and needling ›› Abdominal/PVB ›› Lumbar plexus

5.00 pm Close

CPD STUDY DAY: ANAESTHESIA AND ACUTE CARE IN AUSTERE ENVIRONMENTS 2 MARCH 2016 RCoA, LONDON

5

CPD CREDITS

£200 (£150 for RCoA registered trainees) Organiser: Dr R Verma and Dr A Hughes 9.10 am Registration ›› Overview of the UK emergency medical teams and the role of

the critical care practitioner (3A10, 3A11) ›› Foreign medical teams and the recent deployments of the UK

emergency medical teams (3A14) ›› Debate: Is there a role for foreign medical teams in

humanitarian emergencies? ›› Anaesthesia and acute care in the context of humanitarian emergencies – examples from the field (2A01, 2A02) 1. Complex chronic emergency (Médecins Sans Frontière example) 2. Sudden onset disasters and emergency response 3. Conflict ›› Adapting clinical care and decision making in critical care according to resources (technical anaesthetic skills and decision making) (1I02, 2C01, 2C03) ›› Ethics and culture – understanding and adapting across contexts (1F05) ›› Anaesthesia and critical care in other austere environments – expeditionary and remote – transferrable skills? (2C01, 1B03, 1B04) ›› UK Government response to humanitarian emergencies 4.30 pm Close

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/EVENTS

Page 58 | Bulletin 95 | January 2016

RCoA ANNIVERSARY MEETING

INNOVATING AND IMPROVING WITHIN PERIOPERATIVE MEDICINE 9–10 MARCH 2016 THE MERMAID CONFERENCE CENTRE, LONDON £395 (£295 for RCoA registered trainees) Organiser: Dr S Patel 10

CPD CREDITS

The Anniversary Meeting is an annual event which celebrates the creation of the Faculty in March 1948 and the change from College to Royal College in March 1992. The topic of the meeting changes annually and include lectures presented by national and international speakers. INNOVATING AND IMPROVING WITHIN PERIOPERATIVE MEDICINE OVERVIEW This two day meeting will focus on why anaesthetists are so well placed to help transform the NHS. Home grown and international speakers will deliver a series of general CPD sessions in key areas such as airway, paediatrics and obstetrics. These will be combined with sessions focussed on interacting with industry and quality improvement and talks from non-medical professionals peeking into the exciting future of digital healthcare. The 2016 Anniversary Meeting will bring clarity as to how and why anaesthetists can play a crucial role in innovating and improving within health care, in a time when our own speciality faces new challenges. THE JOHN SNOW ORATION – PROFESSOR DON BERWICK The John Snow Oration will be delivered by Professor Don Berwick, renowned world expert in patient safety. Professor Berwick was appointed by President Barack Obama as the former administrator of the Centers for Medicare and Medicaid Services (CMS). Prior to his work in the administration, he was President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI), a not-for-profit organisation helping to lead the improvement of health care throughout the world. More recently Professor Berwick was commissioned by the Prime Minister to carry out a review following the Francis Report into the breakdown of care at the Mid-Staffs NHS Trust. Professor Berwick will be speaking at the Anniversary Meeting about how to design a high quality healthcare system. THE MACINTOSH LECTURE – PROFESSOR CAROL PEDEN The Macintosh Lecture will be delivered by Professor Carol Peden, Executive Director of a new Centre for Heath System Innovation and Professor of Anesthesiology at the University of Southern California in Los Angeles. Previously Carol was a Consultant in Anaesthesia and Intensive Care at the Royal United Hospitals, Bath and an Associate Medical Director for Clinical Quality for NHS England. She was a member of the ‘Keogh’ review team of High Mortality Hospitals and is a member of the new Care Quality Commission Inspectorate. Professor Peden will be outlining how anaesthetists can engage in improvement science. RCoA ANNIVERSARY WEBSITE Visit www.rcoa.ac.uk/anniversary to find out further information about the event including speaker biographies, awards details, things to do in London and more.

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/ANNIVERSARY

Page 59 | Bulletin 95 | January 2016

RCoA ANNIVERSARY MEETING

INNOVATING AND IMPROVING WITHIN PERIOPERATIVE MEDICINE 9 MARCH 2016

10 MARCH 2016

8.30 am Registration

8.45 am Registration

SESSION 1: INNOVATION IN AIRWAY MANAGEMENT

SESSION 5: LETS GET DIGITAL

››From concept to reality... THRIVE (Transnasal Humidified

Rapid-Insufflation Ventilatory Exchange) (1B02, 1C01, 2A01) Dr A Patel, London ››Assessing airway equipment. Where next? (1C02, 2A01) Professor A Wilkes, Cardiff ››Advances in airway management (1C01, 3A01) Dr S Radhakrishna, Solihull

