Service versus TrainingWho Wins?

C P Shearman

Why Change?

“I once found it quite stimulating but now it is just a job”

1. Reason to change – New Technology

Interventions for leg ischaemia

0

5000

10000

15000

20000

25000

30000

35000

2000 2001 2002 2003 2004 2005 2006 2007

reconstruction

endovascular

diagnostic

www.dh.gov.uk

So what is the problem!

Look if it was electric could I do this?

Who is going to do this?

Formal Endovascular Training

Complex open surgery

2. Reason to change - Training

2. Reason to change - Training

Unfinished Business 2002

• SHO training poorly structured

• Inadequately supervised

• No definitive end point

• Needed Reform

Vascular Syllabus• Basic science+surgical skills• Basic Imaging and IR skills• Vascular biology• Vascular medicine• Professional skills• Critical care• Ultrasound• Lower limb• Venous• Trauma• Diabetes and vascular

disease

• Aneurysms (aortic)• Extra-cranial arterial disease• Upper limb• Visceral artery• Renal vascular disease• Vascular access• Lymphodema• Vascular malformations• Congenital vascular disease• Paediatric vascular

VASCULAR ACCESS Template 15

Indicative training years: Intermediate, Final – ST3-4

Section Aim – To be aware of a range of techniques and to able to provide vascular access

Subject / Topic Knowledge Clinical Skills Relevant Professional Skills

Assessment

Vascular accessDiagnosis and InvestigationSubject objective – ability to diagnose and investigate patients requiring vascular access

Anatomy of upper and lower limb arteries and veins List indications for the establishment of vascular access Knowledge of methods of renal support; advantages and disadvantages.Physiology of an a-v fistula; including velocity, resistance, flow patterns and energy lossesKnowledge of conduit materialKnowledge of suture material

Able to describe anatomy of upper and lower limb arteries and veins and common variations.Able to describe methods of providing renal replacement therapyAble to describe various vascular access procedures in detailAble to describe hierarchy of investigation of patient needing vascular accessAble to describe ultrasound characteristics of acceptable artery and vein for access surgeryAble to perform ultrasound assessment of patient needing vascular access (2/3)Able to describe standard flow patterns in a-v fistulaAble to describe a-v graft types and indications for use.

Able to communicate with patient and obtain informed consent.Able to communicate with vascular laboratoryAble to communicate with radiology departmentAbility to prioritise patients for surgery

In service assessment, ExamsWorkshops/courses

Vascular Curriculum - Modular

Reason to change – Professional Performance

• Medical Expert/Clinical Decision Maker

• Communicator• Collaborator• Manager• Health Advocate• Scholar• Professional

The fuel light is on, Frank we are all going to die,

we are all going to die. Whoops my mistake

that’s the intercom light

Medical Teacher 2000;22:549

European Working Time Directive

48 hours per week

1st August 2009

37 hours Denmark

80 hours United States

How Long to Train?

Annual US trainee log book• Operating 2753 hours• Assisting 272 hours• Post op-care 938 hours

total 3963 hours

• 10-20,000 hours• Duration vs. competency• UK 2+6 years

Purcell Jackson and Tarpley BMJ 2009;339:1069

Time to Train

Max hours per week

No of weeks leave

No of hours per year

Total no hours in 8 years

80 2 4000 32,000

80 4 3840 30,720

56 4 2688 21,504

48 4 2304 18,432

37 4 1776 14,208

Modified from Purcell Jackson and Tarpley BMJ 2009;339:1069

Vascular Training in General Surgery?

• Broad base • General Training• Skills acquired late

• Shifts• Hospital at Night• Service Provision• Limited simulators

3. Case for Change - Outcomes

The European Society for Vascular Surgery. (2008). Second Vascular Database Report

Volume / Outcome Relationship:

Holt et al, Br J Surg 2007

Elective AAA Repair

Variation in Amputation Rates

Holt P et al BJS 2010 Holt P et al BJS 2010

Variation in Mortality

Holt P et al BJS 2010 Holt P et al BJS 2010

Case for Change – Public Concern“Death rates in planned vascular surgery for abdominal aortic aneurysm (AAA – to prevent a burst artery) vary from under 2% in some hospitals to at least 10% in 10 of them.”

