CSQ Bulletin75

The Royal College of Anaesthetists
Bulletin
Inside this issue
FOR ANAESTHETISTS
Revalidation
Issue 75 | September 2012
Annual Review of Competence Progression the ARCP The National Institute for Health Research (NIHR) and the Clinical Research Networks (CRNs) Depression: a personal view The financial strategy of the College Liberia: how volunteers can help Patient Safety Update
Page 2 | Bulletin 75 | September 2012
BULLETIN
The Presidents Statement Guest Editorial SAS and Specialty Doctors Revalidation for anaesthetists NIAA Health Services Research Centre The Faculty of Pain Medicine The Faculty of Intensive Care Medicine Patient Perspective Annual Review of Competence Progression the ARCP The National Institute for Health Research (NIHR) and the Clinical Research Networks (CRNs) Depression: a personal view The financial strategy of the College Liberia: how volunteers can help The Society for Ethics and Law in Medicine Patient Safety Update As we were e-Learning Anaesthesia Report of Council Notices Programme of events 2012 Advertisements
of The Royal College of Anaesthetists

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The Royal College of Anaesthetists is grateful for the contribution to the production of this publication by Laerdal Medical Ltd and Drger Medical UK Ltd. 2012 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 (subs@rcoa. ac.uk) so that their copy of the Bulletin is not misdirected. Articles for submission, together with any declaration of interest, should be sent to the Bulletin Editor via email to: bulletin@rcoa.ac.uk. All contributions will receive an acknowledgement and the Editor reserves the right to edit articles for reasons of space or clarity.
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Views & 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.
ISSN (print): 2040-8846 ISSN (online): 2040-8854
From the Editor

Welcome to the autumn edition of the Bulletin, which should arrive at the end of a long hot summer, but, at the moment, as I write this I am still waiting for any sign of summer at all! This month Dr Venn returns to write the guest editorial to introduce us all to the concept of accrediting anaesthetic departments. He explains the drivers behind the process, how it has developed and how it will work. This is an optional programme and Peter explains why a department may wish to engage. Dr Boyle updates us on the GMC developments on recognition and approval of trainers and explains how this replace the approval to teach register for SAS doctors. Reflection has always been recognised as an extremely valuable educational tool and the threat to morbidity and mortality meetings is causing the GMC concern. In this edition of the Bulletin Don Liu and Dr Brennan gives us some guidance on reflecting on CPD activities for revalidation. I suspect we all know this but need to by nudged into organising our thoughts and creating a permanent record to demonstrate the value of our CPD to a third party. Finding time to stop and reflect on our work and lives in general is invaluable and Mrs Dalton has provided us with her thoughts looking back on her year as chairman of the Patient Liaison Group while Dr Grant has bravely reflected on her struggle with depression and has shares her learning points with us in the hope that we can be both more understanding and if effected ourselves we can recognise when help is needed. The Annual Review of Competence Progression, more generally known as the ARCP, is so integral to training and those involved in training that it is easy to forget that those not directly involved may not quite understand what it is all about. In order to address this and to encourage support for both the trainees and the trainers involved, we asked a number of individuals to reflect on the process and you can read their opinions on page 19. A frequent comment was that the next challenge is to go electronic and use the e-portfolio to make it a paperless exercise and there is some concern raised about this. At the time of going to press the College has just heard that one school in Scotland has just reported successfully completing all their ARCPs electronically and we will endeavour to report on this in a future edition of this journal. Dr Bindal, Mr Scott and Professor Hutton introduce us to the Society of Ethics and Law and explains how a society initiated for anaesthetists is now open to all health specialties. Professor Grocott reports that the National Emergency Laparotomy Audit has been awarded to the College and explains what this means and how it will be run. He also updates us on the progress with Clinical Research Networks and how they will work in Intensive Care. Dr Sheraton introduces us to the Mothers of Africa charity whose aim is to support education of individuals in Africa to help save mothers and new-born babies. This exciting project is looking for volunteers for periods of three to five months as well as opportunities for shorter, two week attachments. Many of you ask what does the College do with our money? This month Kevin Storey, our Chief Executive and financial guru, has obliged by explaining to us the financial strategy of the College. I hope you find it answers some of your questions. Finally, traditionally we have asked for articles for the Bulletin to be about 2,000 words long. We have recognised that sometimes you want to express an opinion that does not quite fit this model so from next edition we will include a Short Communication section with articles of about 600 words, i.e. one page. If you have a burning desire to share something with us in this way please do get in touch (bulletin@rcoa.ac.uk).
Dr Anne Thornberry, Editor
Please visit the News and Media section of the website for the latest news items at: www.rcoa.ac.uk/news Download this and back issues of the Bulletin at: www.rcoa.ac.uk/bulletin The rapid response section is now open for articles published in this issue. Please make your views known to us at: www.rcoa.ac.uk/letters President Dr J-P van Besouw Vice-Presidents Dr H M Jones Dr D Nolan Editorial Board Dr E A Thornberry (Editor) Dr A P McGlennan (Assistant Editor) Dr S Patel (Editor, Trainees Topics) Dr P J H Venn Professor D J Rowbotham Dr R Marks Dr R Verma Dr S Underwood Dr P Davies Professor M Mythen Ms S Payne Mrs M Kelly (Website and Publications Officer)
The Presidents Statement
The times they are a-changin

[Bob Dylan] 2009 2012
Dr P Nightingale
President
When elected as President in June 2009, I immediately sought advice from previous Presidents. What I needed was not information on how the College functioned but on what strategies they had used to survive their three-year term. It seems strangely apt that I come to the end of my tenure during the Olympic Games; more than one person said that the term of a Presidency is akin to a marathon! One of the best bits of advice was to be pragmatic; that was good because I have pragmatism, and also procrastination, down to a fine art. I was told that though you may have a vision, or even plans, for what you wish to achieve it is likely that you will spend most of your time fire-fighting; and to a large extent that is what has happened. Certainly, I think we were all wrong-footed by Mr Lansley when the scale of his reforms became apparent on 12 July 2010 when his White Paper Equity and Excellence: Liberating the NHS was published. The last two years have been a merry-
go-round of meetings and debate before the amended Bill became an Act. Personally, and sadly, I cannot believe this will be the end of NHS reorganisations, whichever party next comes to power. Even more time-consuming has been the work to metamorphose Medical Education England into Health Education England, and contributing to the debate on the shape of training and of the future workforce; work that is still ongoing and causing much anxiety amongst trainees. Professor David Greenaway, an economist and Vice-Chancellor of Nottingham University, is leading a review of the shape of training sponsored jointly by: the Academy of Medical Royal Colleges; the General Medical Council; Medical Education England; the Medical Schools Council; NHS Scotland; NHS Wales and the Northern Ireland Department of Health, Social Services and Public Safety. As a member of the Expert Advisory Group, I am keen to hear your views, either directly or via:
www.shapeoftraining.co.uk/ yoursay/1729.asp. If via the website, I would appreciate a copy of your comments. In a related piece of work, the Working Longer Review will be of interest to those in frontline and physically demanding roles; I take this to include anaesthesia and intensive care specialists. For further details, and how to respond, see www.dh.gov. uk/prod_consum_dh/groups/dh_ digitalassets/@dh/@en/documents/ digitalasset/dh_133003.pdf. Again, in view of my involvement in the work of the Centre for Workforce Intelligence on possible consultant career structures, I would be interested in your views and have sight of any submission you may make. Another piece of advice was to be wary of the inevitable increased intake of calories that occurs when on College business or simply from spending time away from home. Since this is my last Presidents Statement for the Bulletin I have taken the liberty of updating my photograph (the same one has been
The Presidents Statement

in use for three years) to see what ravages Presidency has wreaked on me. In summary, I can still get into most of my clothes but the hair and beard are definitely whiter. However, its time to get back into training and miss a few lunches, I feel; I cannot simply blame the Higgs boson for my mass! In the July Bulletin, I alluded to the huge amount of work the College undertakes. A colleague asked me to expand on this somewhat by detailing the operational structure of the College since they had little appreciation of it. Space does not permit me to do that fully here but this link gives some relevant information www.rcoa. ac.uk/node/2099 and we will look at disseminating our responses to consultations further.
Final FRCA course

We are looking to expand our cohort of Final FRCA Tutors. The Final FRCA Revision Course aims to ensure that candidates are well prepared for the Final FRCA examination and provides candidates with a detailed knowledge and understanding of topics in the examination syllabus. Our Tutors deliver interactive smallgroup tutorials that supplement the didactic lectures, and provide an opportunity for more in-depth discussion of topics. For more information, and details on how to apply, please see page 64.
Trainee Committee. Oliver and Matt have transformed this informative publication into a slick, professional, document that I hope will be attractive and useful for trainees. Finally, as I drift off into retirement, I would like to thank my teachers, role models, mentors and supporters, colleagues, employers, associates and all at the College who, over the years when I have been learning and practising my roles, and maturing as an individual, have made it possible for me to achieve what I have. From my initial anaesthetic training in Truro, to Newcastle and then Manchester, and on to the Intensive Care Society, College, Academy and wider arenas, I thank those who guided me, occasionally through some difficult times and you know who you are so that eventually I hope you feel it was worth it. My best wishes now go to J-P van Besouw as he embarks on his Presidency. Im sure hell enjoy it as much as I have done though whats round the corner for him is anyones guess.
People
I was delighted to read of Dr Mike Durkins appointment as the Director of Patient Safety for the NHS Commissioning Board (www.commissioningboard.nhs.uk/ appointments/) against some stiff competition, including senior people from the defunct National Patient Safety Agency. For this prestigious appointment to go to an anaesthetist is great news for the specialty. Similarly, I was extremely pleased to see Dr Mark Porter, an anaesthetist from Warwick, elected to succeed Dr Hamish Meldrum as the next Chairman of the BMA. Many view the representation of secondary care in the BMA, and the influence of the more radical element on the trade union side, with some disquiet. Marks pragmatic nature, and anaesthetic persona, I think will stand him in good stead for what will undoubtedly be a difficult job; he has my best wishes. I would like to thank Dr Oliver Daly and Dr Matthew Wilkes for their work in producing the latest edition of The Gas, the trainee newsletter created by the members of the
National Emergency Laparotomy Audit (NELA)

I am delighted to inform you that the Healthcare Quality Improvement Partnership (HQIP) has provided 1 million funding to the College to enable the Health Services Research Centre (HSRC), to run the new National Emergency Laparotomy Audit for the next three years. This major piece of work, which will improve the quality of care of adult patients undergoing emergency laparotomy for gastrointestinal conditions in England and Wales, is the first anaesthesia-led national audit and the first to concentrate specifically on perioperative care. Professor Mike Grocott, Director of the HSRC, provides an update on page 14. My congratulations to all involved.
You dont have to be the Dalai Lama to tell people that lifes about change.
[John Cleese]
Guest Editorial
Setting standards: the RCoA accreditation programme

The well tried and tested programme of Royal College visits to training departments in anaesthesia ended in 2006 with the formation of the Postgraduate Medical Education Training Board (PMETB). Such visits were an excellent way for the RCoA to keep in touch with anaesthetic departments throughout the UK and, although primarily targeted at the delivery of training, the quality of delivery of service was touched upon inevitably, often leading to recommendations for improvement.
Dr P J Venn
Chairman, Professional Standards Committee
Since then, the RCoA has been aware that the flow of such important information no longer takes place, and that it feels somewhat out of touch with the typical UK department of anaesthesia, particularly with regard to the quality of the delivery of service. Although all departments strive to deliver excellent care, often in the face of adverse financial circumstances, a co-ordinated benchmarking system is not in place currently at a national level. An idea had hatched some time ago to develop a programme of accrediting departments for the quality of the delivery of their service, but this had never progressed. Now, the recently formed Quality Management of Service Committee (QMSC) has been tasked with bringing to fruition a practical and credible programme of accreditation for anaesthetic departments across the UK. Although entirely voluntary, the programme has already engendered considerable interest amongst clinical directors and regional advisers, with many expressing a desire to sign their departments up for inclusion.
seek their support (Table 1). One of the most important and, indeed, the most supportive, was the Care Quality Commission (CQC). Preliminary discussions suggested that an accredited department might be presumed automatically to meet any quality standards set by the CQC, thus providing an incentive to lead clinicians and chief executives to sign up to the programme. The Conference of Postgraduate Medical Deans (COPMeD) was also consulted, as was the NHS Litigation Authority (NHSLA).
Table 1 Stakeholders engaged at an early stage of programme development
Dr Andy Mitchell Professor Danny Keenan Professor Sir Michael Rawlins Professor Sir Bruce Keogh Dr Robert Ginsburg
Medical Director NHS London Care Quality Commission (CQC) National Institute for Health and Clinical Excellence (NICE) Medical Director of the NHS Head of the London Academy of Anaesthesia Conference of Post Graduate Medical Deans (CoPMED) Health Quality Improvement Partnership
Miss O Lester
Quality Management Service Co-ordinator
Getting them on our side

From the outset, it was obvious that the task would be more likely to succeed if certain stakeholders, and those with a vested interest, were signed up to the programme. During the early part of 2011, the College engaged those that it felt were relevant with a series of meetings, to sound out their thoughts and
Dr Fiona Moss
Dr Robin Burgess
Guest Editorial
During early discussions, the Head of the London Academy of Anaesthesia advised that visits to discuss training issues within London were becoming dominated by service issues that impacted upon training, and went so far as to say that future commissioning of training might include only departments accredited by the College. A preliminary structure was agreed whereby a department could express an interest in the programme by approaching the College, and an initial fact finding form, encompassing a number of the more basic and generic standards, could be sent to the clinical director for completion, and returned for analysis. Initially, a pilot ran through the autumn of 2011 with 19 hospitals included. The data suggested that there was, indeed, a deviation from the standards expected during training visits some five years previously. This information alone underpinned the reason for pursuing the project. At the same time the College made visits to other organisations with an interest in this area, to learn more about how the project might be developed. These included the Royal colleges of pathology, radiology and psychiatry. Dr Ian Barker joined the team and presented a discussion document which helped further development, based upon the information learnt. used for standard setting. All aspects of the accreditation process will be referenced to this publication, which is a multi-author document available to view on the RCoA website, and which gives a comprehensive overview of the benchmarks that the RCoA would like departments in the UK to aspire to. An accreditation matrix encompassing five domains has been defined, within which sub-domains and individual standards are being developed using GPAS, each standard being referenced to a paragraph within the document (Figure 1). Domain 3 (Patient Experience) has been given largely to the Patient Liaison Group of the RCoA to develop. This seems a logical use of lay input, and helps to keep the desired focus upon the patient as the centre of the project. At the same time, GPAS is being rewritten and updated, and the authors (all experts in their fields) have been asked to include all new guidance relevant to their chapters from all sources, for instance, the Department of Health (DH), the National Institute for Health and Clinical Excellence (NICE), and the CQC. Revisions will appear each year on the College website as new guidance is gleaned, and so the accreditation criteria will alter with time to reflect these changes. Following contact from a department, a web-based form will be sent which the department will complete and return. This will enquire about compliance with all the standards relevant to the hospital, as laid out in GPAS. A departmental visit will follow, enabling a gap analysis to be conducted with agreement about the approach to close the gaps, so that the standards are met and accreditation can be granted. For clinical directors, this will form the basis from which they can manage their departments to a high level of compliance with quality delivery of care, and give measurable data with which to present to chief executives and trust boards or equivalent bodies.
Where are we now?