SESSION 2: MAKING INNOVATION WORK ››From innovation to adaption (1A03, 3J03)

Dr T Clutton-Brock, Birmingham ››Disruptive technology in anaesthesia (1H02, 1I03) Professor S Shafer, USA ››Future technology... watch this space (1H02, 1I03) Dr W Denman, USA

SESSION 3: NIAA HEALTH SERVICES RESEARCH CENTRE

THE JOHN SNOW ORATION

›› Old

myths and new designs Professor D Berwick, USA

››Updates from the HSRC (1C01)

››There’s an app for that (1G01)

Dr A Parsa, Healthcare entrepreneur and engineer ››Printing your own drugs (1H02)

Professor L Cronin, Regius Chair of Chemistry ››NHS... the Silicon Valley of healthcare (3J00, 3J01)

Professor T Young, National Director for Innovation

SESSION 6: WHAT IS PERIOPERATIVE MEDICINE? ››DEBATE: This house believes perioperative medicine is no

more than an anaesthetic existential crisis (1I03, 1I02) Dr A McGlennan, London Professor M Mythen, London ››The collaborative approach (1I03, 1I02) Dr R Mahajan, Nottingham

PRESENTATION OF COLLEGE AWARDS

THE MACINTOSH LECTURE

›› Improvement

science for anaesthesia Professor C Peden, USA

SESSION 7: UPDATES IN PERIOPERATIVE MEDICINE ››What’s new perioperative medicine? (3J02)

Dr R Struthers, Plymouth

Professor M Grocott, London ››Using data to improve perioperative outcome (2A07, 3J03) Dr R Moonesinghe, London

››Management of preoperative anaemia (2A03, 2A05)

ANNUAL GENERAL MEETING

››New innovation in labour analgesia (2B01)

SESSION 4: PAEDIATRIC UPDATES ››P  aediatric enhanced recovery…where are we now?

(2D02, 2D04, 2D05, 3D00) Dr D De Beer, London ››What’s new in paediatric anaesthesia? (1A03, 2D02) Dr R Beringer, Bristol

Dr A Klein, Papworth

SESSION 8: OBSTETRIC UPDATES Dr R Fernando, London ››Updates in obstetric anaesthesia (2B01, 2B02, 2B03, 2B04)

Dr N Lucas, Buckinghamshire 4.50 pm Close

5.15 pm Close followed by drinks reception for all

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/ANNIVERSARY

Page 60 | Bulletin 95 | January 2016

BJA/NIAA RESEARCH METHODOLOGY WORKSHOP NIAA National Institute of Academic Anaesthesia

21 MARCH 2016 RCoA, LONDON £150 Organiser: Professor P Hopkins 5

CPD CREDITS

9.00 am Registration

DEVELOPING AN IDEA ›› Research question ›› Literature searches ›› Critique of published work GROUP SESSION ONE ›› Critique of published research paper (circulated in advance)

STUDY DESIGN ›› Hypotheses ›› Data capture ›› Analytical versus interventional research ›› Bias, sampling controls, confounding variables ›› Power ›› Significance, hypothesis testing, estimation (CI)

GROUP SESSION TWO ›› Design a clinical trial (outline given on day) GETTING YOUR STUDY STARTED ›› Ethics committees ›› Sponsorship ›› Clinical trials authorisation and registration ›› Funding GROUP SESSION THREE ›› Common pitfalls in analysis, presentation and interpretation of data

CPD STUDY DAY 23 MARCH 2016 THE TEACHER BUILDING, GLASGOW £200 (£150 for RCoA registered trainees) Organiser: Dr M Daniel 5

CPD CREDITS

The CPD Study Day is designed to cover the essentials you need to keep up-to-date with your revalidation in anaesthesia. During the day there will be ample opportunity to ask questions of the expert speakers who will be happy to answer queries at all levels. The day covers a variety of topics and our aim is that no delegate should leave for home with unanswered questions about any of the subjects. 9.00 am Registration ›› Lessons learned building a successful and productive critical

incident reporting system (1I01) Dr S Lakshminarayan, Larbert

›› Responding when a severe adverse event happens and

caring for the second victim (2A06, 1H01, 3J00) Dr C Meadows, London

›› Getting human factors to work for humans (1I03)

Speaker TBC ›› Co-creating health for the chronic pain population (2E03, 1I05)

Dr D Vyas, Huddersfield ›› Anaesthesia and the elderly – damage limitation (2A07)

Dr R Docking, Glasgow ›› Establishing a preoperative anaemia clinic-processes and

pitfalls (2A03, 3A08)

Dr S McKinlay, Glasgow

DISSEMINATION OF RESULTS ›› Presenting abstracts and posters ›› Writing a paper ›› Getting it published

›› What’s hot in vascular anaesthesia (3A05, 2A03)