“Patients are less likely to die in the bigger, busier hospital units where surgical teams are more skilled because they do more of the operations. The results strongly suggest that smaller units should close.”

4. Reason to change – AAA screening

Quality Improvement Framework for Aortic Aneurysms

• MDT– radiology, anaesthetist,

renal, cardiology

• Procedures undertaken/supervised by consultant

• 24/7 on site vascular cover

• >33 cases per year• NVD

– stop if >6% mortality

• All hospitals and specialists comply with VSGBI QIF

• Usually only one intervention centre with inpatient services

• Screening Network for min 800,000

• Vascular specialists travel to intervention centre

• Network provides full range of services for hospitals without vascular inpatients

5. Reason to change - Unmet need

• Diabetes– Rising amputation rate cf. Finland– 68% no attempt at

revascularisation before amputation

– 3 million with diabetes 2010• Carotid Surgery

– 48hr access times– Under provision (15/100000)

• Vascular Access– 17,140 per year– 66% by vascular teams– waiting list!

• Cardiovascular Risk– 30% PAD patients risk factors

treated0

2

4

6

8

10

12

14

16

1 4 7 10 13 16 19 22 25 28

%CEA/100,000

0

500

1000

1500

2000

2500

3000

3500

4000

96 97 98 99 0 1 2 3 4 5

DM1DM2Non DM

Trend in amputation in England and Wales

Vamos Diabetes Care and Clinical Research 2009

1996-2006

Type 1

Minor 11.4%↓

Major 41% ↓

Type 2

Minor 95%↑

Major 83.5% ↑

Amputation trends in People with Diabetes in Finland

0

200

400

600

800

1000

1200

1988 1990 1992 1994 1996 1998 2000 2002

MenWomen

The number of 1st Amputations of diabetics in Finland 1988-2002

Incidence of 1st Amputation per 100,000 diabetics

Lepantalo 2006

6. Reason to change - Emergency work

• 30-40% of total workload– High risk– Cost– Immediate availability

• Clinical Governance risk– Commissioners – SHA reviews

• Specialty requirements– Endovascular rAAA– Out of hours imaging– Diabetic foot complications

Poor NHS care puts lives of emergency surgery patients 'at risk'Report finds that delays in finding operating theatre spaces lead to deaths while only one in three receives critical aftercare Sam Jones and agencies•guardian.co.uk, Thursday 29 September 2011 09.02 BST•Article history

Hospital patients 'more likely to die at weekends'By Nick Triggle Health correspondent, BBC News

        

                                                                                   A shortage of senior doctors is said to be at the heart of the problem

Being admitted to hospital in England at the weekend is risky, experts say.

BBC News

A shortage of senior doctors is said to be at the heart of the problem

Temple Report– Consultant Temple Report– Consultant expansionexpansion

7. Reason to Change Manpower

0

500

1000

1500

2000

2500

3000

3500

4000

2005

2007

2009

2011

2013

2015

2017

2019

2021

2023

HC est required

projected HC

NHS Workforce Review Team

Headcount - HC

Anticipated number of trained specialists in General Surgery

8. Reason to change - Financial

200

300

400

500

600

700

£b

n

•Highest spending since 1982–83•Lowest tax burden since 1960–61•Highest borrowing since WWII

£178bn borrowing this year

Receipts

Expenditure

During the recession, government expenditure has continued to grow whilst receipts have fallen