As might be expected, there is a variation of opinion about the standards laid out within the GPAS document, and so the committee has decided to put the revised document out to consultation with all Fellows and Members, by publishing it in draft form, chapter by chapter on the College website, and inviting feedback. This has been deliberately timed to coincide with the publication of this article and will run for two weeks. At the time of writing, the accreditation matrix is being populated with standards also in draft format, with a view to running a second more comprehensive pilot in the autumn of 2012. 25 hospitals have signed up, including several in Scotland, Wales and Northern Ireland. The committee hopes to launch the programme in its final format in the early part of 2013 if all goes to plan.
The process
The process will encompass a fouryear cycle of accreditation for a department, following which it will be necessary for it to re-accredit. Because the process is voluntary (the College being approached by departments) it is not regarded as a pass/fail scenario, although inability to maintain standards will result in removal of accreditation.
Standard setting
The programme required the development of measurable standards by which to benchmark the quality of the delivery of service and, from the outset, the committee decided that the College publication entitled Guidelines for the provision of anaesthetic services (GPAS) should be
Why bother?
So, why should departments wish to become accredited with the Royal College?
Guest Editorial
Figure 1 The unfinished accreditation matrix whilst in its development stages, July 2012
Guest Editorial
Firstly, it allows a benchmarking of service which can act as a model for the delivery of healthcare. This allows clinical directors to liaise with senior managers, trust boards and equivalents following the gap analysis, and enables the boards to understand why departments may wish to make any changes to practice that may require investment in equipment or staff. Secondly, following the Royal Assent given to the Health and Social Care Bill in April, Clinical Commissioning Groups (CGCs) will be tasked with setting quality standards for healthcare for their patients. Because anaesthesia is a large part of the surgical service in any hospital, such providers can reassure the CGCs about the quality of care that they can expect for their patients. Furthermore, it is likely that organisations such as the CQC and, possibly, the Clinical Negligence Scheme for Trusts (CNST), will allow accredited departments to have already ticked the box for quality in the delivery of the anaesthetic service, without the need for further detailed inspection during visits that would normally require further time and effort. Last but not least, good departments both deliver a good quality of service and a good quality of training, and there are bound to be positive effects for trainers and trainees alike. recommendations from stakeholders using the document as the final common pathway for publication. As a living document, GPAS will undergo constant revision to reflect the changes in quality required with changing technology and advances in knowledge about healthcare, and updated versions will be posted on the College website each January. The second document with which it will integrate is the Audit Recipe Book, just revised under the editorship of Dr John Colvin. This provides a structure for departmental audit that will be cross referenced to GPAS, and will allow a national approach to data collection that will enable anonymised statistical data analysis about quality of the provision of anaesthesia, and national trends. Each standard in the accreditation matrix will be cross referenced to both documents, with references at the end of each chapter to the source of the standard, be it from peer reviewed and published research data, audit data, or national guidance. Furthermore, individual standards of practice will feed into GPAS from the RCoA publication entitled The Good Anaesthetist. Together, the three documents will provide a complete model for professional standards, encompassing standard setting, departmental auditing, and external assessment for accreditation (Figure 2). Some unfinalised areas remain. For instance, whilst standards need to be practical and not wildly aspirational, there is nothing wrong with aspiration, and the committee is considering whether there should be levels of accreditation. On the other hand, the approach that should be adopted in the unlikely event of finding unacceptable or unsafe practice requires further discussion. Consideration also needs to be given to the resolution of any disputes, and a possible appeals process. The project also has to be sustainable financially, and will require an increase in staff at the Royal College, necessitating the inevitable business case to be submitted to the Finance Committee and Council. This project is exciting and, whilst there is much work in progress, much has been achieved already. Ultimately, it is envisaged that all providers of anaesthesia will be offered the chance to participate, including those in the independent and private sectors of healthcare. The College hopes that widespread interest and engagement will make this model the norm for the future of the delivery of anaesthesia in the UK.
Figure 2 The standards loop
The future
The Professional Standards Directorate does not see this project in isolation, but rather one that fits into a new integrated way of setting, auditing and ensuring good quality healthcare. Two other important documents are therefore integral to the process. Standard setting will continue to channel through GPAS, with all other
SAS and Specialty Doctors | CGC@rcoa.ac.uk | www.rcoa.ac.uk/sas
SAS Bulletin Articles Needed!

Do you have you a story to share? Perhaps you have developed a sub-specialty interest or made an interesting contribution to working practices at your hospital. Are you involved in teaching, training or appraising? What strategies have you adopted to develop your career? The Career Grade Committee is keen to involve our SAS members and fellows further with the College and I would like to encourage you to write an article for submission to the SAS pages of the Bulletin. Further details are available on the website (www.rcoa.ac.uk/ node/4264). This editions excellent article is written by Suzanne Boyle, our Scottish SAS representative. Dr R Laishley Chairman
Recognition of career grade doctors as trainers
Dr S Boyle
Career Grade Committee representative for Scotland
The GMC is currently in the middle of an extensive consultation aiming to recognise and approve trainers in a more formal way to help ensure the safety of patients and trainees and enhance the training environment. Many career grade doctors are already involved in teaching foundation doctors and trainees and function as examiners for undergraduate students; however, the College has been encouraging College Tutors to consider SAS doctors with an interest in teaching and medical education to become trainers with their trusts in both clinical and educational supervisory roles. Once recommended by a College Tutor, approved SAS doctors will then be given access to sign off trainee assessments via the e-portfolio system. In view of the new GMC Recognising and approving trainers consultation, the College has suspended the existing Approval to Teach register for SAS/ SD doctors. The expectation is that the GMC will adopt the framework proposed by the Academy of Medical Educators which includes the use of SAS/SD doctors in teaching and training. The College has now
revised the criteria for trainers and assessors in the curriculum document and this will apply equally to consultants, locum consultants and SAS/SD doctors.
Proposed criteria for trainers/ assessors

To become a trainer, career grade doctors must have a good understanding of the structure of the training programme and the current 2010 curriculum. This needs to be supported by a regular clinical commitment and evidence of relevant and recent CPD which has been assessed through annual consultant appraisal. Successful completion of courses on assessment and assessment tools, along with a trainers course, will become mandatory for anyone wishing to act as an assessor in the future. These courses are aimed at developing an understanding of the current assessment system along with the work involved in completing the documentation mandated in the curriculum by their local school of anaesthesia.
SAS and Specialty Doctors | CGC@rcoa.ac.uk | www.rcoa.ac.uk/sas

Available resources and courses
The RCoA website provides up to date information and advice on how to become a trainer/assessor. There is also a wealth of online CPD through the e-learning portal, webcasts and the BJA/CEACCP. Courses specifically geared towards achieving the proposed trainer criteria are: Anaesthetists as Educators. There is an introductory course which provides an overview of medical education, progressing to Teaching and Training: Delivering in the Workplace which looks at the education and assessment of trainee anaesthetists. Train the Trainer Courses. The number of available courses expands every year to help fulfil the need for a pool of recognised trainers. Along with the difficult airway trainer courses held at the College, many regional centres also hold their own train the trainer courses. The Oxford group is well-established in difficult airway training, and trainer courses in simulation are available at both the Bristol and the Scottish Simulation Centres. The RCOG also runs multiprofessional emergency obstetric training courses (PROMPT 2: Train the Trainers) which may be useful for those with an obstetric interest. Society for Education in Anaesthesia (SEAUK). This nonprofit organisation offers meetings and seminars aimed directly at anaesthetic educators who want to enhance their skills as a trainer. In conjunction with the College they have helped develop the Level 3 CPD Matrix for Education and currently have grants available to support projects of an educational nature in anaesthesia, critical care, or pain. Postgraduate Certificate in Medical Education for Anaesthetists. Run by the University of Dundee in collaboration with the RCoA, the aim of the Certificate is to equip health professionals to practise across the range of domains of teaching and learning, and assessment in their own settings. This Postgraduate Certificate can also be built on by those wishing to progress to Postgraduate Diploma or Masters level. Many deaneries have set up their own training courses for assessors to help them understand the current assessment process, and the Thames deanery has produced a DVD on assessment tools which is available on request from the College (info@rcoa.ac.uk). With revalidation around the corner, taking on the role and responsibility of becoming a trainer will fulfil criteria within the CPD matrix and provide supporting evidence for appraisal. For those looking towards career progression or working towards a CESR, many of the GMC Good Medical Practice (GMP) domains will be achieved during this process.
Further reading
SAS and Specialty Doctors: Examinerships and Teaching Roles (www.rcoa.ac.uk/ careers-training/sas/examinerships-andteaching-roles). Recognising and approving trainers. GMC Consultation. GMC, London 2012 (www. gmc-uk.org/education/10264.asp). Oxford Region Airway Group (www.orag. co.uk/). Bristol Simulation Centre (www.bmsc. co.uk/courses/training.htm). Scottish Simulator Centre (www.scsc.scot. nhs.uk/courses/faculty-development.aspx). Prompt 2 Courses Train the Trainers. RCOG, London (www.rcog.org.uk/events/ prompt-2train-trainers-0). Society for Education in Anaesthesia (SEAUK) (www.seauk.org/). Postgraduate Certificate in Medical Education for Anaesthetists (www. dundee.ac.uk/meded/courses/ awardbearingcourses/cert-anae/).
Revalidation for anaesthetists | revalidation@rcoa.ac.uk | www.rcoa.ac.uk/revalidation
The role of reflection in CPD and revalidation

Mr D Liu
Revalidation Manager
Dr L Brennan
Council Member and Revalidation Lead
For most doctors reflection on their practice will be a new concept and something which they may have previously associated with other health care professionals. However, this facet of professional development has gained wider recognition as being of importance by statutory bodies including the GMC. A high level principle stated in Good Medical Practice is that all doctors are expected to regularly reflect on their medical practice and this is also included in the GMCs new guidance on CPD.1 Reflection, and in particular documented reflection, is also an important element of the annual appraisal. The outcomes of appraisal feeds into the revalidation process. Doctors will need to reflect on their supporting information evidence of CPD, clinical audit, outcome data, significant events, complaints, feedback from colleagues and patients and document that reflection, as a way of providing insight on their work and, in turn, informing the appraisal discussion. So why is this important? Documented reflection is regarded as one of the inputs into appraisal by the NHS Revalidation Support Team, in their Medical Appraisal Guide, as it seen to lead to the identification of areas for improvement and professional development hence directly benefit patients.2
encouraged to reflect on the learning gained and any further learning needs identified when recording your CPD activities. Credits for CPD on the online system cannot be claimed until after this reflection has been documented for each educational activity undertaken. Good reflection goes beyond descriptive observation. Instead, it is demonstrated through evidence of analytical thinking, learning and action planning. If you have attended a doctors as educators type course you will be familiar with the reflective cycle. There are different versions but all require some form of description of personal feeling, evaluation and analysis of activity, and if necessary, any forward-looking action planning. The intention is that you provide insight on your supporting information and, in turn, your professional practice, approach to medicine and whether you demonstrate compliance with Good Medical Practice. You will recall that it is the principles and values in Good Medical Practice against which you will revalidate.
The idea is not to respond to every question or prompt in the template, as some will not be applicable to the activity, event or circumstance. The template also provides guidance for your appraiser, who may want to initiate a discussion which goes beyond mere description of what has taken place in your professional development. The appraiser is looking for insight, understanding and reasoning which underpins the supporting information you have presented. Remember that the appraisal has a summative component, as a positive outcome will indicate progression towards revalidation. The Academys template will provide guidance as to whether a doctors documented reflection presented at appraisal is adequate and, in turn, contributing to this summative judgement.
How much and at what level?

No doubt writing a reflective note will feel awkward at first. Clearly one word or very short responses may lead to your appraiser thinking you lack a real insight into your work. On the other hand, enough text to fill a multi-page document for each item of supporting item will no doubt overwhelm the workload of your appraiser, especially if each of his or her appraisees demonstrates similar levels of commitment! The balance is in conciseness and relevancy in fully communicating your insight on the matter in hand. A short paragraph (three or four sentences perhaps) under each of the relevant reflective template headings will probably suffice. The NHS Revalidation Support Team (RST) has developed a model medical appraisal form.4 Many of you will probably be using this form, or a local
Academy reflective template

To take account the principles of the reflective cycle when recording your reflection, the Academy of Medical Royal Colleges has produced a template3 (see Table 1). The reflective template has been designed with revalidation in mind and contains suitable prompts and questions to aid doctors new to this aspect of their professional development.
Observation is not reflection

Those of you who already use the RCoA online CPD system (www.cpd.rcoa. ac.uk) will have noted that you are
A similar template for CPD has been developed by the Academy which essentially contains the same prompts. The templates are not mandatory to use they have been designed to facilitate the reflective process in a structured manner and provide guidance to doctors when documenting their reflection.
Revalidation for anaesthetists | revalidation@rcoa.ac.uk | www.rcoa.ac.uk/revalidation

Table 1 Academy reflective template
Final reflections
Uploading your supporting information onto the appraisal form and writing up the reflective summaries is likely, for many of you, to be an end-of-year task just prior to your appraisal. To help keep track during the course of the year as to what you have done the College provides access to an online CPD system. The system allows you to record individual CPD activities and reflect on them. Many users have informed us that they record brief, short, notes in the Outcome of Activity and Further Learning Needs boxes, with the intention of using these notes as aide-mmoires when writing up a reflective summary of their CPD in time for the annual appraisal. The College is also developing an online revalidation portfolio allowing anaesthetists to record and manage other items of required supporting information. Again, we envisage the resource will be used in a similar fashion in helping to prepare for appraisal. To keep up to date with our work on revalidation please visit our website: www.rcoa.ac.uk/revalidation. Please email your comments to: revalidation@rcoa.ac.uk.
References
1 Continuing professional development: guidance for all doctors. GMC, London 2012 (www.gmc-uk.org/CPD_guidance_ June_12.pdf_48970799.pdf). Medical appraisal guide: a guide to medical appraisal for revalidation in England. NHS RST, London 2012 (www. revalidationsupport.nhs.uk/CubeCore/. uploads/RSTMAGforReval0312.pdf). Reflective template for revalidation. AoMRC, London 2012 (www.aomrc. org.uk/component/docman/doc_ download/9466-draft-academy-reflectivetemplate-for-revalidation.html). MAG model appraisal form. NHS RST, London 2012 (www.revalidationsupport. nhs.uk/CubeCore/.uploads/PDFForm/ MAG/MAGmodelappraisalformv3.pdf).
Heading
Prompts
Description of activity or event What have you learned?
Which category of activity does this match? (Keeping up to date, review of your practice or feedback from others including complaints or compliments). Describe how this activity contributed to the development of your knowledge, skills or professional behaviours. You may wish to link this learning to one or more of the domains (knowledge, skills and performance; safety and quality; communication, partnership and teamwork; and maintaining trust) of Good Medical Practice to demonstrate compliance with the principles and values in this GMC guidance document. How have your knowledge, skills and professional behaviours changed? Have you identified any skills and knowledge gaps relating to your professional practice? What changes to your professional behaviour were identified as desirable? How will this activity or event lead to improvements in patient care or safety? How will your current practice change as a result? What aspects of your current practice were reinforced? What changes in your team/department/organisations working were identified as necessary? Outline any further learning or development needs identified (individual and team/organisation). How do you intend to address these needs? (set SMART specific, measurable, achievable, relevant and time-bound objectives). If changes in professional practice (individual or team/ department) have been identified as necessary how do you intend to address these?
How has this influenced your practice?
Looking forward, what are you next steps?
in-house version based on this format, to upload your supporting information and present your reflections prior to meeting up with your appraiser. The RST appraisal form does not require you to record reflection on each and every activity or event you provide details of in your supporting information. Instead, you are encouraged to provide a reflective summary drawing on several activities and events. This makes sense as many activities may be related. For example learning about a new innovation gained from attending a conference may be reinforced later on by reading of the
same concept in a journal and discussion in a clinical governance meeting. The prompt on the RST appraisal form states: Provide a commentary on how your CPD activities have supported the areas described in your scope of work. You should also reflect on how this (supporting) information demonstrates that you are continuing to meet the requirements of Good Medical Practice. A similar prompt can be found in each of the main sections quality improvement activity, significant events, feedback from colleagues and patients and review of complaints and compliments of the appraisal form.
NIAA Health Services Research Centre | hsrc@rcoa.ac.uk | www.niaa-hsrc.org.uk
National Emergency Laparotomy Audit contract awarded

