Anaesthesia - aagbi

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Anaesthesia
News
No. 241 August 2007

The Newsletter of the Association of Anaesthetists of Great Britain and Ireland. ISSN 0959-2962
Making
Sense
of MTAS
The Knights of
Anaesthesia
Linkman Meeting Report
21 Portland Place, London W1B 1PY, Tel: [phone], Fax: [phone], Email: [email protected], Website: www.aagbi.org
Anaesthesia News August 2007 Issue 241 1
• Three parallel streams of • Keynote speakers
didactic lectures
• A full and varied social
• Scientific sessions, current issues programme, partner day tour
and update sessions programme
• Workshops on Difficult • Annual Dinner
Airways, Regional Anaesthesia,
• Satellite Symposia and Industry
Independent Practice, CPX and
Workshops
many more…
• Extensive trade exhibition
• Eponymous lectures
MEMBERS OF AAGBI NON MEMBERS

£ € £ €
One Day 225 315 280 392
Two Days 310 434 380 532
Three Days 395 553 475 665
FURTHER INFORMATION
CONTACT: [phone]/3
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2 Anaesthesia News August 2007 Issue 241
Contents
MMC

03 MMC - How was it for you?
09 President's Report
10 Editorial - Stand up for
Stand-ins
– How was
11 Council News &
Announcements
13 World Congress
14 32nd Linkman Conference
Report
it for you?
17 Seminars
22 GAT - On-call Survey 2006/7
24 Unveiling Gillies
26 Dear Editor…
28 The History Page
32 Specialist Society Page sort. It’s not quite comparable - I don’t
- Society for the Advancement think that many disappointed or angry
of Anaesthesia in Dentistry applicants are actively trying to kill
(SAAD) me, but the similarities that lead me to
34 Committee Focus this conclusion are to do with the near
- What is New in Safety impossibility of the task in the first place
36 Ivan Ezegas and uncertainty as to whether the task
was the ‘right thing to do’ anyway. Add
to this the frequent changes of short-term
The Association of Anaesthetists of Great
Britain and Ireland objectives and leadership at the ‘centre’,
21 Portland Place, London W1B 1PY uncertainty about who is actually leading
Telephone: [phone]
or responsible for the whole thing, and
Fax: [phone]
a growing sense that most of this toil
Email: [email protected]
Website: www.aagbi.org and strife will ultimately prove futile
as the grand reckoning (in the form of
Anaesthesia News
Professor Tooke’s enquiry) may result in
Editor: Hilary Aitken
Val Bythell abandonment of even the small triumphs
Assistant Editors: Iain Wilson, Mike Wee and
Val Bythell and victories to date, and I wonder if
Our Editor ably lamented the difficulty
Advertising: Claire Elliott some troops serving overseas may not be
of providing any sort of commentary on
able to empathise with me?
Design: Amanda McCormick MMC in Anaesthesia News in our last
Pips Design, Telephone: [phone] At risk of falling foul of the problem with
edition. The lead time between writing
Printing: C.O.S Printers PTE Ltd – Singapore
lead time, I nevertheless offer a ‘potted
an article and its appearance on your
Email: [email protected]
history’ of MMC to date, from my own
doormat is around two months, and
Copyright 2007 The Association of one of the many tedious features of the rather weary perspective – that of a
Anaesthetists of Great Britain and Ireland recently-resigned Programme Director in
implementation of MMC has been the
a medium-sized Deanery.
propensity for the whole situation to
The Association cannot be responsible for the
statements or views of the contributors. change at the drop of a hat, often in an
No part of this newsletter may be reproduced entirely unpredictable manner. I have, ‘MMC and all that’
without prior permission.
on several occasions when things seemed
particularly bleak to me, reflected that my The fundamental principles of MMC
Advertisements are accepted in good faith.
Readers are reminded that Anaesthesia News own experience might be comparable to were described by the Chief Medical
cannot be held responsible in any way for the that experienced by a junior officer in Officer (CMO) in a paper entitled
quality or correctness of products or services the armed forces during a war of some ‘Unfinished Business – Reform of the
offered in advertisements.
Anaesthesia News August 2007 Issue 241 3
MMC - How was it for you?