What does this all mean? • Improve outcomes/quality

– low volumes– AAA Screening

• Adopt new technologies– endovascular

• Training– More focused– Fewer trainees

• Increased work load– diabetes– AAA screening– unmet need

• Emergency provision– Clinical governance/consultant delivered

• Financial downturn in NHS/save money

Weasel didn’t like the sound of this

Solutions

New ways of working“Interventions should be planned,

executed and measured”

• Training• Consultant role• Service structure

Hamster Health Care. Morrison I,Smith R. BMJ 2000

Technology

Redesign health care delivery

250 to learn to fly; 8 years to do an appendectomy

Accelerated pilot training: simulators

Richard Reznick

Solution 1 - Training

• Simulators • Competency based • Relevant skills early

• Service Focused• Disease focused

Generic Skills

Specific Skills

Solution 1 Training

The Toronto Experiment

6 orthopaedic trainees

•Early Entry into specialty training

•Supernumerary to service

•Early acquisition of skills

•Progression by competency

Richard Reznick

Make Training Cost Effective

The other birds suspected Owl hadn’t worked in a DEANERY at all

Getting Value for Money

• Professional Trainers– Job plan tariff +

assessment– Standards for training

units• Budget (£9.3m)

– Withhold and invite bids

– Competition for posts– Reward success eg

ARCP1s

Fit for purpose training -Train for Service

Core Training ST1-2

Intermediate Stage ST3-4

Advanced Stage ST5-6

Final Stage ST7-8

National Selection

Vascular FRCS 1

Vascular FRCS 2

Standards for Vascular Training VSGBI 2011

Outline of the content of vascular specialty training

Intermediate Stage Final Stage

ST3 ST4 ST5 ST6 ST7 ST8

One year of elective and one or two years of emergency vascular surgery.

One year of elective and one or two years of emergency GI surgery

Four years of elective and at least three years of emergency vascular and endovascular surgery.

Vascular MedicineVascular AccessDuplex UltrasoundAxial imaging, interpretation, reformatting and planning

Professional behaviour, leadership, teaching, audit, research

Standards for Vascular Training 2011 VSGBI

Pre-specialty Training

Role of Medical School, Foundation Schools service training?

Solution 2 Role of Consultants

NHS Employers Confederation• Role of Consultants

• Front line delivery• Career structure/Teams

• Systems Management• Quality improvement frameworks• IT and new technology

• Utilisation of Facilities• 6-7 day working• Step down beds

• Outcome based standards• mortality

• Commissioning Standards• national• providers met

www.nhsconfed.org/publications

Consultant Working Practice – value for money

• No elective commitments• Daily unit ward round• Emergency walk in clinic• Emergency list• Evening ward round

Reduce admissions

Reduce length of stay

Allow better training

Value for money

Intermediate/complex

Routine

Added valueconsultants

trainees

Solution 3 - Restructuring of Services

•Fewer, larger units (50)•Consultant teams - min 6 (8-9)•Change in consultant role

– Service delivery– Sub-specialisation (EVAR vs Open)– Designated trainers

•Surgeon specific outcomes (NVD)•Fewer Trainees (1per unit?)

Provision of Services for Patients with Vascular Disease VSGBI 2011

High quality, cost effective, sustainable

“Centralisation…is the preferred method of providing high standard vascular services”

“There is evidence that even with transfers of more than one hour, transfer to a vascular unit improves patient outcomes”

“There has been little strategic planning in the way vascular services are commissioned and delivered.

As far back as the original Provision of Vascular Services document, it was recommended that coalescence of adjacent vascular services onto a single site is the optimal model for service delivery”

“Access to specialist care will often involve transfer of patients to the nearest hospital where emergency vascular treatment is available. In certain geographical areas this may involve travelling some distance, but there is good evidence that patient outcomes are not related to the distance travelled if they reach a centre where vascular expertise is available”

Solution – Centralisation

A Bright Future

• Embrace service change

• Role of consultant

• Focus on training needs

• Training fit for service

“What do you mean it’s a bit muddy!”