journals Anaesthesia and the British Journal of Anaesthesia, and the specialist societies. The aims of NELA are to measure and improve the quality of care of adult patients undergoing emergency laparotomy (EL) for gastrointestinal conditions in England and Wales. The ambition is to facilitate the development of effective quality improvement initiatives through analysis and publication of comparative data on the organisation (structure and processes) and outcomes of care delivered by providers of EL: in other words, we hope to identify and spread examples of best practice and optimal infrastructure to enable secondary care providers to improve the quality of their care for patients undergoing EL. The first year of NELA will comprise a recruitment of sites and organisational audit. The organisational audit will focus on describing the infrastructure available to deliver care for EL, such as appropriate facilities and staffing. Individual patient data collection will begin in the first quarter of 2014. NELA will adjust for case-mix in the analysis of data and will be able to report both short- and longer-term mortality. In time, we also hope to explore the potential for Patient Reported Outcome Measures following EL, if and when appropriate measures become available. Dr Dave Murray (ELN) will be the NELA clinical lead. The surgical advisor will be Mr Iain Anderson (national clinical lead for emergency surgery, Association of Surgeons of Great Britain and Ireland), and Dr Carol Peden (Health Foundation/ Institute for Healthcare Improvement Quality Improvement Fellow) will advise on quality improvement. The NIAA Health Services Research Centre will deliver the project for the RCoA and will work closely with the Emergency Laparotomy Network to deliver the audit within hospitals. In the coming months we will be recruiting NELA staff, including a project manager and administration team, and the audit will commence in the spring of 2013. This is an exciting time. We have an opportunity, through an anaesthesia led initiative, to improve the care of a group of patients we know to have a high burden of serious complications and death. Please help us to succeed. Updates on the NELA are currently available on the HSRC website, pending development of a dedicated NELA website. NELA site recruitment will commence in early 2013.
Professor M Grocott
Director
Following the 2011 call for proposals for new audits from the Health Quality Improvement Partnership (HQIP), the contract for the National Emergency Laparotomy Audit (NELA) has been awarded to the Royal College of Anaesthetists (RCoA). NELA is the first anaesthesia led national audit and the first to focus specifically on perioperative care. NELA builds on the excellent foundations established by the Emergency Laparotomy Network (ELN) in describing and highlighting the striking variation in processes and outcomes following emergency laparotomy. NELA is a partnership between the National Institute of Academic Anaesthesia (NIAA) Health Services Research Centre (HSRC) and the Royal College of Surgeons Clinical Effectiveness Unit, with consultancy and data linkage provided by the Intensive Care National Audit and Research Centre. All anaesthetists are stakeholders in NELA through the NIAA, whose funding partners are the Association of Anaesthetists of Great Britain and Ireland, the Royal College of Anaesthetists, the
CHANGE OF DATE
First UK Pain Clinical Research Forum Thursday, 1 November 2012
The first UK Pain Clinical Research Forum will be held at the Royal College of Anaesthetists on Thursday, 1 November 2012 and chaired by Professor David Rowbotham. For more info, please go to: www.niaa-hsrc.org.uk
The Faculty of Pain Medicine | fpm@rcoa.ac.uk | www.fpm.ac.uk
News from the FPM

health care professionals is weak at both undergraduate and postgraduate levels with the exception of pain medicine training in anaesthesia. Four basic recommendations have been made: 1 Clear standards and criteria to be agreed and implemented nationally for the identification, assessment and initial management of problematic pain. 2 Launch of an awareness campaign for the NHS and public explaining the nature, extent, impact, prevention and treatment of chronic pain. 3 Development of nationally-agreed commissioning guidance. 4 Creation of a group to define the epidemiology of chronic pain. The FPM has been delegated to lead on the implementation of the first recommendation, working with the British Pain Society (BPS) and Royal College of General Practitioners. This is a considerable challenge; however, it is a vital piece of work. Specific tasks have already been identified in order to deliver this recommendation including: building on the BPS/Map of Medicine clinical pathways; ensuring inclusion of all chronic pain, no matter what the cause (identified or not identified) or complexity; utilising the present development of the e-learning program for all professionals in the NHS; and development of national pain training standards. It is hoped that this work will feed into the forthcoming NICE Quality Standard on Pain Management. We will also be assisting in the delivery of the other recommendations. This represents a considerable amount of work but we are committed to the project. There is a considerable momentum building around chronic pain presently and we must not miss the opportunity to translate this into real advances in care, outcomes and services. Many of you will be aware of the statement from BUPA published in April 2012 stating that the agreement of other specialists must be obtained before an anaesthetist can perform a pain relieving procedure for spinal pain. The FPM does not often get involved with private practice but on this occasion we felt that this statement was entirely inappropriate as it could imply that BUPA had scant regard for our training and revalidation programmes. We contacted BUPA immediately and the statement was temporarily withdrawn pending a meeting for further discussion. We met with BUPA senior management in June along with BPS and AAGBI representatives. It was clear from the outset that this was a misunderstanding and that BUPA wished to withdraw the statement completely and recognised Fellows of the FPM (and the Irish Faculty) as experts in this field who were more than capable of assessing the need for such procedures.
Professor D J Rowbotham
Dean
I reported in a previous issue of the Bulletin, that the First National Pain Summit for England was held in November 2011. This was sponsored by the Faculty of Pain Medicine, British Pain Society, Royal College of General Practitioners and Chronic Pain Policy Coalition. The meeting focused on education of healthcare professionals and patients, public health, and commissioning of services. Much work has been done since then, leading to the launch in July at the Houses of Parliament of Putting Pain on the Agenda: the Report of the First English Pain Summit. At the time of writing this article, the event was about to be cited widely. The full report is available on the website (www.painsummit.org. uk); it was supported by Earl Howe (Parliamentary Under-Secretary of State for Quality, Department of Health) and Linda Riordan MP (Chair, All Party Group on Chronic Pain). It was gratifying to see that the achievements of the FPM were recognised by the report. For example, one of the key points stated that: Chronic pain education for most
The Faculty of Intensive Care Medicine | ficm@rcoa.ac.uk | www.ficm.ac.uk
Recruitment
recruitment process which was popular with both assessors and candidates as evaluated by a post-selection questionnaire. This was a national, single centre process with input into all aspects of selection from all deaneries. The West Midlands Deanery, under the leadership of Manjit Kaur and her team, co-ordinated this logistically challenging two and a half hour process. Prior to participating, assessors were invited to a bespoke training day and for those who could not attend, the materials were sent via email to facilitate remote learning. 114 candidates attended over two days, utilising five selection stations which included three interview style stations presentation, e-portfolio assessment and clinical as well as two OSCE style stations task prioritisation and reflective practice. Of the 72 posts advertised 54 were successfully recruited representing a fill rate of 75%. A consequence of being a new specialty was the uncertainty in predicting demand for posts, and as such we requested all deaneries to keep post numbers small to minimise disruption to established training rotations and trusts in the event of posts remaining unfilled. We anticipate a higher application rate for 2013 since the process will by then be established and trainees will have more confidence in applying for ICM as a primary specialty. In addition, we expect the introduction in August 2013 of dual programmes, where a trainee who already possesses a national training number (NTN) in anaesthesia, acute medicine, respiratory medicine, emergency medicine or renal medicine can apply for a second NTN in ICM and vice versa, thus further increasing demand. The introduction of these dual programmes has been necessarily delayed to 2013 in order to temporally separate the recruitment processes of the separate primary specialties. Each recruitment process is independent of the other and only when the trainee has successfully obtained two NTNs is a pre-determined dual training programme constructed which, by virtue of shared common competencies, is less than the sum of the two individual programmes. In 2013, an automated system, known as the UK Offers System (UKOFFS), will be introduced to facilitate the allocation of training posts following successful interview. As UKOFFS has been designed to ensure trainees are able to hold only one post at a time, which they can later reject in favour of a post offered subsequently in the recruitment round, this system would not be suitable for dual appointments in a single round. Recruitment to two specialties in a single round involves by necessity the trainee holding two offers a scenario UKOFFS is designed to prevent. With 14 deaneries in England alone and five potential partner specialties with ICM, the allocation of posts would have to be done manually. Since we are dealing with regional and national recruitment, rounds 1 and 2 and the possibility of clearing depending on the specialty the logistical problems and potential for administrative difficulties become self-evident. However, the Faculty remains hopeful that in future years recruitment to two specialties in a single recruitment round will become possible and manageable.
Dr T Gallacher
FICM Council Member
Dr A Pittard
FICM Council Member
2012 saw the introduction of the new Intensive Care Medicine (ICM) standalone CCT recruitment process with the creation of 72 new posts across England and Wales, with Northern Ireland and Scotland observing the process with a view to participating in the 2013 recruitment round. Further information, including FAQs, is available on the web (www.ficm.ac.uk). Being an entirely new process, we had no historical or procedural prerequisites and this presented a unique opportunity to utilise examples of best practice learned from other, longer established specialties. Dr Alison Pittard (Chair of the ICM RAs) and her working group collated evidence of good practice, mainly derived from the experience of general practice recruitment. They devised a
Patient Perspective | plg@rcoa.ac.uk | www.rcoa.ac.uk/plg
My first year as Chairman

Some things I have learned
In these reflections on the year, I have tried to concentrate on those which would be of general interest to anaesthetists from the patient perspective. Since being involved with the College, I have learned a great deal, both by listening at meetings and in being privileged to spend time with colleagues on the ward in intensive care and in theatre in perioperative anaesthesia, watching them practise, teach, diagnose and reassure patients. Yours is a quiet profession and only the well-informed are able to give the credit you deserve for what you do. We talk a lot about informed choice for patients, and rightly so. However unless both GPs and surgeons direct the patient to information on the anaesthetic as part of the initial diagnostic discussion, patients will seldom be able to make a fully informed choice about what to expect when they consent to a procedure.
Ignorance and choice

I applied to join the PLG 18 months ago being generally interested in anaesthesia; partly because I had had personal experience of it, having undergone several (mainly elective) surgical procedures over the last ten years and had had very different experiences following the anaesthetic, and partly because my interest had developed through numerous conversations with a good friend in the trade. I thought I knew a bit about it when I started but the last year has proved that, in fact, my ignorance was astounding. I did not even know about post-qualification I thought that doctors specialised within initial training and that becoming a consultant was a matter of having your excellence recognised. I freely admit this because the depth of ignorance by the laity needs to be fully grasped. As a patient who always asks GPs exactly what are the implications of taking any drug and avoids medication unless essential, and who asks consultant surgeons what, exactly, they are going to do and what the recovery period will entail, I walked blithely and ignorantly into the anaesthetic, thinking that it was a simple, standard business of having ones consciousness of pain reduced to the lowest point possible without actually being dead. I had little concept of the range of the anaesthetists responsibilities for monitoring, postoperative pain relief and assistance in recovery, and preoperative assessment of fitness to undergo surgery. The relationship between the pre-assessment clinic and the anaesthetist was never made clear.
Mrs I Dalton
Chairman
When we are old

I am deeply interested in improving the care of the elderly and, since observing major heart surgery, have come to reflect on choice when it comes to surgery for the elderly and frail. What can be done nowadays is truly amazing, and what the human body can undergo and recover from equally so. As a healthy, active patient in my 70th year, still able to walk for miles, do heavy gardening and with no obvious underlying conditions, I would have no problem in consenting to major surgery, as I know what it entails. Six weeks of inactivity three years ago, with my foot elevated following surgery, left me feeling flabby, apathetic and perhaps more importantly, utterly frustrated by being unable to do things for myself. Imagine having the desire to walk to the local shops for a pint of milk as a major ambition! Since being better informed, I believe that ten or 20 years from now, I shall be very reluctant to go through this again, even if the surgery
Patient Perspective | plg@rcoa.ac.uk | www.rcoa.ac.uk/plg

were essential to the prolongation of my life. The possibility of ending ones life in a debilitated state is harder to contemplate than death itself. But how can the average patient, or the concerned relatives of such a patient, make an informed choice in the matter of consent? How much information is compatible with not scaring the patient silly? Providing accurate, comprehensible and comprehensiv information, as the population ages, must be addressed. I would very much like to see this debated across the medical profession, although I understand the sensitivities involved. activities is under close scrutiny, if not actual threat, but as a patient, I hope that more candidates will come forward every year to join the College Council. What goes on there matters. I have found the rigour of the examinations reassuring; and the calmness and dedication of operating theatres and ICU wards impressive. I avoid hospital programmes on television like the plague they are! how I would feel being in a meeting consisting entirely of doctors. This is never a problem, as the clinicians involved value our input, often because we are outsiders and can spot things that they have not considered to be at issue. At meetings we are colleagues, not outsiders. We are always happy to contribute a lay view to general issues raised by anaesthetists, within our terms of reference. It has been a memorable year in my life and a privilege to serve both the PLG and the College.
PLG matters
When I joined the PLG I had little idea of its scope, other than as a sounding board for the College on patient thinking but did not realise its full relevance and importance to the business the College conducts. We are currently recruiting three additional lay members, a recognition by the College that the workload is expanding. As well as representing patients on College committees, responding to consultations by the Department of Health, NCEPOD, NICE and other organisations, and being consulted by the College on such matters as revalidation and department accreditation, we are about to broaden our brief by working closely with research projects through the NIAA. We are encouraged to raise patient issues through Council, and have access to any information or proceeding on an equal footing. The College respects the independence of our views. The committee itself is diverse in age and experience; backgrounds include IT, education, the law, public service, business and the navy. The work is entirely voluntary and I am impressed by the willingness of lay colleagues to undertake very time-consuming and complicated, sometimes delicate, work within our terms of reference. I was asked, at my initial interview,
Working with Council

A word to those who do not have much to do with the College post-CCT. I served, for some years, on the Council of the Secondary Heads Association and am sure that many of my colleagues thought that all I was doing was having a high old time on four jolly weekends a year. As Chairman of the PLG, one of my tasks is to ensure that we represent the patient view on (currently) 34 College committees, as well PLG meetings. I therefore have a good idea of the amount of complex work that the College undertakes in addition to its essential concerns with education and safety, and the burden this places on Council members who undertake the leadership of committees as well as their clinical responsibilities. Being on Council is no sinecure. As a patient, I now understand what the College provides in education, rigour in examinations, patient safety, high professional standards, information for patients and guidance for clinicians, as well as work with government, other colleges and overseas medicine. I know that hard times are upon us and time for release to undertake external
Annual Review of Competence Progression the ARCP

Reflections from the front line
INTRODUCTION
There are numerous ways of undertaking the process, which tends to be school dependent, but the underlying principles are set out in the Gold Guide.1 Because there are trainees, both in run through (2007) and in post 2008 appointments there are slightly different versions of the Gold Guide relating to each group. with a comprehensive list of the material that they would be required to submit. Hopefully, in the not too distant future, this will be simplified by the advent of the e-portfolio, which should help reduce the quantity of paperwork that needs to be presented. At the end of the process, consideration is given to the suitability of the trainee to progress to the next level of training (or if training has been completed). The trainee is issued with an Outcome, against which they may or may not wish to undertake an appeal. Although the whole process appears, on the surface, to be somewhat bureaucratic there is evidence that trainees value the opportunity to assess their progress and it is certainly valued by trainers to get feedback about how training is being delivered. There should always be opportunities to learn from others examples of good practice and that is why the external assessment system, which allows senior trainers to act as College representatives at ARCPs, is so useful, as it allows the promulgation of good ideas to the wider community.
Reference
1 The Gold Guide: A Reference Guide for Postgraduate Specialty Training in the UK (4th Edition) June 2010 (not Scotland for Core training).
Making them successful