4.30 pm Close

›› Dr I Quasim, Clydebank

Dr P Harrison, Glasgow ›› Mending broken hearts – how a general anaesthetist and a

cardiac anaesthetist can help the patient (1A01, 2A04, 3G00)

4.15 pm Close

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/EVENTS

Page 61 | Bulletin 95 | January 2016

Image courtesy of Visit England

CPD STUDY DAY 3–4 MAY 2016 RCoA, LONDON £355 (£265 for RCoA registered trainees) Organiser: Dr R Verma 10

CPD CREDITS

DAY ONE

9.00 am Registration ›› Management of refractory pain in the recovery room ›› Pain medicine ›› Maternal Critical Care ›› Challenges in managing a patient with learning disabilities ›› Science and practice of simulation to improve practice ›› Immediate response to global disasters ›› Managing anaesthetic provision for global disasters

5.20 pm Close

DAY TWO

8.40 am Registration ›› Robots in the theatre ›› Telemedicine – is it viable? ›› Intravenous fluid therapy crystalloid vs colloids ›› Sepsis revisited ›› Medico-legal pitfalls in obstetric anaesthesia ›› TIVA and NAP5 ›› Anaphylaxis and NAP6

4.30 pm Close

UPDATES IN ANAESTHESIA, CRITICAL CARE AND PAIN MANAGEMENT (formerly known as Recent advances in anaesthesia, critical care and pain management)

9–11 MAY 2016 LIVERPOOL, MARRIOTT HOTEL £490 Organisers: Dr J Fazackerley, Dr R Dodwell and Dr C Brearton 15

CPD CREDITS

EVENT OVERVIEW: A three day meeting consisting of lectures, followed by ample time for discussion. The meeting is intended for doctors engaged in clinical anaesthesia, pain management and intensive care medicine (i.e. Consultants, Staff and Associate Specialist Grades or their overseas equivalent) who feel they may benefit from a refresher meeting in the latest updates in areas of practice they may be exposed to regularly or only occasionally. To achieve this goal, experts will present up-to-date information on a wide range of topics. Some lectures will also inform participants on updates in basic sciences relevant to anaesthesia and allied specialties. The learning objectives are to facilitate familiarisation with the latest developments in the various areas covered, to make participants aware of progress in a structured manner, and to bring them to understand better how changes in practice based on new information will benefit their patients. Sessions will include: Regional anaesthesia Perioperative medicine ›› POM leading the team Acute pain ›› Acute pain in chronic pain patients ›› Acute pain in POM ›› Acute pain management in children Airway ›› Recent DAS guidelines ›› Extubation

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/EVENTS

Obstetrics ›› Massive obstetric

haemorrhage 2015 ›› Debate – Thio in obstetrics

PHEM ›› Relationship of PHEM to anaesthesia/ ICM ›› Human factors ICM

Page 62 | Bulletin 95 | January 2016

RCoA SUMMER SYMPOSIUM IMPROVING PATIENT OUTCOMES IN ANAESTHESIA AND PERIOPERATIVE MEDICINE 7–8 JUNE 2016 HILTON BRIGHTON METROPOLE HOTEL

10

CPD CREDITS

£395 (£295 for RCoA registered trainees) Organiser: Dr C Carey 7 JUNE 2016 9.00 am Registration

SESSION 1 ›› Ischemic pre-conditioning ›› Fitness ›› CPEX testing SESSION 2 KEYNOTE LECTURE ›› Pharmacological modification of outcomes in

cancer surgery

›› Predicting risk ›› Communicating risk

SESSION 3 ›› Improving care for patients with diabetes ›› Carbohydrate preloading ›› Fluid management and outcomes

SESSION 4 ›› Anaesthetic research: Where are we and where are we going ›› SNAP 2

THE JOSEPH CLOVER LECTURE 5.05 pm Close

OPTIONAL WORKSHOPS (limited availability)

Delegates may choose one workshop from the list below. (£25 per workshop, 1 CPD credit per workshop) ›› CPEX Machine ›› Thromboelastography ›› Transthoracic echocardiogram ›› Ultrasound – regional guided blocks

8 JUNE 2016 9.00 am Registration

SESSION 4 ›› Management of anaemia ›› Testing and management of haemostasis ›› Lessons from the battlefield

SESSION 5 ›› Quality improvement ›› Human factors ›› PRESENTATION OF COLLEGE PRIZES ›› RANK LECTURE ›› TRAINEE ORAL PRESENTATIONS

SESSION 6 ›› Improving outcomes for patients with fractured neck of femur ›› Management of bariatric patients ›› Analgesia and outcomes after major surgery ›› PRESENTATION OF ABSTRACT PRIZES

4.40 pm Close

CALL FOR ABSTRACTS

Trainee anaesthetists are invited to submit an abstract on the topics of either Quality Improvement or Research for presentation at the event. Please submit your abstract to [email protected] Deadline for abstracts submissions: Midnight, Sunday 13 March 2016 Full guidelines are available on our website.