SHO grade’ in 2002. ‘Reform’ in this context essentially means attractive training packages, but a majority of the service deficit
abolition, leaving a ‘slimmed down’ portion of SHO posts for is likely to be in DGHs. For many DGHs, attempting to appoint
incorporation into a unified training grade; occupants of which longer-term, service-oriented sub-consultant staff is likely to be
(at the time of writing) are to be called ‘Specialty Registrars’ - on the cards – these may be traditional SAS grade doctors, but
abbreviated as StR. Pay scales for the new grade were published I think it probable that in many Foundation Trusts such posts
recently on the Department of Health website. will be advertised as ‘Trust Doctor’, with non-standard terms
and conditions of service. This latter development is a matter of
I don’t think MMC is a bad idea in principle. The structure of
concern – I don’t blame the departments/Trusts for doing it, but
training (which is what MMC is about) was a mess. There was
we must watch these developments carefully.
quite significant expansion in the SHO grade (mainly to do
with managing the introduction of the EWTD) in 2003, with Of course there are other options for dealing with the ‘work gap’
the result that competition for entry to SpR programmes was that I haven’t mentioned so far. The work we are talking about
very severe over the last couple of years. At SpR appointments is largely out-of-hours, resident on-call work, covering theatres,
panels in 2005-6 we were forced to turn away some good or ITUs and obstetrics. The brave few amongst us have already
even excellent candidates; a complete reversal of the situation stepped into the breach and are providing a consultant-based
4-5 years ago. service. I salute you. I daresay that that is a pretty expensive
way of getting the work done, and is probably only practical
I think one of the reasons the introduction of MMC has been so
where the out-of-hours commitments are fairly light. The
difficult is that reforms to training have been addressed without
workload in obstetrics and ITU is not easy to contain; the best
considering service. To deal effectively with this imbalance
you can hope for (from this point of view) is for the work to
between SHO and SpR grades, there needed to be some
disappear to another hospital nearby. In fact, there is a fair bit of
realistic, overt plan to deal with service at the same time. If you
this going on - there is a crisis in obstetric manpower, so there
are going to tell a department that instead of the ten, twelve or
has been strong pressure to merge medical obstetric units. The
however many SHOs they currently have that they will have
theatre workload is probably easier to manage. One delegate
four ST1/2s, then you ought to also be able to suggest who is
at the Linkman meeting this year described her experience of
going to do the work.
consultant-delivered out-of-hours care. Once a decree had
Unfortunately there has been a vacuum in the plans for the been issued that no operation should proceed after hours unless
introduction of MMC on this front. Many departments are the consultant surgeon and anaesthetist were both physically
waking up to this harsh reality now, and the job section of the present, the amount of operating done out-of-hours dwindled to
BMJ has made interesting reading over the last couple of weeks. a manageable trickle.
I’m sure that we will have seen plenty more imaginative adverts
So much for the principles; on to the practice.
by the time you read this. Perhaps
when the dust settles we will at
least have a more honest reality Re-mapping
– posts that offer decent training,
but little likelihood of progress The initial phase of implementation as far as I was concerned
towards a CCT in this country was re-mapping (see glossary). A year ago, I knew roughly what
will be clearly identified as such. was to be done in terms of re-arranging the deck-chairs, and
Many doctors from overseas will set about doing it. The issue was discussed in various regional
still be likely to apply for meetings and letters, and I spent many hours with a pencil and
these – as long as rubber doing fairly questionable arithmetic. The first premise
they do receive upon which all our subsequent arithmetic was based (if loosely)
decent training was that we would stick to our current level of output from the
and are able to sit training programme. This gave us the number of trainees per
the exams. One year of training needed for run through as follows:
problem with this
N = X
approach to fill
Y
the void will be
that big teaching where N = no. of current NTNs (pre MMC), Y = length of training
hospitals will be in years and X = no. of NTNs per year.
better able to offer
4 Anaesthesia News August 2007 Issue 241
No-one ever told me what sums (if any) we were supposed to national standards and methodology. This represents over 20%
be doing. I imagine other regions may have used totally different of the consultant anaesthetic workforce in our Deanery. We are
equations. now battle-hardened veterans – we spent 845 hours scoring
685 application forms (pointlessly; since we ultimately had to
X (22 for our programme) is now cast on tablets of stone at the
interview all applicants who had put us 1st choice following
core of our plans for MMC; we are recruiting to fill this ‘virtual’
the MTAS review, regardless of the quality of their application).