Dr P Brodrick
Head of the London Academy of Anaesthesia
Basic principles and rules

The three key elements, which support trainees in training, are appraisal, assessment and annual planning. Together they contribute to the Annual Review of Competence Progression (ARCP). It is a cornerstone of trainees career path and is an opportunity for trainee and trainer to analyse the progress the trainee has made during the previous years training and to plan for the future year. The change for the RITA was initiated by PMETB (now GMC), as they required a more explicit evidential base and better linkages to the NHS and the public, as set out in the Principles of Assessment. The ARCP maps the assessment processes against the curriculum, and is referenced to the four domains in the GMCs Good Medical Practice: 1 Knowledge, skills, performance. 2 Safety and quality. 3 Communication, partnership and teamwork. 4 Maintaining trust.
It is my personal belief that face-to-face contact with the trainee is essential although, at what particular stage of the process, may vary. The reason for this is that occasionally pertinent information may be elicited from the trainee about their circumstances that might otherwise not come to light in a paper based exercise. I also believe that trainees gain considerable benefit from the personal involvement of school officers and indeed in the circumstances when a Dean needs to be present, for whatever purpose, it means that the entire process can be accommodated in the shortest possible time, without recourse to a separate event. The success of an ARCP, for a trainee, is very much dependent on the organisational skills and efficiency in which the trainee has gathered and collated their documentation. They should have already had a meeting with their Educational Supervisor, who will have gone through their portfolio and had a discussion of the documentary evidence that they have collected, to demonstrate that they have gained the necessary competence and confidence in a particular unit of training. They would have received notification of the date of their ARCP, at least six weeks in advance, together
HEAD OF SCHOOL
Dr C Carey
Head of the KSS School of Anaesthesia
An important responsibility of a School of Anaesthesia Conducting ARCPs is one of the most important responsibilities of a school of anaesthesia, requiring much consideration and effort. They represent one of the few times that College Tutors, Training Programme Directors (TPDs) and Heads of School will review a large number of trainees in a short space of time and the way in which an ARCP functions is an important part of the relationship between a school and its trainees. Dialogue is an important part of the process. Outcomes must be clearly explained, especially when trainees do not achieve outcome one, which can be a complex and stressful process for all of those involved. It is also common practice to provide careers advice, particularly when planning specialist placements during higher and advanced training. ARCPs can also generate useful trainee feedback and allow a more open approach than other mechanisms such as the GMC survey. However, there is considerable pressure to run to time whilst still providing trainees, who will have spent many hours preparing, with an appropriate level of attention.
Gathering documented evidence the Educational Supervisors report A considerable amount of documentation is required from trainees and it is important that schools provide clear guidance and support for this throughout the year. Much of the information required is presented within the Educational Supervisors Structured Report, which is the cornerstone of the training record. It is therefore essential that schools also provide appropriate advice and training for Educational Supervisors through the College Tutor network. Manpower challenges Conducting ARCPs requires a high level of manpower, especially when the format includes face-to-face meetings. Schools depend on the support of trusts to release consultants to fulfil this role although this is becoming increasingly difficult with many trusts severely restricting non-clinical activity of senior medical staff. This is unfortunately one of the most difficult problems encountered when organising ARCPs and looks set to remain a significant concern. Future developments There are significant developments, which will affect the ARCP process in the future. Firstly, increasing numbers of ARCPs will be completed using the e-portfolio. There will undoubtedly be a learning process associated with this although the e-portfolio team have worked hard to ensure that trainers and trainees are supported. It will be a challenge for schools to provide the infrastructure to run ARCPs using the e-portfolio and also a test of the system to function under the high load that will be placed on it during the time around the ARCPs. The ARCP process will also form the basis of trainee revalidation in the future with Postgraduate Deans acting as Responsible Officers for trainees
within each region. To facilitate this additional information will be included in the Educational Supervisors Report, Form R and ARCP Outcome Form. Deans will make appropriate recommendations to the GMC regarding revalidation, which will occur every five years. Ultimately, despite the frequently long and challenging days spent conducting ARCPs, it is very satisfying to see doctors advancing through the programme and completing their training successfully.
TRAINING PROGRAMME DIRECTOR
Dr T Simpson
ACCS Training Programme Director, Severn School of ACCS
Since the introduction of the ACCS training programme in 2007 it has faced some unique challenges in running an efficient and effective ARCP process.
Major challenges
Merging four specialties into one syllabus The original syllabus for the ACCS training programme was put together in 2007 and revised in May 2010 when the competencies required by the trainees were reorganised into major and acute presentations, practical procedures, anaesthesia for ACCS and common competencies. While this formed the first two years of the emergency medicine syllabus it did not fit neatly into the anaesthesia or acute medicine curriculums, although parts of it were common to both. Individual portfolios The Royal College of Emergency Medicine (RCEM) had set up their e-portfolio to match the new ACCS curriculum and therefore was ideal for ACCS trainees to keep a record of their competencies and Educational
Supervisors reports from all components of the first two years of the ACCS programme. However, not all assessors had suitable access. Unfortunately, both the RCoA and the RCP portfolios were focused purely on their own specialties. Either the trainee had to register with multiple colleges to gain access to various portfolios or resort to paper versions of the WpBAs. This was a major issue for the ACCS Anaesthesia and Acute Medicine trainees, trainers and specifically Educational Supervisors/ TPDs who were trying to co-ordinate the evidence for training to be assessed in the ARCP process. The order of rotations The trainees will all complete the requisite training within the twoyear process but may not have neatly completed two of the four rotations at the end of the first year. This was particularly a problem for the ACCS Anaesthesia trainees who were doing a nine-month anaesthesia/threemonth ICM rotation. These problems were fairly easily overcome by clear record keeping and good supervision of the trainee by their Educational Supervisors/TPD. Co-ordinating trainers from different specialties Initially, the Educational Supervisors from the different ACCS specialties were not aware of the training programmes of other specialties or the specific needs of their trainees.
A local ACCS training committee This was set up in 2007 and allowed representatives from each specialty within the seven hospitals in the region that train ACCS trainees to meet up on regular basis. This enables a clear mechanism for dissemination of information and discussion on how to ensure the ARCP process is fair and equitable. It allows us to get the message across of the importance of a high quality Educational Supervisors report. An ARCP book To overcome the problem of multiple portfolios and also to be able to easily assess all the information at the ARCP a single document was created. This covers all the basic demographic information of the trainee as well as all the specific competencies described in the ACCS curriculum. It also contained templates for all specialties, Educational Supervisor reports. This document is then all that is submitted by the trainee along with a copy of their CV for the ARCP assessment. It has proved very popular with all trainees from all specialties and has subsequently been utilised by several other deaneries nationally. An ARCP paperwork day To ensure continuity and fairness of the process we introduced a paperwork assessment day. We gather together trainers from all specialties and a number of different hospitals (usually about ten) and then go through the submissions from all trainees. This has many advantages: such as efficiency with 67 trainees, paperwork being assessed in a morning, fairness as a consistent line can be taken on issues around WpBA by all, but most importantly it helps to further share and build the skills and knowledge of the trainers present.
Once the outcomes have been decided we then hold a face-to-face interview with each trainee, to give and receive feedback and discuss career progression. The importance of manpower All these processes rely on consultant time and will come under threat continually as further restrictions are put on leave. The many challenges in the ARCP process that have evolved over the years can be overcome, but this does rely very much on having enthusiastic and knowledgeable Educational Supervisors as they are essential in providing detailed and accurate Educational Supervisors reports which are the cornerstone of the ARCP process.
COLLEGE TUTOR
Dr P Davies
College Tutor, Northampton General Hospital
Local solutions
Faced with these challenges many ACCS training programmes have come up with a number of local solutions. The process of carrying out the ARCPs has evolved and been slightly different year on year. The specific areas we have developed are as follows.
In my opinion, the role of the College Tutor in the ARCP process is to ensure Educational Supervisors accurately complete their reports, and to adequately prepare the trainees. College Tutors are also on ARCP panels. Educational Supervisor preparation I believe it is vital for the Tutors to keep the Educational Supervisors informed of the requirements for trainees to achieve an outcome one. The requirements are well defined,
but with the change from the 2007 to the 2010 curriculum, and frequent readjustments to the paperwork with each passing ARCP round, I have at times found it difficult to keep up not ideal when you are the person responsible for disseminating the information from the school. Trainee preparation The trainees usually seem very aware of what is required of them. However, as some get so fixated on the exam, Ive found that I need to repeatedly emphasise the importance of continuously doing their paperwork (particularly given the volume and number of assessments required to complete units of training in the 2010 curriculum), rather than leaving it to the last minute. ARCP panels Outcomes are usually obvious from the submitted paperwork, but not always. One difficult group are the trainees seen two to three months before the end of their rotation. The decision whether or not to pass them based on the proportion of completed paperwork is not straightforward. Ive also found ACCS ARCPs challenging, as Im not overly familiar with the curricula of the non-anaesthetic specialties. To add to the confusion, these trainees have rotated through multiple specialties with differing requirements, some electronic and some paper based, with some on the old curriculum and some on the new. The transition from the 2007 to the 2010 curriculum is now largely over, which I hope will clarify things. I see our next challenge as the imminent introduction of the e-portfolio to our school, which may or may not simplify the process.
EDUCATIONAL SUPERVISOR
Dr S H Koh
Educational Supervisor, Severn School of Anaesthesia
The role of the Educational Supervisor The Educational Supervisors role has both educational and pastoral elements. We meet formally at least three times during the trainees time in the department. Initially, this is to identify the trainees training needs and to highlight opportunities (e.g. teaching or managerial activities) available in the department or trust which will complement the clinical experience. The mid-term meeting is often one to check that goals are being achieved, training is being met (or not, as the case may be) and that the trainee is getting through the numerous WpBA and competencies that they are meant to be achieving in that year. Hopefully, any problems will be identified and addressed before the completion of the structured training report that will be submitted to the ARCP panel. The recommended allocation of PAs for this role is 0.25PA per trainee. This covers the formal and informal meetings we have with trainees, CPD specific to the Educational Supervisors role, trainee assessments and other activities, e.g. interview panels. The benefits for the trainees It is useful to the trainees to have a nominated person in the department (which can be large, my department
has 30+ consultants) with whom they can form a relationship, and hence be able to discuss issues. We have regular meetings with the College Tutor and Educational Supervisors in our department where problems can be picked up early and dealt with in a team approach before they become an obstacle to receiving an outcome one at the annual ARCP. We can be a gentle nudge to the trainees to ensure that they are keeping up with the mountain of paperwork they need to complete. The school runs a policy that there should be no surprises on the day so any trainee likely to fail to receive an outcome one should be aware and be identified to the TPD in advance. Potential difficulties With the trainees working shifts, particularly in a large department, it can seem like ages before we see individual trainees. Occasionally, personalities may clash and this is when it is useful to have both a College Tutor and an Educational Supervisor in the department to support the trainee. It is immensely satisfying to see a trainee develop during the time they are in the department and progressing on to the next stage of their training, with a little guiding hand from us.
TRAINEES
the trainee who is solely at fault when failing their ARCP. The value of the Educational Supervisor The end of year assessment of today is, however, a fairer system. Trainees no longer face an interrogation if they have a face-to-face meeting at all. The requirements are clear, transparent, and deadlines given ahead of time. The role of the Educational Supervisor also ensures that trainees know where they stand before the ARCP date, and if struggling, have a pre-prepared advocate. ARCPs ensure that trainees are meeting their training requirements, and should help identify those that would benefit with more time. They potentially provide a forum for feedback, and can be used to determine future training requirements. Still, a simpler system less dependent on paperwork, that acknowledged markers of excellence prizes, publications, presentations and recognised that progress is not solely the responsibility of the trainee, would perhaps improve the assessment of training and the aspirations of the trainee.
and a CBD in each. This worked up to a point but the inevitable flurry of paperwork still occurred towards the end. I had met with my Educational Supervisor in my hospital a few weeks before the ARCP, to look over the paperwork and fill out the structured training report. That meeting had gone okay and gave me a chance to complete one or two more points. The ARCP on the day A slight nervousness has to creep in on the ARCP day. One station of the ARCP was more about paperwork and my assessments. The overall feeling was more of a meeting with an Educational Supervisor than an interview. The panel reviewed my logbook to check numbers and types of anaesthetic I had been giving; the use of the structured training report made the event relatively straightforward. The next panel was more about my training, what I thought of the hospitals that I had worked in, how they compared and if the programme could be improved in any way. Also what were my further plans for my career? This felt less formal, more of a pastoral meeting. Overall impression The ARCP seemed to want to ensure that trainees werent getting left out or behind with a positive effort to want to improve the training for the region. It was far less of an exam to pass but more of a routine check up.
Dr S Scott
ST6 Trainee, Leicester Royal Infirmary
Challenges collecting the evidence ARCPs are undoubtedly stressful. The day of assessment looms large throughout the year. Every list seems to require a signature, a competency completed. Audits need presenting, and in the midst of it all are the FRCA exams. Years of training are now years of continuous assessment, the ARCP a mark of validation. If there are problems with ARCPs it is not the assessment itself, but what is assessed. Curricula revisions move the goalposts, affecting trainees as much as the consultants tasked with assessing us. New paperwork invariably means more paperwork, completion of which is apparently the main focus of training. The trainee who asked to be moved to a gynaecology list to complete paperwork, rather than attend the excision of a phaeochromocytoma, is symptomatic of this disturbing trend. Service vs training pressures ARCP outcomes are still viewed by trainees as markers of success or failure. However, pressure to cover rota gaps, cover elective lists to maintain service, and to limit leave so as not to fail an increasing number specific modules, all contribute to unsuccessful ARCP outcomes. Despite this, the impression remains that it is
Dr T Jacobs
ST2 Trainee, University Hospitals, Bristol
Preparing The CT2 ARCP held more significance for me, as it was the finishing touch to my anaesthetic basic training. I just had to pass it. I had tried to split the year into three monthly quarters and complete three DOPS, two CEX
Dr A Dodd
ACCS Trainee, Gloucester Royal Infirmary
Gathering the evidence The ease of completing work-based assessments, in my experience, varies between specialties. In anaesthetics, with a considerable amount of consultant supervision, all competencies can be achieved with relative ease. Similarly, the regular presence of a consultant on the intensive care unit and in the emergency department makes completing all the necessary paperwork less arduous. Completing the ACAT is logistically the hardest as this requires the combined fortune of seeing a number of interesting/ relevant patients and co-ordinating this with a single consultant with whom you can review your cases. This is particularly difficult in the acute medicine block when it is the F1 who goes on the post-take ward round, leaving the SHO to continue on the clerking treadmill. Completion of assessments in the last placement of the year is more stressful due to the submission date being two months prior to completion of the rotation and often more than one month ahead of the ARCP date. This means that you have relatively little time to complete a large number of assessments, and relies on the goodwill of the consultants to assist the trainee in completing all the paperwork.
Multiple Educational Supervisors One of the key benefits of the ACCS training is working in four different acute specialties. This also offers the opportunity to be supervised by four different consultants; however, this may be at the expense of regular input from your parent specialty supervisor. The ACCS curriculum and ARCP workbook have been very useful; however, the lack of a uniting ACCS e-portfolio has proved a challenge as an acute medicine trainee in that I have had to complete three out of four rotations using paperbased assessments. Overall impression The ARCP process provides the opportunity to discuss your training to date, reflect on your achievements of the year and receive feedback. It also allows time to discuss your career progression and goals for the coming year. Despite the stress of the preparation, I do feel it is a valuable experience for ACCS trainees.
process itself, making sure that there is transparency of decision making, consistency in approach and that it would stand up to scrutiny; and also from the Colleges view, in that the standards applied to trainees are in line with the curriculum, that there is a consistent approach by schools of anaesthesia across the UK and that the assessors achieve high standards of professionalism. There is no doubt that the manner in which the ARCP is undertaken will evolve over time. This is ever more likely, with the widespread introduction and use of the e-portfolio system, which has the potential to simplify the collection and demonstration of the evidence. Finally, for schools of anaesthesia, the ARCP is a golden opportunity to make a difference to trainees lives, shaping their futures and providing opportunities for them to benefit from the best available training.
Reference
1 The Gold Guide: A Reference Guide for Postgraduate Specialty Training in the UK (4th Edition) June 2010 (not Scotland for Core training).
CONCLUSION Dr P Brodrick
Head of the London Academy of Anaesthesia
It is quite clear from the contributions above that there is a genuine desire, from all parties to this process, to see it succeed and provide the necessary evidence for those who would regulate the training environment. There are many ways to achieve the best outcome for trainees and this article does not wish to proscribe one way, but merely to demonstrate that this can be made to work for both trainees and trainers. It is important to note that externality is a significant feature of the process. This is both from the lay perspective, looking at the
The National Institute for Health Research (NIHR) and the Clinical Research Networks (CRNs)
Putting principle into practice in critical care
Introduction
Intensive Care research in the UK is thriving. Over the last decade a series of high quality, multicentre studies have evaluated both cutting edge treatments (e.g BALTI-II)1 and pragmatic assessments of common interventions (e.g. TRACMAN) and led to better evidenced-based clinical practice for all of us. The Intensive Care Society (ICS) and its sister organisation the Intensive Care Foundation (ICF), as two major stakeholders, have been instrumental in prioritising areas of clinical research important to their membership and delivering pragmatic studies relevant to NHS practice. Since 2006, the advent of the National Institute for Health Research (NIHR) has also greatly facilitated these developments. research funding, governance and infrastructure and to ensure that support is directed according to the needs of the research activity taking place. Detailed information about the NIHR is available: www.nihr.ac.uk/. The one billion pound NIHR annual budget funds research programmes (dispersing grants), infrastructure, research schools (Primary Care, Social Care and Public Health), research management and governance systems, and the NIHR faculty. Key NIHR components for hospital-based specialties such as intensive care are the grant giving research programmes (e.g. Health Technology Assessment programme, Research for Patient Benefit programme), the Clinical Research Networks (CRNs) and the Biomedical Research Centres and Units (BRCs and BRUs) (see Figure 1). The aim of the grant giving programmes is to provide the direct research costs of conducting a study. The aim of the CRNs is to provide support to NHS Trusts to support screening and enrolment of patients into studies and the costs of routine interventions as well as service support costs (e.g. pharmacy costs associated with drug packaging). The BRCs and BRUs are funded to be the translational medicine pipeline between major academic institutions and the NHS (Table 1 and 2). The list of topics for which the BRCs and BRUs were funded gives an interesting prism onto the research priorities of the NHS (Table 1 and 2).
Professor M Grocott
Deputy Chair, UKCRN Critical Care Specialty Group
Dr A Walden
Deputy Chair, UKCRN Critical Care Specialty Group
The National Institute of Health Research (NIHR)