7.00 pm – Social evening for all delegates Social Evening: The Summer Symposium Social Evening will be an informal event (included in the fee) in an exciting venue in the heart of Brighton’s vibrant city. This will take place on the first evening of the Symposium, providing the opportunity to meet the speakers and network in a social environment. FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/SUMMERSYMPOSIUM

Page 63 | Bulletin 95 | January 2016

NIAA National Institute of Academic Anaesthesia

ACUTE PAIN MANAGEMENT IN A COMPLEX WORLD 8 FEBRUARY 2016 RCoA, LONDON £175 (£140 for trainees) A joint rate of £330 (£255 for trainees) is available for those attending both the FPM Acute Pain Study Day and FPM Neuromodulation/NSUKI Study Day

Organisers: Dr S Gupta, Dr S Balasubramanian and Dr M Rockett 5

CPD CREDITS

9.00 am Registration ›› Acute pain services in the UK, what

state are we in? ›› Raising the standard: developing a

pain app ›› Acute pain management in trauma ›› Managing acute neuropathic pain ›› Discussion session: two complex cases:

(1) Acute pain management in opioid dependent/abuse patients (2) Perioperative pain management in patients with chronic pain ›› Frequent attenders: the psychiatry of

acute pain (re)admissions ›› Chronic post surgical pain – prediction,

prevention, mechanisms ›› What happens after hospital

discharge? – rapid access clinics 5.00 pm Close

STUDY DAY ON NEUROPATHIC PAIN AND NEUROMODULATION Joint meeting with the Neuromodulation Society of the United Kingdom and Ireland

9 FEBRUARY 2016 RCoA, LONDON £175 (£140 for trainees) A joint rate of £330 (£255 for trainees) is available for those attending both the FPM Acute Pain Study Day and FPM Neuromodulation/NSUKI Study Day

Organisers: Dr A Gulve, Dr S Gupta and Dr S Balasubramanian 5

CPD CREDITS

9.00 am Registration ›› Pathophysiology of neuropathic pain ›› Pharmacotherapy of neuropathic pain ›› CRPS: pathophysiology and treatment ›› Phantom pain ›› Chronic post-surgical pain ›› Failed back surgery syndrome ›› Techniques of peripheral and spinal

cord stimulation

NIAA ANNUAL SCIENTIFIC MEETING 14 APRIL 2016 RCoA, LONDON £45 Organisers: Dr J Yeung and Professor F Gao Smith 5

CPD CREDITS

The NIAA will be launching the new, NIAA Research Award at the NIAA Annual Scientific Meeting on Thursday 14 April 2016. The award will be open to all research active investigators of anaesthesia, critical care, perioperative medicine and pain within the UK who are engaged in a higher degree programme. Applicants will be asked to submit an abstract based on a clear, evidence based research question, and shortlisted applicants will then be invited to present at the meeting. The meeting will also focus on the launch of the UK Perioperative Medicine Clinical Trials Network and provide an opportunity for those wishing to participate in the network to discuss the art and craft of clinical trials. Further details will be advertised on the NIAA website shortly.

›› Mechanism of action of spinal cord

stimulation ›› Who and when to refer spinal cord

stimulation: indications and patient selection ›› Complications of spinal cord

stimulators ›› Anaesthetic Management of Patients

with implantable neurostimulation devices and intrathecal pumps 5.00 pm Close

FOR FURTHER INFORMATION AND TO BOOK ONLINE, PLEASE GO TO: WWW.RCOA.AC.UK/SUMMERSYMPOSIUM

For further information about any of our events or to book online please visit www.rcoa.ac.uk/events

Page 64 | Bulletin 95 | January 2016

Report of meetings of Council At a meeting of Council held on Wednesday, 21 October 2015 the following appointments/ re-appointments were approved (re-appointments marked with an asterisk):

Regional Advisers West Yorkshire Dr J Jones in succession to Dr A Fale

Deputy Regional Advisers There were no appointments this month.