number of posts per year. Whether or not this is the number of
We have interviewed just over 300 applicants, over five days
CCT-holders that we ought to be producing we have no idea, it
– round 1 on March 5th,6th and 7th and round 1b on May
simply is the number we are producing, on average, now. I say
16th and 17th. When I say ‘interviewed’, what I really mean is
‘on average’, because this year (06-07) we will probably produce
‘selection centred’*, but as this is a tedious descriptor I will use
about 20 CCT-holders, but the following year will produce about
‘interview’ for now.
28 or 30 CCT holders. I mention this because there is a popular
misconception that under MMC, we will somehow end up with Interestingly, scores by application and at interview seem to
a much more rigid, fixed year size, like a school or university. correlate reasonably well:
I don’t think this is at all likely to happen, for all the reasons it
doesn’t exist now. Consider the following: Dr A in training year
3 has a baby, is on maternity leave for a year and then returns to
work less than full time (LTFT). When Dr A returns to work, she
will join the year 3 that was year 2 when she left, which will now
have an extra person in it. As Dr A is training LTFT, assuming she
does this for the rest of her training at about 60%, she will obtain
a CCT at approximately the same time as the people joining the
programme when she went on maternity leave. This kind of life
event does not commonly happen to children of school age,
but is entirely proper for the 27-35 year olds who populate our
training programmes.
The 22 trainees per year at ST1 and ST2 were shared out round
the region at a re-mapping meeting in September 06, at which
every department in the region was represented, except my own
Anaesthesia ST3 application vs interview scores,
– so unsurprisingly we haven’t got any. There was subsequently a
Northern Deanery.
relaxation on the control of numbers of trainees at ST3 (perhaps
a whiff of disaster has reached London?). We were encouraged Candidates scoring less than 44 at interview were deemed not
to convert spare SHO or ‘other’ posts to new ‘temporary’ ST3 appointable to an NTN, and candidates scoring below 42.5 were
posts (see glossary). We decided that some degree of restraint deemed not appointable to either an NTN or LAT. Candidates
was proper, and are recruiting a modest 26 extra trainees at ST3, scoring less than 44 on application were not shortlisted, so all
but August 2012 is going to produce a bumper crop of CCT- ‘dots’ to the left of that score represent candidates who had
holders. put us 1st choice but whom we hadn’t shortlisted, so they
were interviewed in round 1b. No applicant scoring 30 or
For better or for worse, following the ‘signing off’ of the final
less on application was deemed appointable at interview – so
numbers by chief executives round the region, the numbers and
this is probably close to a ‘true’ cut-off score for short-listing.
distribution of posts were uploaded onto the MTAS website to
Unfortunately we originally had to draw the line higher than
inform applicants, and we were on to the next phase.
that, because our capacity to interview people was limited,
mainly by the fact that we had ‘only’ trained 64 recruiters.
Hence, for the record, I believe the MMC application form was
Recruitment to MMC posts
a reasonably valid tool for short-listing at ST3.
This is the aspect of proceedings to date that has generated the The feasibility was a different matter - we really struggled to score
most work and the most public of debacles. the forms. This, combined with lack of familiarity with the type
of questions asked, particularly on the part of trainees, was the
Since January this year we have trained a team of 64 consultant
main factor in the brevity of existence of the MTAS application
anaesthetic colleagues in recruitment and selection as per
Anaesthesia News August 2007 Issue 241 5
MMC - How was it for you?
system. Alas, poor MTAS. I find myself feeling almost nostalgic advise trainees who have not yet obtained a secure post to try
about it. The security problem was the final nail in the coffin. and focus on looking ahead and planning for the future, rather
than spending too much time looking back in anger which is
Of course, any tool is useless if used incorrectly, so I would
not, generally speaking, a recipe for long-term happiness.
hesitate to generalise from our results – we only just managed
to make the deadline for uploading our application scores to Seek feedback about your performance in round one, and apply
MTAS. I can’t imagine how those Deaneries and specialties that for appropriate posts in round two. I am sure there will be a
had much greater numbers of applications per scorer managed round two, though most posts are likely to have been filled in
to even read all the forms, let alone score them. This story is round one. Seek and take advice about completion of application
littered with heroes, mostly unsung, although there seems to be forms (currently being hurriedly re-written at Deanery level,
more enthusiasm for seeking villains and victims. The human based on the same person specifications as round one).