The vision of the NIHR is to improve the health and wealth of the nation through research. The NIHR strategy is to achieve this vision through: creating a health research system in which the NHS supports outstanding individuals, working in world class facilities, conducting leading edge research focused on the needs of patients and the public. Whilst clinical research has always been pivotal within the NHS, infrastructure and support were historically fragmented and unresponsive. Money did not follow activity but was allocated on a block-grant basis as so-called Culyer Funding. The NIHR was created as the research arm of the NHS to improve the processes of clinical
Professor T Walsh
Chair, UKCRN Critical Care Specialty Group
Table 1 NIHR Biomedical Research Centre NHS-academic partnerships
NHS Organisation
Academic Partner
Cambridge University Hospitals NHS Foundation Trust Great Ormond Street Hospital for Children NHS Trust Guys and St Thomas NHS Foundation Trust Imperial College Healthcare NHS Trust Moorfields Eye Hospital NHS Foundation Trust Newcastle upon Tyne Hospitals NHS Foundation Trust Oxford Radcliffe Hospitals NHS Trust Royal Marsden NHS Foundation Trust South London and Maudsley NHS Foundation Trust (SLaM)
University of Cambridge University College London, Institute of Child Health Kings College London Imperial College London University College London Newcastle University University of Oxford Institute of Cancer Research Institute of Psychiatry, Kings College London
to each of the CLRNs through Activity Based Funding (ABF) which takes into account the complexity of studies. This acts as an incentive for Trusts to participate in research through the sharing of the local budget according to levels of activity and the requirements of individual studies. Studies are automatically eligible for the portfolio if they are funded by the NIHR or by a non-commercial NIHR partner. The Intensive Care Foundation and the National Institute of Academic Anaesthesia are both non-commercial NIHR partners as are many other UK research funders (www.crncc.nihr.ac.uk/about_us/ processes/portfolio/p_eligibility/). A general principle is that grants should have been won in open competition with high-quality peer review and that the research is of value to the NHS. Studies may also be adopted onto the UKCRN portfolio if they have alternative sources of funding and are deemed to be feasible to deliver and of sufficient quality. These are often commercial studies and supporting the UK Life Sciences Industry in this way is seen as a critical role of the NIHR: A thriving life sciences industry is critical to the ability of the NHS to deliver world-class health outcomes. An up-to-date list of UKCRN portfolio studies can be accessed at: http:// public.ukcrn.org.uk/search/. A new resource to alert local investigators to up-coming studies is being developed as part of the NIAA Health Services Research Centre website at: www.niaa-hsrc.org.uk/.
Southampton University Hospitals NHS University of Southampton Trust University College London Hospitals NHS Foundation Trust University College London
Clinical Research Networks (CRNs)

The Clinical Research Networks are divided into the topic specific networks (cancer, dementia, diabetes, stroke, mental health and medicines for children), the Primary Care Research Network and the Comprehensive Clinical Research Network (CCRN) (Figure 2). The CCRN includes all the areas of healthcare research not covered by the topic specific networks, including critical care and anaesthesia (anaesthesia, perioperative medicine and pain). The CCRN is sub-divided into 25 Comprehensive Local Research Networks (CLRNs) and there are similar research networks in the three devolved nations (Wales, Scotland, and Northern Ireland). The principal goal of the CLRNs is to support recruitment to UKCRN portfolio studies (see below). Specialty Groups (SGs), such as the Critical Care SG, provide topic-specific expertise to the CLRNs through local SG leads. These SGs are key to the success of
the research networks and work at national and local levels to ensure the successful delivery of research to target and on time within their specialty (www.crncc.nihr.ac.uk/about_us/ ccrn/specialty/critical_care).
UKCRN Portfolio Studies

As a consequence of the support available through research networks, acceptance onto the UKCRN portfolio has become a near essential step for the financial viability of a clinical research study in the UK. A study that is adopted onto the UK portfolio is eligible for NHS support costs through the NIHR Clinical Research Networks. Specifically, this includes funding for research coordinators/nurses to screen and recruit NHS patients into studies, which is otherwise time consuming for consultants and other staff given increasing pressure on job plans and Supporting Professional Activity time. The number of patients recruited into portfolio studies is a major determinant of the funding allocated
Establishing research infrastructure in your ICU

The way-in to this system at a local level is to start recruiting patients into portfolio studies. Use your local Research and Development Department to help you through study setup using the Integrated
Table 2 NIHR Biomedical Research Unit NHS-academic partnerships
NHS Organisation
Academic Partner
Priority Area
Barts Health NHS Trust University Hospitals Bristol NHS Foundation Trust University Hospitals of Leicester NHS Trust Royal Brompton and Harefield NHS Foundation Trust Nottingham University Hospitals NHS Trust Cambridge University Hospitals NHS Foundation Trust Newcastle upon Tyne Hospitals NHS Foundation Trust South London and Maudsley NHS Foundation Trust (SLaM) University College London Hospitals NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust Nottingham University Hospitals NHS Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust Central Manchester University Hospitals NHS Foundation Trust Leeds Teaching Hospitals NHS Trust Nuffield Orthopaedic Centre NHS Trust University Hospitals Bristol NHS Foundation Trust University Hospitals of Leicester NHS Trust University Hospitals of Leicester NHS Trust Royal Brompton and Harefield NHS Foundation Trust Southampton University Hospitals NHS Trust
Queen Mary University of London University of Bristol University of Leicester Imperial College London University of Nottingham University of Cambridge Newcastle University Institute of Psychiatry, Kings College London University College London University of Birmingham University of Nottingham University of Liverpool The University of Manchester University of Leeds University of Oxford University of Bristol Loughborough University University of Leicester Imperial College of Science, Technology and Medicine University of Southampton
Cardiovascular Disease Cardiovascular Disease Cardiovascular Disease Cardiovascular Disease Deafness and Hearing Problems Dementia Dementia Dementia Dementia Gastrointestinal Disease Gastrointestinal Disease Gastrointestinal Disease Musculoskeletal Disease Musculoskeletal Disease Musculoskeletal Disease Nutrition, Diet and Lifestyle (including Obesity) Nutrition, Diet and Lifestyle (including Obesity) Respiratory Disease Respiratory Disease Respiratory Disease
Research Application System (IRAS). Lean on your local Critical Care or Anaesthesia/Perioperative Medicine SG representative to support your case for research nurse funding. This is how most currently research active centres have got going over the last few years. The rest will follow. Additional support can be achieved through securing so-called Research Capacity Funding (RCF) which is awarded to a Trust based on their record of securing NIHR funding from grants and other sources. The triple whammy, which achieves maximum support for your Trust (and in theory for you as an investigator), is to win an NIHR grant yourself, negotiate for a share of the RCF that this brings to the Trust, and then effectively recruit patients into the study thereby bringing in the associated ABF to your CLRN. Best of all, make sure this is a complex randomised trial that will benefit patients... Good luck! If you want more information about the NIHR Specialty groups, who your
local lead is, or how to get involved in research we suggest you look at the Specialty Group websites:
Reference
1 Gao Smith F et al. BALTI-2 study investigators. Effect of intravenous -2 agonist treatment on clinical outcomes in acute respiratory distress syndrome (BALTI2): a multicentre, randomised controlled trial. Lancet 2012;379(9812):229235.
www.crncc.nihr.ac.uk/about_us/ ccrn/specialty/critical_care/. www.crncc.nihr.ac.uk/about_us/ ccrn/specialty/anaesthetics/.
Figure 1 Components of the National Institute of Health Research (NIHR)
Figure 2 Structure of the UK Clinical Research Network
Depression: a personal view

I think she will be fine. She just doesnt seem very happy at the moment. I read my CT1 year feedback and sighed. I was surprised that one of the consultants had actually recognised my low mood, but saddened that they felt unable to say anything, save a single sentence on an anonymous feedback form. My first year in anaesthetics had indeed been challenging, with the symptoms of my previous depression recurring.
I had always been a bit of a worrier, but had had a happy upbringing, inheriting my parents quirky sense of humour and generally enjoyed life. However, in my last few terms at medical school I became increasingly down and low in mood. I found the many sad situations and patients I met during my training weighed heavily on my mind and stayed with me long after they should have. I became frequently tearful, lost interest in hobbies and isolated myself socially. I slept for as long as possible and struggled with motivation. In hindsight, the likely cause was unresolved grief from the loss of my father when I had just turned 14 years old. The rapidity of my loss meant I never dealt with my feelings. Frequently, I felt his death resonate with the patients and relatives I encountered, and found myself trying to grieve and move on all these years later. I lived for the weekends when I could see my (now) husband, family and friends. I sought help from my GP when my husband and sister expressed their concerns and stated that it just wasnt like me to be crying all the time. I had a short number of sessions of a talking therapy and then used an SSRI, citalopram, for a period following this. As I began to feel better I could see just how abnormal my mood had become. I enjoyed my foundation training and during an FY2 placement on ITU I decided to apply for anaesthesia specialty training. The College Tutor was a real inspiration and supported me fully and helped build up my self-esteem. I knew anaesthetics would be tough and I was both excited and a bit terrified as my new role commenced. I had lovely trainees around me but I didnt feel that I was a natural anaesthetist like my fellow novices. A consultant made a throw-away comment saying how so-and-so made it all look so easy, which I took to heart as a criticism of my own abilities and felt my fragile confidence slip away. Although I was told I was safe and competent and had no disasters (unlike some of my peers), I was soon hiding in tears in the toilets at lunchtime. I became increasingly anxious about solo lists and I slept poorly the night before work. However, I did cope and did not need to take any time off work. I tried my best to cover my mood with my usual funny, smiley demeanour. In hindsight I can see that I didnt always manage this and received mixed feedback from senior colleagues. Guilt was a big problem when I was depressed, because I felt that I should be happy. I had an excellent job and training opportunities, good income and wonderful support but still felt feelings of inexplicable doom and hopelessness. I worried about being a burden and not being good enough for my husband, family, colleagues or patients. I was unable to see or feel anything positive and switched into a mode of just working, sleeping and revising. Preparation for the Primary gave me a focus and allowed me to legitimise my social withdrawal. I worked hard and once I passed the MCQ everything seemed to slowly improve. My confidence grew and as I returned to a more familiar environment for my second year I again received great support from the College Tutor. With his help, the support of a wonderful husband, family and fellow trainees I began to feel happy in myself once more, continuing my training with far fewer tears!
Dr K Grant
ST4 (Anaesthesia), St Georges Rotation, London School of Anaesthesia
Depression
Depression is influenced by both biological and environmental factors, with an increased incidence in those with affected first-degree relatives even when brought up in separate households. Symptoms which can lead to a diagnosis include:

Guilt was a big problem when I was depressed, because I felt that I should be happy.
may be unpredictable and on-call commitments for both trainees and more senior staff involve anti-social hours. Disturbing cases or crisis situations may not always be formally debriefed leading to poor coping and even the potential for development of post-traumatic type disorders. The current climate in the NHS is one of great change and with that comes great uncertainty. The amalgamation of smaller hospitals, loss of a specific service or even threat of redundancy can have obvious effects on ones stress levels. Predicted changes in workforce planning can mean that trainees may feel they are working towards an impossible goal of a consultant post. Most trainees move jobs annually and I personally used to struggle with settling in and getting to know people quickly. I think this improves with time, but many trainees do feel some apprehension at moving on each year. The examinations are rigorous and extensive and this is essential in maintaining the high quality of our training and performance. In 2010, colleagues in Wales published results of a questionnaire of their trainees who had recently sat one part of the FRCA with 12.8% demonstrating symptoms of moderately severe to severe depression.4 Additionally, receiving complaints, undergoing disciplinary hearings or being bullied can all cause additional stress. Personal lives are inevitably affected by ones working life. Maintaining
low mood decreased interest or pleasure in previously enjoyed activities sleep disturbance (too much or too little) fatigue or loss of energy poor concentration psychomotor agitation or retardation suicidal ideation feelings of worthlessness or excessive/inappropriate guilt.1
happy relationships when revising, working in a stressful environment or keeping irregular hours can be challenging. Many anaesthetists have young families and find time management and emotional demands difficult to fulfil. Guilt and feelings of inadequacy can be additional factors affecting mood. In some cases there is no obvious cause for low mood. This is difficult to acknowledge and as doctors we may resist seeking help for fear of stigmatisation. Use of alternative mood-enhancing substances or behaviours may be chosen as a method of self-treatment, but professional help should be sought.
Suicide
Most anaesthetists will sadly know or have heard of a colleague who has taken their own life. Doctors as a whole demonstrate higher suicide rates with a relative risk varying between 1.1 and 3.4 (in male) and 2.5 and 5.7 (in female doctors).5 Anaesthetists are one of the medical specialties at a higher risk of self-harm with the availability and access to pharmaceutical agents meaning that as a specialty death by self-poisoning is disproportionately high. The availability of a reliable, dangerous method of suicide may increase actual suicide risk.
It is normal to have episodes of feeling down and being sad in response to stressful life events, but I would suggest that its the impact on your life and duration of symptoms that can suggest if depression could be a problem.
Why are doctors prone to mental illness?