College Tutors Anglia Dr A Obideyi (James Paget Hospital) in succession to Dr P Linga Nathan

North Thames East Dr S Giannaris (Bart’s Heart Centre) in succession to Dr A Sarang

Mersey Dr R Craig (Alder Hey Hospital) in succession to Dr N Raj

North West Dr J Humphreys (Royal Oldham Hospital) in succession to Dr S Mirza

South East Scotland Dr J Morton (Western General Hospital) in succession to Dr D Morley

West of Scotland Dr C Urquhart (Queen Elizabeth University Hospital) in succession to Dr K Morley

Wales Dr Helen Jewitt (The Royal Gwent Hospital) in succession to Dr V Victor

Head of School(s)

West of Scotland

London Academy of Anaesthesia

Dr Manikandan Chandran

Dr Cleave Gass in succession to Dr P Brodrick

At a meeting of Council held on Wednesday, 18 November 2015 the following appointments/ re-appointments were approved (re-appointments marked with an asterisk):

Certificate of Completion of Training Council noted recommendations made to the GMC for approval, that CCTs/ Certificate of Eligibility for Specialist Registration (Combined Programme) [CESR (CP)] be awarded to those set out below, who have satisfactorily completed the full period of higher specialist training in anaesthesia. The doctors whose names are marked with an asterisk have been recommended for Joint CCTs/ CESR (CP)s in Anaesthesia and Intensive Care Medicine and those with a # have been awarded a CESR (CP).

September 2015 Anglia Dr Thomas Kriz Dr Parveen Kaur Dhillon

North Central Dr Simon Timothy Ilott* Barts and the London

South East Dr Navjot Panesar Dr Martin Makesi Ryding John

St George’s

Regional Advisers There were no appointments or re-appointments this month.

Deputy Regional Advisers There were no appointments or re-appointments this month.

College Tutors Oxford Dr S F Mc Douall (Royal Berkshire Hospital) In succession to Dr C M Skinner Dr A McGill (John Radcliffe Hospital) in succession to Dr H Hann Dr J M Chantler (John Radcliffe Hospital) in succession to Dr M Speirs

West Yorkshire Dr S Lotia (St James University Hospital) in succession to Dr B Duncan

North Thames West Dr R Bartlett (St Mary’s Hospital) in succession to Dr J Lowe

Dr Mark Stephen Salmon

North West

Northern Ireland

Dr K Srirangadarshan (Royal Bolton Hospital) in succession to Dr A J Putland

Dr Karen Goddard

North of Scotland Dr Ruthra Coventry

Oxford Dr Nabi Haghi Khatibi Dr David Andrew Garry* Dr Carolyn Louise Griffith Dr Dana Louise Kelly Dr Alexandra Eleanor Reeve

Sheffield

West Midlands South

Dr Katy Shuker*

Dr C Persad (The Alexandra Hospital) in succession to Dr Domingo Bosch

Birmingham Dr Sanjay K Agarwal Dr Chaitanya K H Vasappa Dr Narayana G R Bankenahally

Severn Dr N Harvey (University Hospital Bristol) in succession to Dr R Craven Dr H Hunton (Cheltenham General Hospital) in succession to Dr M Rees

Nottingham and Mid Trent Dr A Kathirgamanathan (Kingsmill Hospital) in succession to Dr S Narra

Sheffield and North Trent Dr S Moss (Barnsley Hospital) in succession to Dr S Siddiqui

Page 65 | Bulletin 95 | January 2016

Head of Schools

South East

West of Scotland

Dr Kate Klocker

Dr S Marshall (in succession to Dr J Chestnut)

Mersey

Certificate of Completion of Training

Northern Ireland

Council noted recommendations made to the GMC for approval, that CCTs/ Certificate of Eligibility for Specialist Registration (Combined Programme) [CESR (CP)] be awarded to those set out below, who have satisfactorily completed the full period of higher specialist training in anaesthesia.

Dr Zoe Margaret Turner Dr Peter McGuigan*

North of Scotland Dr Laurin Gemma Allen Dr Michael Leggate #

North West Dr Yuet Meng Ng Dr Hakeem Oluwatoyin Yusuff* Dr Brian Gray Williams

The doctors whose names are marked with an asterisk have been recommended for Joint CCTs/ CESR (CP)s in Anaesthesia and Intensive Care Medicine and those with a # have been awarded a CESR (CP).

Oxford

October 2015

Dr Simon James Slinn Dr Andrew Paul Hadfield

Leicester

Dr David Christopher Hallsworth

Tri Services Dr James Paul Chinery

Wales

Dr Raghavendran Krishnaiyan Dr Vandana Girotra Dr Navreet Ghuman

Stoke

Nottingham

Birmingham

Dr Pitor Jerzy Ohly Dr Cyril Jacob Chacko*

Dr Joanna Michelle David # Dr Georgina Elizabeth Margaret Pipe Dr Thomas Paul Heinink

Dr Somasundaram Jeyanathan # Dr Naginder Singh

KSS

Dr Bethan Rachel Hale

Dr Thomas James Bevir Dr Andreas James Zafiropoulos*

West of Scotland

London – Imperial Dr Celia Anne Whelan Dr Li-Jen Carolyn Chan Dr Julie Karen Wakeford

North Central Dr Saadia Afzal Mir Dr Megan Emma Smith Dr Stephen Kendrick Harris* Dr Gary Yap