resources team in our Deanery have worked flat out for months
Take this opportunity to review medium and long term goals.
now, meeting deadline after deadline. Anyway, all this can be
Ask yourself some difficult questions – reconsider your choice of
consigned to the history books now.
specialty, choice of place (hospital, region, country) and the type
We made our initial offers last week, and informed definitely of career post you are aiming for. Seek help with this. Consider
unsuccessful candidates. We are braced for some particularly any feedback you receive from your trainers, but beware of
harrowing feedback meetings with the disappointed. One of last people telling you ‘what I would do’. You are you, and your
week’s tasks was to rifle through the boxes of paper littering my solution must be your own to really work for you. The BMA
office, to find the interview records of unsuccessful candidates so is planning to improve its careers guidance. If you believe you
that these are available to inform feedback. The paper problem have a genuine grievance, the BMA offers helpful advice.
is a serious nightmare – the HR team in our Deanery can hardly
Well, I think that is where we are now. Good luck to all of you in
move because of the boxes of detritus generated so far are
August. Hopefully August 1st will be a damp squib, like ‘Y2K’ and
crammed into their offices. So much for an e-based system.
the introduction of the last phase of the working time directive in
2003, and we’ll all be working with a full complement of happy
What next?
trainees, with the workload covered to everyone’s satisfaction
(see picture - I am unable to offer a suitable photo of flying pigs to
I believe a great tragedy is about to unfold. The delays to the
help you through August, but hope this substitute is of interest).
process caused by the MMC review and implementation of
Of course, no-one will be on holiday, (unless MMC-panic as
its recommendations have effectively cost the candidates who
manifested in my own department is just a local phenomenon)
were ranked ‘unappointable’ at interview in their first choice
so you’ll all have plenty of time to pore over offerings such as
Unit of Application in March another chance to look for a post
this, and send us your own tales. So go on; how was it for you?
in a time for August 2007. It seems inevitable to me that many of
these doctors will be unemployed, or in temporary employment, Val Bythell
from the beginning of August, because we won’t have time to
conduct round two (in whatever form it takes) before then.
The information officially given to applicants in order to inform
their ‘re-preferencing’* decisions prior to round 1b via MTAS
was a list of National and local ‘competition rates’; ie numbers
of applicants per post, and number of 1st choice applicants
per post. This was not really adequate to enable a proper
decision. I think it would have been better at that point to give
those interviewed in round 1a an idea as to whether they were
judged ‘appointable’ or not, and to have tried to offer ‘fill rate
estimates’ for posts following round 1a, rather than the initial
competition rate.
What options are open to trainees who have not been offered a
post following this round?
By the time you read this, I am hoping that help will no longer Pigs may or may not fly, but they do swim.
be required by the majority of applicants. I would strongly Photo Courtesy of J.C. Bythell.
6 Anaesthesia News August 2007 Issue 241
MMC glossary had given on their application. An interview was guaranteed to
applicants in their 1st choice UoA, in the ‘extended round 1’,
Unit of Application (UoA): ‘ A unit of application is a unit/ regardless of application score.
recruitment team where recruitment into specialty training will
Selection centre: The National training material for recruitment
be administered’ according to the factsheet for applicants. In
to MMC dictated a minimum standard for interview of a
England this usually means Deanery, but Scotland, Wales and
30 minute structured interview. However, as was helpfully
Northern Ireland are mostly single UoAs.
explained: a selection centre is a process, not a place. (So why
Re-iteration: The sequential process of going down a list of not call it something else?) Hence the verb ‘to selection centre’.
candidates to make offers. Because candidates were able to The precise nature of the selection process was left to Deaneries
apply to up to 4 UoAs, many people in the final rankings after to determine. In our case, we were lucky (I really do mean that)
interview didn’t actually want the job, so refusals had to be to have learned from Professor Patterson (lead professional for
obtained before progressing further down the list of appointable the National training programme for recruitment to MMC) how
candidates. to bring our selection processes up to the suggested standard
over the past 18 months.