Doctors tend to be high-achieving type A personality types.2 Perhaps unsurprisingly, research suggests that doctors are prone to higher rates of mental illness, with the armed forces and medical professions having the highest rate of work-related mental ill health.3 The personality traits of individuals entering medicine may pre-dispose to mental illness, with the additional stresses from work resulting in ill health in certain individuals.
What can be done?

Depression can present in a variety of ways and can affect all ages, genders and seniority of doctors. Professional assessment should be made and then treatment tailored to each individual dependent upon the severity of illness and impact on life, as well as locally available services. In general, treatment includes the talking therapies and pharmacological management or a combination of both. Seeking help is key in accurate diagnosis and treatment. Some areas
Stressors
Anaesthetics is a stressful specialty, involving the most demanding and complex cases in the hospital. Shifts are often long, workload
provide specialist health services for physicians which are independent of their GPs. Illness in the medical profession is stigmatised, and none more so than mental illness. Absence due to sickness is still so much lower in doctors (averaging less than three days annually compared to the national average of eight). Psychiatric disorders are not visible and can be perceived as weaknesses or even fabricated. The thought of being labelled as mentally ill may deter doctors from presenting to medical services, as the stigma may affect colleagues views and lead to their abilities being questioned. However, as doctors we have a responsibility to our patients, colleagues and most importantly ourselves. Good clinical care requires healthy, fully functioning doctors. As with many pathologies, avoidance of early symptoms can lead to delayed treatment and greater morbidity and even mortality. As for me, the years that followed have been much better. I appreciate how much difference it makes having colleagues to whom I can talk and am again lucky to be surrounded by friendly and reliable work friends. My experience of depression was certainly not as severe as some I know, but I hope it makes me more sympathetic to both patients and colleagues who may have had or be currently dealing with a mental health problem. I would hope that attitudes are changing. The Department of Health, RCoA and AAGBI all take mental health problems in medical professions seriously.67 I would urge fellow anaesthetists to seek help if anything in this article has struck a chord. We will all soon be completing and requesting multi-source feedback for revalidation purposes. Although this feedback may be anonymous, I would hope that if you think a colleague may
be struggling or simply seems sad, you would be able to approach them and ask whats wrong. This could make all the difference. For a caring profession, we arent always that great at looking after ourselves.
References
1 2 Mental Health Today DSM IV (www. mental-health-today.com/dep/dsm.htm) Thomas I et al. Occupational hazards of anaesthesia. CEACCP 2006;6(5):182187 (http://ceaccp.oxfordjournals.org/ content/6/5/182.full). Mental health and ill health in doctors. DH, London 2008 (www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@ dh/@en/documents/digitalasset/ dh_083090.pdf). Evans T et al. Testing times: stress related impact of FRCA examinations. RCoA Bulletin 2010;63:1113. Hawton K et al. Doctors who kill themselves: a study of the methods used for suicide. QJM 2000;93(6):351357 (http://qjmed.oxfordjournals.org/ content/93/6/351.full). Career and personal difficulties. RCoA, London (www.rcoa.ac.uk/careers-andtraining/career-and-personal-difficulties/). AAGBI welfare resources (new edition of resource pack coming soon) (www.aagbi. org/professionals/welfare).
My survival guide
1 Talk to someone. Its amazing how much better you can feel after sharing your feelings. 2 Seek professional advice, whether from your GP, occupational health or specialist physician support clinic if available. 3 If youd prefer non face-to-face contact try one of the various telephone support numbers or internet forums to start sharing your feelings. 4 Get advice early. Depression is not anything to be ashamed of and early help may avoid months/years of struggling or just existing. 5 Avoid alcohol/other substances as an emotional crutch. A drink and chat in the pub may do wonders but keep intake in check. 6 If you feel unsafe to work then you must not. If you cant cope tell your manager and occupational health service. Your welfare is key to patient safety. 7 Get perspective and take a reality check as advised by the AAGBI.7 8 Give yourself a break. Medical training and mindsets can cause us to compare ourselves to our peers and impair selfesteem. 9 Stop trying to do everything. If you can afford for someone to clean/iron for you why not make life easier? 10 Take a break. Spend time with people away from the hospital crowd. Sometimes having time away can aid self-reflection and readdress goals.
Acknowledgement
With much thanks to Dr R Thomas, College Tutor, Royal Hampshire County Hospital, Winchester, for all his patience, support and help.
The financial strategy of the College

regulation so the number of staff has grown; for example, in revalidation. There is more lay involvement, so the size of the Colleges Patient Liaison Group has had to grow. Anaesthetists have taken on more managerial roles, so the College has had to raise its profile. Pain medicine and intensive care medicine have grown in importance to UK healthcare, so the College has created faculties to represent these areas. The financial strategy has supported this growth. The key to financial success is simple: know the market in which you operate, know your numbers, set budgets that generate a surplus of income over expenditure, live within your means and constantly review your numbers. It really is that simple, yet so many organisations get it wrong. Why? In my experience it is nearly always due to the numbers not being known. The people involved are well intentioned but, without the numbers, decisions are made in either hope or fear! Fortunately, anaesthetists have an inbuilt tendency to work in teams and they do not have large egos I know that is a generalisation but I really believe it to be the key to good working. I have been extremely fortunate that successive Finance Committees and Council have allowed me to know the numbers and have based their decisions on these. This Colleges successful track record has resulted in some other organisations asking us for advice, a very rewarding position in which to be in. At the end of June 2012 the College had 15,839 fellows, members and trainees, which makes the RCoA one of the largest medical royal colleges, especially as 93% of those are UK based. By comparing this UK membership with the Census data, we can see that the Colleges membership includes some 96% of UK practising anaesthetists. The total membership has grown considerably over the past 13 years. It was just 8,940 in 1999. I consider the current period to be the fat years and expect the membership to reduce around the year 2020, due to a likely reduction in training numbers from now on and the fact that we have a bulge of members whose ages suggest they are likely to retire around that time. Financially that means that we should be using these fat years to invest in infrastructure to support the lean years when they come. Accommodation is a good example of this. In 1999 the College had leases on 12,000 square feet of office property and one flat in Russell Square. In 2004 it began selling those leases and purchased the freehold of Churchill House (35,000 square feet) and in 2010 it purchased the freehold of the adjoining building, 34 Red Lion Square, which provides six two-bedroom flats and two floors of office accommodation. By the end of 2010 the College had paid off both mortgages and became asset rich but cash poor, the assets being worth 27 million. The last couple of years have seen the College generate a small cash reserve; however, it also wants to link 34 Red Lion Square to Churchill House to improve our education facilities. This requires budgets to be set so that this expenditure can be funded. Also, the Charity Commission requires the College to have a reserves policy to ensure that it is able to continue in the light of a reduction in income. Council
Mr K Storey
Chief Executive and Director of Finance, RCoA
It is fundamental that the financial strategy for the College supports the general strategy for the College and as I am fortunate in being both the Chief Executive and the Finance Director I am well placed to link the financial strategy to the Colleges strategic aims. This position also allows me to be aware of the parameters in which the College has to operate as a registered charity. I do not want to give the impression that I operate alone, far from it. I am supported by excellent staff both in finance and the general running of the College. There is also a Finance Committee of seven elected Trustees of the College and the Chairman of this Committee, the President and the two Vice-Presidents are Co-Treasurers. There is also an independent Audit and Internal Affairs Committee that has overall responsibility for the Colleges financial controls. This is the only committee in the College which the Co-Treasurers may not attend. In really broad terms the College has to grow as the role of anaesthetists grows in UK healthcare. There are more anaesthetists now so the accommodation requirements have grown; for example, more examining space is required. There is more
has agreed that the College should, by 2020, have a reserve equal to 50% of annual income, which equates to 4 million. Happily, I can confirm that we are currently on target to achieve this. A most important principle was agreed before any accommodation spending was incurred; it must not be allowed to restrict the day to day funding required for normal College activities. This has meant that the development of the Trainee e-portfolio, the online CPD system and the shortly to be released online revalidation system must not only be funded but must be made available to fellows, members and trainees at no additional cost. This has been achieved due to the growth in membership and therefore income together with strict financial control. The RCoA subscriptions are in the lower quartile of all colleges subscriptions. 85% of members pay their subscription by direct debit, and all UK members can claim tax relief on this. It makes sense therefore only to charge doctors once a year and provide all services within that sum (examinations excepted!). I have said that knowing the numbers is critical. Each Friday afternoon I receive a list of those whose subscriptions are not yet paid so that I know that it is a reducing sum, and I am pleased to report that in excess of 99% of all subscriptions requested are received. Having strong financial control allows College Presidents and Councils to undertake new ventures with confidence. The creation of the Faculty of Intensive Care Medicine (FICM) is a good example of this. Its predecessor, the Intercollegiate Board for Training in Intensive Care Medicine, was equally funded by seven parent Colleges and, although this worked well for the Board, it would
be restrictive for a faculty to have to gain agreement from six other Colleges on an ongoing basis. Dr Judith Hulf invited her six fellow Presidents to her office and offered to create the FICM on an intercollegiate basis except for the finance and governance, which would be administered solely through the Royal College of Anaesthetists. This meant that the College was underwriting the venture should it fail, subsidising its activities until a breakeven point be reached and offering that the Faculty retain any surpluses generated. This was not a profligate action on her part, but was based on knowing the numbers and minimising the risks to ensure that the reward was obtained. I am pleased to be able to confirm that the FICM grew quickly and that its membership now includes sufficient fellows, members and trainees to already make it financially viable. Writing this makes me think that my term knowing the numbers may be better defined as evidence-based business, a term more familiar to doctors. The Charity Commission allows a charity to trade outside its charitable objectives but states this cannot exceed 50,000 per annum. The College trades outside its charitable objectives by taking rent from four of the flats, by renting spare meeting room space and catering to non-anaesthetic organisations and by receiving income from advertising and some sponsorship. This amounts to more than 1/2 million a year and so the Charity Commission requires that a Trading Company be set up and taxes paid on the profits unless these are Gift Aided to the Charity. The RCoA Trading Company does Gift Aid all profits to the College and this provides an annual income in excess of 1/3 million. The College recently submitted its first bid to HQIP for funding of a three-year National Emergency
Laparotomy Audit. HQIP has rigorous processes in place to ensure that it only funds organisations that have secure finances, and I am pleased to report that our bid was successful and we shall be receiving 1 million funding for this audit. I would like to finish this article with an anecdote that shows that business can be fun as well as serious. I have mentioned that we required a mortgage to purchase 34 Red Lion Square. We were offered a 2.8 million mortgage facility by a leading UK bank using the building to be purchased as collateral. Unfortunately, the bank kept on finding trivial problems with the building that prevented them from transferring the cash to our bank and thus allowing us to complete the purchase. Every time we cleared one obstacle they thought of another this was in March 2009 and the banks had received strong criticism for lending money too easily so were very wary about providing new loans. The delays frustrated the vendor who threatened to withdraw the property and find another buyer. As a last ditch attempt to salvage the deal I agreed with the President that I should write to the Chairman of the bank a single paragraph saying that if the RCoA was having trouble, what hope was there for the rest of the UK economy. I copied the letter to Sir Mervyn King, the Governor of the Bank of England, and to Gordon Brown who was then the Prime Minister. Within two hours the bank had telephoned me and within 24 hours the cash had been transferred and we had exchanged contracts. I received a polite note from Number 10 and never heard from the Bank of England!
Liberia: how volunteers can help

The Mothers of Africa charity was founded in 2004 by consultant anaesthetists from Cardiff. Dr Judith Hall (now professor) attended the World Congress of Anaesthesia in Paris 2004 and was moved to hear of the high risk that mothers face when giving birth in Sub Saharan Africa, illustrated by the experience of Professor Martin Chobli in his native Benin. 12 months later in May 2005, Paul Clyburn and Judith Hall boarded a plane to Cotonou, the first city of Benin, and the charity was born.
Since the charity started in 2005, trained anaesthetists have travelled to Benin, Togo, Ethiopia, Tanzania, Zambia and Liberia to support the training of healthcare workers in these countries. We have had most input into Liberia so far and wish to build further on our progress through an innovative two-year project in partnership with the charity Maternal and Childhealth Advocacy International (MCAI).12 We are seeking experienced anaesthetists (ST5 or above) to volunteer for 3.5 months or more in Liberia.
Mothers of Africas mission Saving the lives of mothers and new-born babies in Africa by supporting the education of the people who provide medical care This means that local people are empowered and that care for pregnant women is sustainable Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime Chinese proverb
Dr T Sheraton
Consultant Anaesthetist, Royal Gwent Hospital, Newport; Chair of Trustees, Mothers of Africa
continue using them for training purposes. He had promised the medical anaesthetist who set up the school in Phebe (wife of the current Liberian minister of health, Mr Gwenigale) that he would look after the school and continue training anaesthetists. Despite the obvious difficulties, he managed to inspire young nurses to take up the training. One of these nurse anaesthetists Gogoe Augustin now runs the training school alongside Mr Fassah. See opposite for more information about nurse anaesthesia training in Liberia. We believe that the success of our projects is dependent on reliable personal contacts on the ground in the countries that we visit, and on the excellent skills of our volunteers to both teach and to teach in country teachers. We work with others to achieve our aims. Our partners have included Gwent Link,3
Partners in Liberia
Our activities focus on training and education. We only provide input at the invitation of local people and work alongside them to develop appropriate training for their own setting. One of our most inspiring men on the ground is Mr Wilmot Fassah. He is in his 60s and for many years was the only nurse anaesthetist in the main hospital in Bong County, Liberia, serving a population of over 300,000. During the 15 years of civil war, which ended in 2003, the hospital came under attack three times. Each time Mr Fassah would take the training manikins and move them somewhere safe so that he could
Mr Fassah: Head of the nurse anaesthesia school in Phebe stands outside thaeatre. He is committed to rejuvenating nurse anaesthesia training in Liberia to be the best in West Africa
Nurse anaesthesia training in Liberia
During the civil wars the school of anaesthesia in Monrovia was unable to continue training anaesthetists and the school in Phebe struggled with frequent moves of the hospital to safer areas The civil wars have meant that there are very few young trained anaesthetists in Liberia; although this is improving In 2009 there were 42 nurse anaesthetists in Liberia; 12 were over 60 years old and ten were middle aged. Ten nurse anaesthetists were in the capital Monrovia (where there are 12 hospitals) MOA has supported nurse anaesthesia training in Phebe Hospital, Liberia, since 2005 and supported The Liberian Association of Nurse Anaesthesia (LANA) Conference on four occasions (once in collaboration with Mercy Ships) In 2012 there are 60 nurse anaesthetists in Liberia There are no medically qualified anaesthetists although Dr Keith Thomson (Mercy Ships) has recently been contacted by a medical student interested in pursuing a career in anaesthesia Hospitals which do not have trained anaesthetists are either having : dd anaesthetic care provided by untrained personnel dd have surgeons acting in dual capacity dd or are undertaking no surgery Map of Liberia: Liberia is situated in West Africa, bordering the North Atlantic Ocean to the countrys southwest. It lies between latitudes 4 and 9N, and longitudes 7 and 12W. The landscape is characterised by mostly flat to rolling coastal plains that contain mangroves and swamps, which rise to a rolling plateau and low mountains in the northeast
Maternal and Childhealth Advocacy International (MCAI), and Association of Anaesthetists of Great Britain and Ireland (AAGBI) International Relations Committee.4 We do not set up supply chains for drugs or equipment; nor dump unwanted/second hand/inappropriate medical equipment or unwanted educational resources.
Needs assessment, Bong County, Liberia, February 2012
Partners in the needs assessment: dd Dr Williams (Director, Bong County Health and Social Welfare) dd Dr Bernice Dahn (Chief Medical Officer, Ministry of Health, Liberia) dd Mr Sherman (lead for WHO GIEESC) dd Professor Southall (Director of Maternal and Childhealth Advocacy International) dd Dr Meena Cherian (World Health Organization, Geneva) dd Dr Tei Sheraton (Mothers of Africa) Findings: dd Population 357,431, area 8,772 sq km dd 8,216 deliveries in 2011 dd Three hospitals and 37 clinics (two hospitals very close to each other) dd Five physicians dd 123 nurses dd 80 midwives
What volunteering would mean