Barts and the London Dr Aarjan Peter Snoek # Dr Alistair Stuart Hughes Dr Richard Mark Thomas*

Warwickshire

Dr Karen McCluskey Dr Anurag Singh # Dr Ogechi Nneka Lubeigt

Hull Dr Rebeca Beruete Perez Dr Kate Victoria Henderson To note recommendations approved by the GMC, that CESRs be awarded to those set out below: ■■ ■■ ■■

Dr Baber Zaheer Dr Nihal Maha Gamage Dr Burhan Shawki

Page 66 | Bulletin 95 | January 2016

Perioperative Medicine Clinical Lead and Perioperative Medicine Fellow The Royal College of Anaesthetists is seeking two highquality individuals to help drive the development of its Perioperative Medicine programme:

Perioperative Medicine Clinical Lead The Clinical Lead will be responsible for discrete projects within the Perioperative Programme, working alongside the Perioperative Medicine Advisory Board and Leadership Group to develop pilots for new referral pathways, as well as championing and supporting the wider development of existing perioperative pathways and best practice. The post is supported by the cost of two PAs per week. The post will commence in March 2016. The closing date for applications is 5.00 pm on Monday, 4 January 2016 and interviews will be held on Wednesday, 27 January 2016. The Lead will also be expected to participate in the shortlisting, interviewing and appointment of the Perioperative Medicine Fellow.

Perioperative Medicine Fellow The Perioperative Medicine Fellow will be a trainee at ST5 or above in anaesthesia or a dual ICM/anaesthesia programme, who will provide clinical support and knowledge to the delivery of the Perioperative Medicine Programme and work on specified projects. The role will be equivalent of 0.5 WTE for 12 months. The post will commence in August 2016. The closing date for applications is 5.00 pm on Monday, 22 February 2016 and interviews will be held in April 2016. Full details and job descriptions can be found at www.rcoa.ac.uk/perioperativemedicine. Please send any queries to [email protected].

Integrating care throughout the patient’s surgical journey 9 February 2016 The King’s Fund, London W1 Aimed at health and care professionals who come into contact with patients throughout their surgical journey, as well as commissioners and policy-makers, this one-day conference will explore how to improve multi-disciplinary working to deliver the best possible outcomes for patients before, during and after major surgery. Run in partnership with the RCoA, Royal College of Surgeons, Royal College of Physicians and Royal College of General Practitioners, this conference provides a key opportunity to discuss and debate how best to ensure that the patients’ care is coordinated from contemplation of surgery to full recovery.

Background to the event 10 million patients undergo surgery every year, with over 250,000 people falling into the high-risk category. Increasing demand and the increasing complexity of surgical procedures calls for renewed efforts to be focused on establishing efficient patient-centred care pathways, led by a multidisciplinary team. With the NHS five-year forward view acting as the catalyst to creating new ways of delivering care that are more joined up and better suited to modern health needs, now is the time come together and find solutions to improving outcomes for people undergoing surgery. Aligning the objectives of the NHS five year forward view and the College’s Perioperative Medicine Programme (www.rcoa.ac.uk/perioperativemedicine), this conference will explore the actions needed to achieve a greater focus on prevention, to empower patients to take more control of their care, and to deliver more integrated care pathways. For further information and to book your place on this event, please go to The King’s Fund website (www.kingsfund.org.uk/node/5746) and quote ‘RCoA’ when making your booking to receive a 25% discount.

Page 67 | Bulletin 95 | January 2016

Education

EDITORIAL BOARD MEMBERSHIP PAIN MEDICINE

ADVERTISING IN THE BULLETIN

The RCoA Bulletin is published bi-monthly and distributed to over 16,000 anaesthetists worldwide, the vast majority being in the UK. Advertisements for courses and meetings from anaesthetic societies, or those organisations that are of interest to anaesthetists, are accepted with prior approval of the Editor or Editorial Board.

The British Journal of Anaesthesia invites applications for membership of the Editorial Board of BJA Education (formerly Continuing Education in Anaesthesia, Critical Care & Pain – CEACCP) to commence in February 2016. The appointment will be for a 5 year term in the first instance, renewable for a further 5 years.

Advertisements must fit with the aims and aspirations of the RCoA and be related to anaesthesia, critical care and pain medicine.

To be eligible for appointment, applicants should be engaged in a substantive academic or clinical position in pain medicine. It is also expected that the successful applicant will have experience of teaching and training in relation to pain medicine.

