Can our future consultants be adequately trained within a maximum 48-hour working week?
Here is a summary of the key messages of the Temple Report.
Dr Ciara Donohue (ST6 Airway Fellow)
"Learning from experience - it takes too long. It often takes a lifetime" - Reginald Hine (1949)
Historically, medical staff gained the skills and experience to provide quality care to patients during hours of service provision. How do we compensate for the dramatic cut in hours that has impacted our generation of doctors-in-training since 2009? How, in a 48 hour week, do we gain the necessary skills and experience to become competent independent practitioners?
Training can be provided within a 48 hour week – but requires reconfiguration of current NHS models and seizing of opportunities.
• Those 48 hours need to work for both trainees and patients.
• There are 15,000 hours in a 7-year training program.
• Out of hours work is necessary and offers its own learning opportunities.
• Emergency specialties (like anaesthetics/ICU) are more heavily impacted by need for out of hours cover.
• Out of hours care requires shift work. This necessitates higher numbers of trainees and there are often gaps on rotas. This can lead to a dilution of experience.
• Trainees lose time for more elective/specialised/supervised training through having to work out of hours shifts.
• Shift work risks loss of continuity of patient care and increased handovers – but in theory leads to a fresh rested workforce.
• Consultant job plans frequently don’t factor in training needs, or reward excellent training.
Some examples of how training can be fostered despite reduction in hours:
• MDT working – eg. hospital at night or courses with dissemination of skills to share the load of service provision and free people up for training opportunities.
• Simulation and use of new technologies to accelerate learning, especially of less common clinical scenarios/procedures.
• Better work/life balance should leave trainees refreshed for learning and involvement in a variety of projects.
• Expansion of consultant body – more supervision in office hours and beyond.
• As consultant-delivered care gains momentum, more out of hours care and acute care decision making will be consultant led, providing support and supervision opportunities for on call doctors in training. In anaesthetics we tend to have very approachable, hands-on seniors. This is not the case across all specialties.
Temple’s recommendations are:
1. Consultant delivered healthcare
Direct consultant input 24/7 is called for in this report. This will be met with mixed feelings from trainees nearing CCT. The ominous ‘flexible’ consultant job plan in order for consultants to deliver service, training and out of hours cover will divide opinions. A need for mentoring of new consultants to facilitate this is recognized.
Temple says that expansion of any grade other than consultant will not enable implementation of this shift in care delivery – but what is in a name? What if
you put a prefix in there followed by ‘consultant’ – will this appease the powers that be and allow them to tick the consultant delivered care box?
Having a consultant delivered out-of-hours service will of course be expensive and in order to get value for money you might envisage trainees being taken off these shifts and returned to weekday daytimes. Will aggrieved consultants have the inclination or energy to take on training once their working landscape has been flipped on its head?
2. Service delivery must support training
Reconfiguration of services from national to local/departmental levels may be needed to enable excellent patient care and training. It sometimes feels like a tug of war between these two pivotal roles of the NHS – yet Temple envisages a utopia where both are synchronous and even synergistic. We have probably all worked at places where we have experienced the sweet combination of great teaching and a sense that excellent care is being delivered to patients – what is it that works in these centres? How can we recreate this environment in places where one or other or both are lagging? Taking away training posts from some
hospitals where appropriate, division of emergency and elective services, construction of robust rotas that are well staffed and better MDT working are
all cited as strategies for providing a service and supporting training.
3. Make every moment count
Involving a proactive college tutor or educational supervisor in list allocation can hugely augment your experience during a placement and enable planned, focused training. When trainees are happy in getting the training they need, there is always a reserve of good will to make sure things get done. There is (and rightly so) an onus on us to make the most of the opportunities for learning day to day – there is always something we can take from most clinical situations when we seek it out. For those clinical scenarios that we don’t encounter often (especially when we no longer exist within the walls of our hospitals for days on end) but ones we need to feel confident to manage when they do, the simulator has become a vital tool. We can gain knowledge, situational awareness and brush up on drills and skills in a safe environment. Temple comments that we must be engaged in decision making regarding our own training and future working conditions and that squeezing the juice from the hours we have rather than extending them or prolonging training is the way forward.
Trainee numbers are set to fall in an attempt to redress the over recruitment of recent years. This could lead to more favorable consultant/trainee ratios with a
wealth of consultant training lists to choose from and perhaps a shift from trainees being allocated to an all day list and instead cherry picking training opportunities. Again, consultants may take umbrage with the implications for their working day.
4. Recognise and reward trainers
All consultants inherently have a teaching role, however some will have a formal direct training role. They should have access to training and support themselves and have their responsibilities recognised in job plans and rewarded accordingly.
5. Training excellence requires regular planning and monitoring
Training should be incentivised and accountable with evidence of quality, positive impact and outcomes. Educational governance should be recognised on every trust board.
Changes to the way we work are afoot.
We must take an active interest in the decisions being made around us if we are to attempt to have some control over our future working lives both as trainees and consultants.