Re-mapping: Existing training posts that would cease to exist
from August 2007 had to be ‘remapped’ to fit into the basic Temporary: A temporary increase in ST3 posts has been allowed
MMC scheme. In the main, this involved re-labelling SHO posts or even encouraged for this year. The definition of temporary
as either ST1, ST2 or ST3 posts, or FTSTAs in this context is unclear. It will take the trainees given the
temporary numbers 5 years to obtain a CCT – so this might be
Re-preferencing: Following the recommendations of the MMC
the actual meaning. 2012 is likely to produce a bumper crop of
review team, applicants were allowed to change the order of
CCT-holders.
preference for units of application and /or specialty that they
Final F.R.C.A. Examination
Intensive Preparation Course
The Bristol Crammer
Monday 17th – Friday 21st September 2007
This five day course includes sessions on
DEPARTMENTAL
examination technique, intensive therapy,
new drugs, current topics, and practical
PROJECT GRANT
subjects (ECGs, X-rays), as well as mock
examinations and performance analysis.
(Up to £25,000)
Conducted by national and local experts at
Burwalls Conference Centre, Bristol.
The grant is to enable a department of anaesthesia to
pursue a research project either by the purchase of For further details, please contact:
equipment or the part funding of a salary for medical
or technical help or other support. Jane McLean
Further information and application forms are available Department of Anaesthesia
from the Association website: Bristol Royal Infirmary
www.aagbi.org Marlborough Street, Bristol BS2 8HW
or Chloë Smith, Association of Anaesthetists of Great Britain Telephone: [phone] (Direct Line)
and Ireland, e-mail: [email protected]
Direct Line: 020 7631 8807, or email: [email protected]
Course Director: Dr S Underwood FRCA
Closing date for applications: 12 October 2007
Association Educational Awards are only open to members of Some Accommodation Available Course Fee £400
the Association of Anaesthetists of Great Britain and Ireland Includes coffee, lunch and tea
Anaesthesia News August 2007 Issue 241 7
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“If you feed the children with a spoon, they will never learn to use the chopsticks”
8 Anaesthesia News August 2007 Issue 241
PRESIDENT’S REPORT
The country has a new Prime minister and Secretary of State for Changes are also
Health. It has already been suggested that Gordon Brown will occurring in our
slow down some of the NHS reforms and this time of change own organisation
could be a good political opportunity to drop some of those and you have
that have not been value for money, not worked so well or had all elected three
unintended consequences. PFI has already been stalled, although new Council
the full scale of the scandal may take some years to unravel, members whom
and Richard Granger (Chief Executive of NHS Connecting I look forward
for Health, the £20bn IT monument) is quitting his post to return to welcoming to
to the private sector. The eighteen week target from GP referral AAGBI Council
to treatment seems to continue as an important goal with some when they take
areas talking about making it seven weeks. There's quite a bit office at the
of healthy scepticism about this target and it will be interesting AGM in Dublin
to see if it has been adequately resourced and what anaesthesia in September.
will be expected to do to achieve it. As always we should all This year we had an unprecedented 22 members standing for
maintain good clinical standards for our patients, only work if election and the Association must be doing something very
the arrangements are transparent, and do so for parity. right or very wrong to attract such a number. I hope it is the
former! My thanks and commiserations to all those who put
To get last year's NHS budget back in balance, crisis measures
their names forward but missed out on this occasion. I hope you
were taken including the cutting of study and training budgets.
will consider standing again next year.
With the final balance of around £500 million in the black this
now appears to have been totally unnecessary and we must all Our membership also continues to grow and we expect to enrol
press for its restoration as soon as possible. We are told that £4 our 10,000th member soon in our 75th year. We plan to mark
billion is expended on training each year, but it is very difficult the occasion with a prize for the lucky person so if any of your
to identify if and where exactly it is spent. colleagues - consultants, SAS or trainees - are not signed up,
download an application form from the website and get them
Whilst you're reading this in August you will also be aware
involved.