Rates below are valid up to and including the May 2016 issue:

Applicants should, in addition, have experience of the editorial process for medical journals and in the preparation and submission of high quality articles for publication, as well as the ability to work to deadlines and a proactive approach to editorial tasks. The duties of Editorial committee membership include: 1

To commission at least five BJA Education articles per year

2

To attend and contribute to the Editorial Board Meetings each year (two in London and two via videoconferencing)

3

To assist the Editor in Chief by providing editorial expertise and reviewing articles submitted for publication

4

To use and familiarise themselves with Scholar One, the editorial management software used to manage commissioned manuscripts in progress

5

To keep on top of editorial tasks and timelines for their articles and meet publishing deadlines

Applications should consist of: ■■ covering letter ■■ brief CV (maximum 2 sides of A4) ■■ two referees (including email contact details) ■■ list of publications in the past 5 years Application should be sent to the Editor-in-Chief, Dr Jeremy Langton, at [email protected] by 17 January 2016.

Please contact [email protected] for separate commercial advertising rates.

Quarter page (portrait) (85 mm by 124 mm) £283 +VAT Half page (portrait) (85 mm by 252 mm) £560 +VAT Full page (175 mm by 252 mm) £897.50 +VAT Please go to the website to complete the necessary Terms and Conditions before submitting your advert online: www.rcoa.ac.uk/the-bulletin/advertising-deadlines

RCoA

WEBCASTS www.rcoa.ac.uk/webcasts

RCoA Webcasts are free video recordings of lectures (including lecture slides) from selected RCoA Events. To assist with your revalidation needs, you can record CPD Credits for viewing RCoA Webcasts. Step 1  Visit www.rcoa.ac.uk/webcasts. Step 2 Select the Webcast you’d like to watch from our Catalogue of Webcasts. Step 3  Watch the Webcast and earn your CPD Credits. Step 4 Log your CPD Credits earned by logging a Personal Activity on the CPD System/e-Learning/e-Portfolio.

Page 68 | Bulletin 95 | January 2016

Appointment of Fellows to consultant and similar posts The College congratulates the following Fellows on their consultant appointments: Dr K E Adams Royal National Orthopaedic Hospital Dr R Perez Beruete Pinderfields General Hospital in Wakefield Dr U K Chakka University Hospitals Coventry & Warwickshire Foundation Trust Dr P James Nottingham University Hospital. Dr E Johnson Worcester Acute Hospitals NHS Trust Dr P Kumar University Hospital Coventry Dr I Mowat Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Appointment of Members, Associate Members and Associate Fellows The College congratulates the following, who have now been admitted accordingly:

Member Dr Anastasia Aslani Dr Nosakhare Alexander Edokpolor Uwubanmwen Dr Sami Omran

Associate Member Dr Tracey Leanne Fitchat Dr Tamas Varga Dr Pamela Louise Mcgibbon Dr Hasnain Saeed Dr Chandramouli Chandrasekaran Dr Chiara Tosini Dr Temenuzhka Yaneva Radeva Dr Christopher Frik Van Wyk

Affiliate Physicians’ Assistants (Anaesthesia) Miss Aileen Anne O’Neill

Dr J T Paul University Hospitals Coventry & Warwickshire Dr R Srinivasagopalan Hillingdon Hospital

Deaths

Dr S Williams Royal Berkshire NHS Foundation Trust

With regret, we record the death of those listed below. Dr Isabel Maganas Aguilera, Wales

Consultations

Dr Charles Gleave, Kent Dr Kate Larcombe, London Dr Jennifer Pugh, London Dr Patricia Mackay, Australia

Consultations the RCoA has responded to in the last two months are listed below: Originator

Consultation

Department of Health

Independent Patient Safety Investigation Service Expert Advisory Group – Call for Evidence

National Institute for Health and Care Excellence (NICE)

Preoperative tests (update): Draft guidance consultation

Royal Pharmaceutical Society

Consultation on a draft professional error reporting standard for pharmacy

Dr Ruth Owen, England Dr John C Richardson, Holyhead Professor Stoyan K Saev, Bulgaria Dr Timothy J Stanton, Essex Dr Cyril Joakim Stephens, Essex Dr Claire Thomas, West Yorkshire Dr John Young, Hampshire Dr William R Watson, Tunbridge Wells Please submit obituaries (of no more than 500 words), with a photo if desired, of Fellows, Members or Trainees to: [email protected]. All obituaries received will be published on the College website. (www.rcoa.ac.uk/obituaries).