Providing training and support Following a needs assessment in Bong County, Liberia, in February 2012, Mothers of Africa is seeking up to eight experienced (ST5 or above or consultant) anaesthetic volunteers to be resident in Liberia for a minimum of 3.5 months. The programme will start in January 2013 and there will be time included for handover to the next volunteer. Volunteers would be supporting nurse anaesthesia training as well as monitoring and evaluation of that training in collaboration with the Ministry of Health in Liberia and the World Health Organization (Liberia
This means that on a daily basis lives are put at risk because of a lack of trained personnel
Recommendations from needs assessment, Bong County, Liberia, February 2012 1 Train eight nurse midwife surgeons and eight additional nurse anaesthetists to provide emergency obstetric surgery and anaesthesia in rural areas using developed curriculums and UK experienced medical volunteers in obstetrics and anaesthesia respectively 2 Improve capacity of doctors, nurses, midwives, and nurse anaesthetists to treat obstetric emergencies and undertake neonatal resuscitation through EESS/EMNH (Emergency and Essential Surgical Skills/Emergency Maternal and Neonatal Healthcare) three-day courses incorporating the WHO Integrated Management for Emergency & Essential Surgical Care toolkit by UK visiting teams and long-term volunteers 3 Training of trainers by Liberian healthcare workers completing a Generic Instructor Course (GIC) and becoming competent to teach EESS/EMNH courses by UK visiting teams and long-term volunteers. 4 Training nurse anaesthetists (NAs) to provide high dependency care for obstetric and neonatal emergencies, including management of respiratory failure, major sepsis and intravenous fluid management and three NAs able to train others following the introduction of critical/high dependency care training into the already established NAs programme by UK visiting teams and long-term volunteers 5 Robust monitoring and evaluation of training and training outcomes throughout the two-year programme overseen by WHO, Geneva
how a woman dies in childbirth despite her familys best efforts to get her to his team. The long distances and dire shortage of skilled healthcare workers mean women die unnecessarily in childbirth.5 He also told of a midwifery colleague who lost her newborn baby despite their best efforts and the need for more training in basic neonatal care. Introducing critical care In addition to supporting training of the extra eight nurse anaesthetists, the long-term volunteers would support the current two-year nurse anaesthesia training (approximately six students per year) and oversee the introduction of context appropriate critical care for adults and newborns into the curriculum. Dr Paul Fenton reported in the BMJ in 2003 that 80% of maternal deaths in 25 hospitals in Malawi occurred on the ward in the postoperative period.6 Dr Ray Towey (Consultant Anaesthetist) recently presented at a World Anaesthesia Society Seminar held at the AAGBI. He has more than ten years of experience from a critical care unit in rural Uganda and collected data from July 2005 to date representing 2,314 critical care admissions. The unit has usually one trained nurse to four patients and offers basic critical care including sedation, ventilation, and good fluid management. ICU mortality ranged between 27 and 31% over a six-year period. It is likely that most of the IPPV and many of the HDU patients would have died without this facility. Dr Toweys experience suggests that even in remote rural African areas an effective ICU/HDU facility is possible with modest funds. Support for the volunteer Following successful application the charity Mothers of Africa would provide training prior to departure, cover the costs of vaccinations, antimalarial tablets, travel, insurance,
Mr Gogoe Augustine wins a prize at an MOA sponsored Liberian Association of Nurse Anaesthetists (LANA) conference in 2009. He is now one of the three nurse anaesthesia trainers in Phebe Hospital, Bong County, Liberia, and current secretary of LANA
and Geneva). Volunteers would be working alongside an experienced UK obstetrician who will be undertaking an equivalent role in obstetrics, training eight nurse midwives to undertake emergency obstetric surgery over a period of two years. If this programme, which is part of a comprehensive Emergency Obstetric Care (EmOC) programme, is successful it will mean that areas of Bong County where there is no access to emergency obstetric surgery will have this provided by pairs of nurse anaesthetists and nurse midwife surgeons. Again, if this proves successful, there is potential for the programme to be rolled out in other countries where there is a dire shortage of trained personnel. Dr Samson Arzuquio, experienced Liberian GP surgeon, was interviewed as part of the needs assessment at the newly opened CB Dunbar hospital in Gbarnga. This hospital is one of the three in the county that can provide comprehensive EmOC and one of two in which the volunteers would teach. During the interview he explains
accommodation, car hire and petrol in Liberia, daily subsistence allowance, and provide access to a personal laptop with internet connection in Phebe Hospital within the accommodation. The team that have been drawn together to support this initiative are experienced in the field and collaborative in their approach. Volunteers will have an opportunity to learn from experts in this field as well as helping the people of Liberia to help themselves. Opportunities for shorter attachments Short-term volunteers (two weeks) will also be required three times per year to support the nurse anaesthesia training and to train healthcare workers in the county on the Emergency Maternal and Newborn Health course developed by MCAI, Advanced Life Support Group (ALSG), and World Health Organization. Dr Barbara Phillips of ALSG says: Our skills based training programme, Emergency Maternal and Newborn Health, has been successful in driving up standards in The Gambia where it is now sustainably taught by the Gambians themselves. It is a vital component of our Strengthening Emergency Care programme which will now be enhanced by this new project to train midwives in emergency obstetric surgery and nurse anaesthetists in high dependency care for mothers and babies, bringing the whole range of self-sufficient emergency care for the most vulnerable. Both the short-term and long-term volunteers will also assist in the monitoring and evaluation, which is being overseen by the World Health Organization, partners in this project.
commitment but believe that it brings personal benefits as well as benefits to the people of Liberia. Benefits to the NHS are outlined in the Department of Health document entitled The Framework for NHS Involvement in International Development.7 Within Wales there is significant support for international activity through Wales for Africa Health Links.8 Dr Iain Wilson (President of the AAGBI, and WHO representative for World Federation of Societies of Anaesthesiologists) says of his experience working in Zambia: I learnt more about resource management and training in healthcare during my two years in Africa than I have in my entire career since. I would recommend anyone who has the opportunity to do this to grasp the opportunity wholeheartedly. Dr Mike Dobson (Former Director on the Oxford course Anaesthesia in Developing Countries and author of the WHO manual Anaesthesia at the District Hospital) says: In 30 years I have seen many doctors attend our course before serving overseas. They return hugely enriched, more confident and capable as a result of their experience, to the benefit of their patients and the NHS. Dr Oliver Ross (Editor of the Anaesthesia Video Library DVD available from Teaching Aids at Low Cost) has recently returned from long-term volunteering in Nepal. He says, Volunteering for a co-ordinated country led programme is an effective use of experienced UK anaesthetists. For further information about this project please contact either: Professor David Southall (MCAI) at davids@doctors.org.uk. Dr Tei Sheraton (MOA) at Tei.Sheraton@wales.nhs.uk.
References
1 2 www.mcai.org.uk/ (accessed 28/06/2012). www.rcoa.ac.uk/news-and-bulletin/ rcoa-news-and-statements/mothersof-africa-educational-initiative (accessed 28/06/2012). www.ethiopiagwentlink.org/v2/ (accessed 28/06/2012). www.aagbi.org/international/ international-relations-committee (accessed 28/06/2012). www.facebook.com/pages/Mothersof-Africa/225767807515632 (accessed 28/06/2012). Fenton P et al. Caesarean section in Malawi: prospective study of early maternal and perinatal mortality. BMJ 2003;327:587. www.vso.org.uk/Images/ TheFrameworkforNHS InvolvementinInternationalDevelopment_ tcm79-26838.pdf (accessed 28/06/2012). www.wales.nhs.uk/sites3/home. cfm?orgid=834 (accessed 28/06/2012).
3 4
Personal development through volunteering

We recognise that volunteering to work overseas in Liberia is a significant
The Society for Ethics and Law in Medicine

Ethics with their associated beliefs and rules of life have existed in some form for almost as long as man has lived. Sometimes these lifestyle conventions have developed from secular sources, but more often they have followed from systems of religious belief. World history teaches us that no matter how well intentioned the foundations of a system of ethics or religious belief are, the outcome can unfortunately be personal or interpersonal conflict, or regional or international war.
In order to manage such hostilities, laws have developed to regulate, for example, personal behaviour, interpersonal tolerance, and crimes against society: justice systems regulate life and resolve disputes. Through history, at any one time, the accepted ethics and permitted religions have varied from place to place and, in any one place, the acceptable conventions have varied over time. There is therefore an inevitable and mutually dependent bond between ethics and the law: the existence of each is created by, and dependent upon, the existence of the other. This is as true now as it was in 1700BC when the secular Hammurabi Code was the basis of societal regulation. However, law is not the same as ethics. In his classic 1963 series of lectures on Law, Liberty and Morality, HLA Hart1 outlined the distinction between morality and law and posed the question: Ought immorality as such to be a crime? Hart felt the famous dictum of John Stuart Mill on limitations to the enforcement of morality was correct; it was, in the main, right to enforce morality only for the purposes of preventing harm to others. Today, we might pose for those working in the medical sphere, a similar question: Should ethics be defined, interpreted and enforced by legal processes? We certainly see similar tensions today in the potential overlaps between what is ethical and what is lawful, as society saw in previous decades between what should be considered immoral or illegal. In current society there are many reasons why ethical, religious and legal conflicts occur: indeed they are part of the daily national and international news and range from interpersonal to intercontinental proportions. Within the practice of medicine, these problems feel as if they are magnifying in both frequency and gravity. For some years the courts have resolved a growing number of ethical problems, and particularly those around death. The future looks as if it will generate more and not less interplay between medicine, the ethics of medical practice and the need for resolution within the law. Some of the key factors that differentiate the future from the past are:
Dr N Bindal
Consultant Anaesthetist, Queen Elizabeth Hospital, Birmingham
An increasing expectation at a personal and family level of what a patient can expect from what is medically possible. An increasing appreciation of the greater role that personal autonomy will play in determining individual clinical pathways, particularly in terminal disease. An increasing proportion of elderly citizens with multi-system disorders who will consume large numbers of life-extending drugs and resources. A growing culture of patient expectation that their rights will be protected and enforced by legal means, whether that be by regulation, by compensation, or by the criminal courts. A decreasing national economic growth profile which will, however one looks at it, make choices between therapeutic
Mr P Stott
Barrister, QEB Hollis Whiteman
Professor P Hutton
Consultant Anaesthetist, Queen Elizabeth Hospital, Birmingham
regimens for patients inevitable: in short, rationing and the availability of medical treatment may again, possibly, become related to the ability to pay.
Superimposed upon all this, there is good evidence that society is becoming increasingly secularised and, in doing so, is possibly losing its bonds to established systems of religious ethics and moral codes.
Recently, one of the Societys legal committee members, Bertie Leigh, writing in the Foreword to the recent NCEPOD report2 said: As a lawyer, when I accept a client I have a professional duty to agree with them in writing what the objectives are, what the scope of my authority is to be and what the risks and benefits may be. Our increasing respect for the autonomy of the patient ought to lead the medical profession to embrace a similar course. The right to consent to treatment is not confined to surgery. The ceilings of treatment should be described and agreed whenever possible. The patients views on resuscitation should be canvassed wherever possible and appropriate. Where it is not possible and the doctors have to act in what they perceive to be the patients best interests, that should not be interpreted as an obligation to administer CPR to the dying. The doctors right to act in this context is coterminous with his duty: a patient may only be resuscitated where they have consented to the process or the doctor is satisfied that it is in their best interests... One final thought. The negative connotations of Do Not Attempt CPR orders may be associated with a concern that other aspects of care will be compromised. It has been suggested that what people are really trying to say is that when the inevitable occurs they should Allow Natural Death AND, or Allow Dignified Death ADD.
It is clear from this extract that the future is already partly upon us, and it is within this background that the new society has been formed. Already, many institutions have ethical committees and, in several, law and ethics are brought closely together. The creation of this society is not to fail to recognize the considerable contribution that these bodies have already made, and continue to make. Its objectives, as set out in the constitution are to provide a different forum, working at national level, which will bring together interested parties from medicine, law, academia and the laity to:

Origins
The society, although now for all health specialties, was initially intended for those interested consultants and trainees within anaesthesia, intensive care, pain medicine and the law. The creation of the societys first committee therefore included those within anaesthesia in combination with representatives from the legal field and laity. The committees initial responsibilities were to agree a constitution, to create a website and most importantly to develop membership. The natural progression from this anaesthetic base was to become affiliated to the Association of Anaesthetists of Great Britain and Ireland (AAGBI). With help from the Associations managerial team it was first launched as the Society for Ethics and Law in Anaesthesia, Intensive care and Pain Medicine with its inaugural meeting in March 2011. The programme included a combination of specific topics of interest to anaesthetists and also more general topics of coronial process and law. All content was mapped to the RCoA Continuing Professional Development (CPD) matrix to enable those attending to obtain CPD points. This first meeting was fully attended and feedback was very encouraging. Another successful meeting followed in December 2011 held at the Institute of Physics. On this occasion there were presentations on human rights, interesting legal cases in anaesthesia, ethics of intravenous testing on unconscious patients, and ethics of resource management in intensive care. Responding to feedback from our first meeting, the programme also included a debate entitled This house believes clinical negligence litigation is good for patients and medicine; it was slogged out in good spirits by all concerned. Overall feedback for both meetings was excellent, with scores for all speakers between eight and nine out of
promote study and understanding provide education encourage research
In particular, and perhaps above all, it is intended to be open to all as a place where difficult ethical issues of the day are discussed, along with identifying those issues that may be of concern in the future. There are real issues arising from more effective lifeextension and allocation of resources, which practitioners and policy makers are having to grapple with now. There will, no doubt, be yet more medical developments in the near future that will again test our currently understood model of what is ethical, and will therefore require further interaction with legal processes. Our strength, as a Society, lies in our joint membership areas of doctors, lawyers, academia and the laity. Too often there has been a disconnection between these groups. Mistrust and misunderstanding of the roles and responsibilities of each has sometimes clouded perceptions. It is sincerely hoped that, by bringing the different fields together, real and valuable progress can be made on some of the extremely challenging and complex questions outlined above.
ten, and 8090% of delegates finding the content of the meetings useful. Since the 2011 December meeting, membership has continued to grow, its wider relevance has become inescapable and the name has been changed to the Society for Ethics and Law in Medicine. We have maintained our links with the AAGBI and are pleased to report new ones with RCoA. On 11 June 2012 the society jointly held a study day for Ethics and Law for Anaesthetists with the RCoA and the link will be recognised at our next November 2012 meeting and through the commitment to CPD.
The Societys objectives ... are to provide a different forum, working at national level, which will bring together interested parties from medicine, law, academia and the laity.
Finally, this is still a fledgling society and, while membership is growing, it is essential that we continue to expand to fully achieve our aims of providing a national platform for current ethical and legal issues within medicine to be openly discussed. We are always receptive to comments and suggestions and look forward to meeting new members at our meetings. Membership and application forms for all upcoming events are available online at: www.societyforethicsandlaw.org.uk. Please join: the fees are low and there is a financial incentive if you attend meetings. Current rates are 55 per year for consultants, dentists, solicitors and barristers, and 35 for trainees, with a special rate of 10 per year for undergraduate or postgraduate students.
References
1 2 Hart HLA. Law Liberty and Morality. Stanford University Press, 1963. Time to Intervene? NCEPOD, London 2012 (Pg 7) (www.ncepod.org.uk/2012cap. htm).
A study day on assisted dying