of the extent to which the MTAS debacle has disrupted your
hospital and the services you are able to give the patients over The Association's 32nd Linkman Conference was held at the
this period. Some hospitals were planning to operate on a Royal Society of Medicine and covered topics such as MMC/
bank holiday basis for the first week or so whilst new staff were MTAS, the consultant contract and job planning (see report
inducted and gaps filled. Only 60% of training posts in London in this issue). Professor Jonathan Montgomery, Chairman of
were filled in the first round and a rescue plan was drawn up the ACCEA, braved the lion's den to discuss the data about
to help fill the remaining jobs through a single application on anaesthesia and its continuing poor position in the award
a London-wide basis. The MTAS review group disbanded in system. He said this year he will be having a ‘hard look’ at
June feeling that it could achieve no more and a further review anaesthesia to see if the current system is working fairly both
has been set up under Professor John Tooke. Anyone can send at a local and national level. The local system in particular is
comments in and the College and Association will be submitting very variable, largely unmonitored, and can delay anaesthetists’
some detailed observations. A simpler application system and progression to the stage where they can compete for national
more flexibility in the first few years whilst trainees decide what awards. Linkmen provided further evidence and their views
they want to do and trainers decide what they are capable of are on the ACCEA system through the digital voting system and
some of the ideas that will be promoted. Professor Montgomery took considerable time to answer their
questions. Large numbers of well-completed ACCEA forms at
The BMA sees revalidation and the GMC reforms as the next
both local and national level are the key to beginning to address
key professional issue and it is in everyone’s interest to see the
anaesthesia’s historic disparity so make sure you submit yours
system become ‘fit for purpose’. From self regulation to the
this year.
funding arrangements; all are to be in play and Association
Council will contribute to this important concern. David Whitaker
President, AAGBI
Anaesthesia News August 2007 Issue 241 9
Editorial
Stand up
for
Stand-ins
A few years ago, the Scottish Standing Committee had the But it does happen: Association Council members regularly
unfortunate experience that their keynote speaker had to pull out receive emails from the events team which start with the word
of the annual Open Meeting at about three weeks’ notice. There “HELP!”, and a replacement is found or recommended from
was a hot political topic at the time, and this speaker was, if not within the ranks. You may be unaware of this, but at most
the horse’s mouth, pretty darn close to the stable. A replacement Association meetings, the events team ensure that a few Council
speaker was found, but with no disrespect intended, could not members arrive with one of their hardy perennial party pieces
really deliver the anticipated level of information. This was saved on a memory stick, ready to fill in if there’s a last minute
before my time at the Association, and I was not at the meeting, no-show. It’s an organiser’s worst nightmare.
but a few of my colleagues were, and were a bit brassed off that
the big draw in a one-day meeting was not as advertised. If you bought tickets to see Robbie Williams and he was replaced
at the last minute by Val Doonican, you would be storming the
This is not intended to slag off the Scottish Standing Committee, box office to ask for a refund, and nobody would argue with
a fine body of which I am a member, but to highlight the issue you. However, in the theatre, if the star is unwell, the understudy
of the non-appearance of a big name speaker. It happens from goes on and so does the show – as many people who wanted
time to time, and irritation is for the most part (like that of my to see Connie in “The Sound of Music” discovered earlier this
colleagues) transient. Most anaesthetic education in this country year. Perhaps an anaesthetic meeting is “a show” in which the
is organised on a not-for-profit basis by organisations like the star performer is only one ingredient, and taken as a whole, the
Association and the College, all the way down to the Nether product is delivered as advertised. A bit of grumbling at coffee
Wallop Tricky Vein Society’s annual shindig (not to be missed). time seems to be as far as it goes, as everyone realises that the
Nearly everyone has been involved, if only peripherally, in money they have spent is reinvested in education. Organisations
the organisation of some sort of meeting, and knows that the such as the Association and the College provide anaesthetic
organisers sweat blood to provide a decent programme, and that CPD because it is in the interest of the specialty as a whole to
speakers also sweat blood to be there – I once introduced a ensure this is done; not for any other reason.
session at the Winter Scientific Meeting with one speaker whose
plane to London had caught fire on the runway that morning; the However, a relatively recent development is the appearance
second speaker arrived in plaster and in obvious pain, having of a number of commercial operations who organise medical
made an unscheduled exit from his bike a day or two previously. education. What happens if their keynote speaker does not
Both turned up and delivered their lectures perfectly. appear? Should they be any different to the “not for profit”
10 Anaesthesia News August 2007 Issue 241