Page 69 | Bulletin 95 | January 2016

Page 70 | Bulletin 95 | January 2016

Page 71 | Bulletin 95 | January 2016

THE MSA SAQ WRITERS CLUB The Writers Club has seen more than 500 trainees through the SAQ Papers with a successful pass rate for those who have kept to the necessary disciplines. But many trainees apply far too close to the examination to derive anything like the full benefit from Membership. That full benefit includes free admission to the SAQ Weekend Courses, the acquisition of a large and useful collection of answer sheets and a valuable motivation towards sustained revision. Membership Fee: a single payment of £400 Members are entitled to all benefits until successful in the SAQ Paper Attendance to the SAQ Weekend Course – free of charge Writers Club Motto: ‘Within the Discipline, Lies the Reward’ Candidates are urged to join sooner than later for the Autumn 2016 Examination to reap maximum benefit

COURSES FOR THE ROYAL COLLEGE OF ANAESTHETISTS EXAMINATIONS Courses

Dates 2016

Capacity

Primary SBA & MCQ

5–11 February

August 2016

No Limit

Primary SBA

5–7 February

August 2016

No Limit

Primary MCQ

8–11 February

August 2016

No Limit

Primary OSCE Weekend

22–24 April

October 2016

48

Primary Viva Weekend

8–10 January

April 2016

No Limit

Primary OSCE/Orals

15–22 January

May 2016

48

Final SBA & MCQ

12–18 February

August 2016

No Limit

Final SBA

12–14 February

August 2016

No Limit

Final MCQ

15–18 February

August 2016

No Limit

Final SAQ Weekend

19–21 February

August 2016

No Limit

Final Written ‘Booker’

21–26 February

August 2016

90

Final Viva Revision

May 2016

November 2016

No Limit

Final Viva Weekend

June 2016

November 2016

90

“Well, it is finally done! It is a very long and exhausting day and candidates need to be well prepared. The best way to do this is to get as much realistic practice in as you can, and your course helped me hugely with this. I passed the OSCE first time round (after going to only your OSCE course) and then passed the SOE on the next sitting (this time after attending your SOE course – coincidence?!). There is no substitute for the hard work that needs to go in to passing this exam; like you said you should not attend ‘hoping’ that you will scrape through based on luck. But once you have put the hours in learning the facts the next hurdle is fine-tuning your presentation skills. That is where your course really helped me. I felt so nervous and inadequate at the start of your course, but as the days went by I started to really get an idea of what examiners want and that actually most candidates’ knowledge is generally of much the same level, but how they deliver that knowledge is what sets apart those that shine.”

Primary OSCE/Viva Candidate, May 2015 To see details of all of our courses please visit: www.msoa.org.uk or contact us at: [email protected] Find us on Facebook Badge

CMYK / .ai

CHIEF EXECUTIVE’S OFFICE Tom Grinyer Chief Executive 020 7092 1612 Mark Blaney Director of Finance [email protected] 020 7092 1581 Natasha Marshall Facilities Manager [email protected] 020 7092 1510 Richard Cooke IT Manager [email protected] 020 7092 1712 Membership and subscriptions [email protected] 020 7092 1701/1702/1703

EDUCATION & RESEARCH DIRECTORATE Sharon Drake Director of Education and Research 020 7092 1681 Mary Casserly Education and Research Manager [email protected] 020 7092 1680 Daniel Waeland Head of Faculties (FICM and FPM) [email protected] 020 7092 1727 Anne Marie O’Donnell Human Resources Manager [email protected] 020 7092 1541

National Institute of Academic Anaesthesia (NIAA) [email protected] 020 7092 1680

CLINICAL QUALITY DIRECTORATE Charlie McLaughlan Deputy Chief Executive and Director of Clinical Quality 020 7092 1694 Sonia Larsen Director of Communications [email protected] 020 7092 1532 Carly Melbourne Quality and Safety Manager [email protected] 020 7092 1699 Advisory Appointments Committees [email protected] 020 7092 1571 Anaesthesia Clinical Services Accreditation (ACSA) [email protected] 020 7092 1575 Anaesthesia Review Teams (ART) [email protected] 020 7092 1571 Bulletin [email protected] 020 7092 1692/1693 Guidelines for the Provision of Anaesthetic Services (GPAS) [email protected] 020 7092 1572 Patient Safety [email protected] 020 7092 1574

e-Learning Anaesthesia (e-LA) [email protected] 020 7092 1542

Presidential Secretariat [email protected] 020 7092 1600

Meetings and Events [email protected] 020 7092 1673

Revalidation and CPD [email protected] 020 7092 1699

Website [email protected] 020 7092 1692/1693

TRAINING & EXAMINATIONS DIRECTORATE

Russell Ampofo Director of Training and Examinations 020 7092 1522 Graham Clissett Examinations Manager [email protected] 020 7092 1525/1526 Claudia Moran Training Manager [email protected] 020 7092 1552/1553/1554 Equivalence [email protected] 020 7092 1655 International Programmes Co-ordinator [email protected] 020 7092 1552 Regional Representatives Support (College Tutors and Regional Advisers) [email protected] 020 7092 1573 SAS and Specialty Doctors [email protected] 020 7092 1552 Trainees [email protected] 020 7092 1573 Quality Assurance 020 7092 1652