Friday, 30 November 2012 RCoA, London
Programme 9.30 am to 10.00 am Coffee and Registration 10.00 am to 10.10 am Welcome and Introduction Professor Peter Hutton 10.10 am to 10.55 am UK law: the lawyers perspective Zoe Johnson QC 10.55 am to 11.45 am UK law: how it affects clinical practice Cancer patients Dr Dave Spooner Neurological conditions Dr Steve Sturman 11.45 am to 12.30 pm UK law: how does it differ from Europe? Professor Penny Lewis 12.30 pm to 12.50 pm Panel questions and discussions 1.00 pm to 2.00 pm Lunch 2.00 pm to 2.45 pm A view from the public Mrs Irene Dalton 2.45 pm to 3.30 pm A retrospective on Tony Bland Anthony Lester QC 3.30 pm to 3.45 pm Coffee 3.45 pm to 4.30 pm Debate: This house believes that UK law in relation to assisted dying is indefensible For: Dr Peter Nightingale Against: Dr Tom Clutton Brock 4.30 pm to 4.45 pm Close of meeting Professor Hutton Fees Consultant and Lawyer members: 130 Consultant and Lawyer nonmembers: 200 Trainee members: 100 Trainee non-members: 150
The future
The society will be participating at the next AAGBI Annual Congress in Bournemouth September 2012 and running a workshop on mental incapacity. The societys next annual meeting will be held on 30 November 2012 at the Royal College of Anaesthetists. This meeting will focus on the very emotive and hugely topical theme of assisted dying. The programme is shown across. It will review the current state of both medical thought, and the legal position, and attempt to come to some conclusions as to the way forward. This should be a fascinating and informative day that will no doubt demonstrate the divisions of current opinion.
CPD
The society understands the need for accumulating CPD points for appraisal and revalidation, and our future plans include having our meetings mapped for CPD points for anaesthetists, other medical specialties, and for solicitors and barristers. Plans are also underway to develop the learning resources available on the website which will include the ability for CPD points to be obtained online for members.
Safe Anaesthesia Liaison Group
PATIENT SAFETY UPDATE
Including the summary of reported incidents relating to anaesthesia

1 JANUARY 2012 TO 30 MARCH 2012
This document aims to achieve the following:

Outline the data received, the severity of reported patient harm and the timing and source of reports. Provide feedback to reporters and encourage further reports. Provide vignettes for clinicians to use to support learning in their own Trusts and Boards. Provide expert comments on reported issues. Encourage staff to contact SALG in order to share their own learning on any of the incidents mentioned below.
Morbidity and mortality meetings
The SALG Patient Safety Updates contain important learning from incidents reported to the National Reporting and Learning System (NRLS). The Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) would like to bring these Safety Updates to the attention of as many anaesthetists and their teams as possible. We would like to encourage you to add this Update to the agenda of your next morbidity and mortality meeting and we would also like to hear your feedback on learning points. Feedback from M&M meetings on how the Patient Safety Update has informed action can be sent to the SALG administrator at salg@rcoa.ac.uk.
Summary
A total of 3,188 anaesthesia-related incidents were reported during the specified time period. 69% of cases were reported as near miss (harm was prevented from reaching the patient), and 7.5% resulted in moderate or severe harm or death (10 deaths reported) (Figure 1). 65 incidents were reported using the anaesthetic eForm; 40% of these incidents were reported to the National Patient Safety Agency (NPSA) within one day of occurrence. 3,123 incidents were reported using Local Risk Management Systems (LRMS); 0.6% of these incidents were reported within one day and 48% were reported more than 30 days after they had occurred (Figure 2). All incidents graded as death or severe harm were reviewed by the National Patient Safety Agency (NPSA) and if identified as having potential cause for concern, were reviewed by consultant anaesthetists from the RCoA or AAGBI. This review was carried out in accordance with the NPSAs data sharing protocol (no information about the Trust is disclosed; only information about the incident). Most incidents were reported by consultant anaesthetists, but the eForm is available to all members of the peri-operative team. As with any voluntary reporting system, interpretation of data should be undertaken with caution as the data are subject to bias. Many incidents are not reported, and those that are reported may be incomplete having been reported immediately and before the patient outcome is known. Clarity of degree of harm to patients who experience a patient safety incident is an important aspect of data quality.
Anaesthetic eForm
The anaesthetic eForm was designed to allow specific clinical information relating to anaesthetic incidents to be reported by anaesthetists and other members of the anaesthetic team and can be found at: www. eforms.npsa.nhs.uk/asbreport. The NPSA will be closing in 2012 as a result of the Arms Length Bodies review in 2010. Responsibility for the NRLS has moved to the NHS Commissioning Board and operational management of the NRLS has moved to Imperial College Healthcare Trust. SALG would like to encourage you to continue to use the eForm (or your local reporting systems), and we would like to reinforce the importance of continuing to report patient safety incidents during the transition period so that trends and incidents can be acted upon and learning maximised. The eForm is particularly useful as it provides a mechanism by which high quality information can be rapidly reported by members of the anaesthesia team and disseminated nationally.
Degree of harm (actual incidents)
Figure 1 shows the degree of harm incurred by patients within the anaesthetic specialty during the period 1 January to 31 March 2012. All ten deaths were reported though LRMS, rather than the anaesthetic eForm.
Figure 1 Reported degree of harm
2,500 2,000 Number of reports 1,500 1,000 500 0 No Harm Low Moderate Degree of harm 723 204 2,226
25 Severe
10 Death
Timeliness of reporting
Figure 2 shows the time taken to report incidents via the anaesthetic eForm (directly received into the NRLS) and via LRMS (uploaded to the NRLS periodically via local systems) during the period 1 January to 31 March 2012.
Figure 2 Reporting timeliness of anaesthetic incidents
60%
Reporting timeliness (local risk management system)
50%
Reporting timeliness (eForm)
Percentage of reports
40% 30% 20% 10% 0% Within same day By next day Within one week Within one month More than one month
Time taken to report an incident
Incident Type
Figure 3 shows the type of incidents that occurred within the anaesthetic specialty that were reported using LRMS or the anaesthetic eForm for the period 1 January to 31 March 2012. The categories were determined at local level.
Figure 3 Type of incident reported
Patient abuse (by sta /third party)
2
Self-harming behaviour
Disruptive, aggressive behaviour (includes patient-to-patient)
Infection control incident
50
Clinical assessment (including diagnosis, scans, tests, assessments)
91
Incident type
Other
132
Patient accident
133
Consent, communication, con dentiality
135
Access, admission, transfer, discharge (including missing patient) Documentation (including electronic and paper records, identi cation and drug charts) Infrastructure (including sta ng, facilities, environment) Implementation of care and ongoing monitoring/review
170
227
286
336
Medical device/equipment
391
Medication
418
Treatment, procedure
805
100
200
300
400
500
600
700
800
900
Number of reports
Summarised examples of reported incidents Medication Errors
Medication errors are common in all areas of clinical practice, and have been estimated to occur in around 1:133 anaesthetics.1 Medication errors are the second most common category of incident reported to the NPSA and many more are likely to remain unreported.2 Many medication errors do not result in patient harm, but some can have devastating effects, as can be seen in one of the reports this quarter. Anaesthetists are unusual in that they are responsible for prescribing, dispensing and administering potent drugs, often in rapid succession, whilst monitoring the patient in the complex environment of the operating theatre. The NPSA has issued guidance to reduce medication errors, including a feasibility study (www.nrls. npsa.nhs.uk/resources/?EntryId45=59845) exploring the double-checking of anaesthetic drugs. Many errors could be avoided if guidance was better implemented.2 Common medication errors in anaesthesia include drug swaps (thiopentone in place of antibiotics, suxamethonium in place of fentanyl or syntocinon); duplication of drugs or errors of drug dosage, particularly opioids or paracetamol in children; and problems with TIVA. Many examples have been described in previous Patient Safety Updates. Further examples of medication errors are described below.
Residual anaesthetic drugs in IV lines have devastating consequences Patient had appendicectomy. On returning to the ward had IV with short extension flushed with saline. Shortly after had a cardiac arrest thought that residual muscle relaxant in the line caused a respiratory arrest followed by a cardiac arrest.
The NRLS continues to receive reports of severe harm due to anaesthetic drugs remaining in IV lines, particularly in children. A Signal Alert (www.nrls.npsa.nhs.uk/resources/type/ signals/?entryid45=65333&p=2) was published to highlight this concern. The NPSA states: Good practice suggests that after intravenous administration, the anaesthetist should ensure that the cannulae have been flushed through to remove any residual anaesthetic drug before children are returned to recovery wards or wards where they may be given further fluids, antibiotics or pain relief intravenously.
Take care with charting Relieved colleague for a break. Patient showed signs of requiring further analgesia. I could not see any evidence that the patient had received paracetamol (not on drug chart/anaesthetic chart and no empty bottle visible) so I administered a dose of paracetamol. Colleague returned... revealed that a dose had already been given.

Repeat dose of antibiotics given (patient record not checked). Patient had revision hip surgery. PCEA in situ (epidural fentanyl and bupivacaine). Also started on enhanced recovery drugs by team previous night, so had MST 10mg first post-op morning as well as the PCEA. (MST omitted by nurses previous night). Reported as slightly drowsy in the morning. Confusion about prescription of systemic and epidural opioids; contributing factor training, induction of new staff and documentation.
Document all drugs administered consistently, accurately and contemporaneously. Check the patient record before drugs are administered. Automated methods of recording and administering drugs may improve the accuracy and legibility of anaesthetic records in future.3 Ensure all new staff are aware of local treatment protocols.
Identify latent errors in the anaesthesia environment, do not tolerate safety violations; avoid distractions I administered two incremental doses of morphine in place of the intended drug atracurium... no consequences because I had intended to administer the morphine at some point anyway... Contributing factors: distraction as had medical student to teach, failure to label syringe and failure to check...

I had a CT1 anaesthetist with me who was preparing drugs... we were talking while this was going on and in the process a syringe was wrongly labelled. Took a box of ephedrine from drug cupboard... was just about to draw up drug when I noticed that it was adrenaline 1mg (epinephrine) and not ephedrine 30mg. There were two more ampoules of adrenaline in the ephedrine box. Patient being set up for sitting craniotomy prior to knife to skin. Colleague had been using CVP to give boluses of metaraminol (their preferred method). The metaraminol syringe (labelled) was left attached to CVP line. Colleague asked me to inject a bolus of saline into the CVP line so that we could check Doppler signal. I injected the contents of the syringe into the patient (7.5mg metaraminol). I noticed the blood pressure rising, looked at the syringe and realised what I had done. I alerted the team... aspirated the line and treated (increased depth of anaesthesia and labetalol). The maximum BP was 200/135 and the max HR was 120 sinus rhythm. The effects of the metaraminol bolus lasted about 15 minutes. Young, fit patient no harm caused.
All drugs should be clearly labelled; the label on both ampoule and syringe should be read carefully before the drug is drawn up or injected. Ideally drugs should be drawn up and labelled by the anaesthetist who administers them. The workspace should be kept tidy, unused medications disposed of and unused ampoules should not be mixed or replaced in boxes. Keep hazardous drugs separate. Minimise distraction during the preparation and administration of drugs.
Be aware of fixation errors Anaesthetic equipment checked by both the anaesthetic nurse and the anaesthetist... included checking both the sevoflurane and desflurane vaporisers and checking the anaesthetic machine and vaporisers for leaks (GE Aespire, Datex Ohmeda monitoring, Drager D vaporiser). Patient anaesthetised and transferred to the operating theatre... desflurane set to 7% and fresh gas flow set to less than 1 litre.min-1. Gas analyser did not detect any desflurane being delivered; correct functioning of the gas analyser queried, and reset. Repeated attempts made to reset the analyser. Water trap changed. Fresh gas flows and desflurane increased. Requested further assistance and a consultant colleague and experienced operating department practitioner attended. Patients blood pressure was noted to be higher than would be expected but there was no tachycardia (patient taking beta-blockers). New gas analyser brought to the theatre; at the same time surgery ended. New analyser also did not detect any desflurane; sevoflurane administered. When the anaesthetist examined the desflurane vaporiser it was found not to be locked onto the back bar of the anaesthetic machine. The patient recovery was uneventful but at follow up it became apparent that the patient did have recall. Both the consultant anaesthetists who were involved assumed that if the vaporiser could be turned on it must be locked onto the back bar of the anaesthetic machine; it was this assumption that led them to concentrate on the gas analyser as being the cause of the problem.
Be aware of fixation errors and confirmation bias during an anaesthetic crisis. Do not ignore conflicting information; take time out to reassess the situation if appropriate. Incident reporting is fundamental to improving medication safety. Reports to the NRLS form the basis of Signal Alerts (www.nrls.npsa.nhs.uk/resources/type/signals/) that describe emerging safety issues and Patient Safety Alerts (www.nrls.npsa.nhs.uk/resources/type/alerts/) that are cascaded to the NHS in England and Wales. In summary, it is essential to consider the contribution of human factors and system errors in order to improve medication safety for our patients.4 Evidence-based strategies have been published to improve the safety environment and reduce drug administration errors during anaesthesia.5 It would be useful for individual clinicians and departments of anaesthesia to consider these interventions and how they can be applied to their own work environment:

Read the label carefully on the drug ampoule and syringe before drawing up the drug. (Labels on ampoules and syringes should be legible). Syringes should be labelled. The drug drawers and workspace should be organised and tidy; similar or dangerous drugs should be separated, or removed if possible. Labels may be checked by a second person before a drug is drawn up or administered. Drug errors should be reported and reviewed. A pharmacist should be appointed to the operating theatre, and changes in drug presentation notified ahead of time. Similar packaging and presentation should be avoided where possible. Drugs should be presented in prefilled syringes where possible. Drugs should be drawn up and labelled by the anaesthetist who will administer them. Drugs should be colour coded by class, according to national or international standards. Coding by syringe position, size or needle on the syringe could be used.
A Critical Incident Involving TAP Blocks
An anaesthetist contacted SALG directly to highlight a concern about a possible serious complication of TAP block that has not been reported before. Simultaneously, the case had been reported to NRLS and, as a result of the NPSAs usual process for incidents of this severity, 15 similar incidents had been found. The initial report was:
A man underwent laparoscopic sigmoid colectomy. The operation had to be converted to an open procedure. At the end of the operation bilateral TAP blocks were performed while anaesthetised, consent having previously been given. The TAP blocks were repeated a further three times on the ward over the next two days as PCA alone was inadequate. The patient developed signs of severe sepsis. He had a further laparotomy that did not reveal a source for the sepsis, however some turbid fluid was found and a loop ileostomy was raised. Spreading erythema was noted on the left flank and a clinical diagnosis of necrotising fasciitis was made (but not confirmed by pathology). He underwent an extensive debridement of this tissue.
There was concern at the possibility that TAP blocks had either introduced infection or had pierced the peritoneum and seeded infected fluid into the skin. There is no evidence that aseptic technique was inadequate or that these blocks had punctured the bowel or peritoneum. The blocks were all done using the landmark method. The other related incidents, that had been found during the NPSAs search, did not include any graded as severe harm or death. Examples of other problems reported relating to TAP block include inadequate pain relief after wearing off, inability to perform TAP blocks because of lack of equipment and wrong side block. TAP block is a relatively new procedure with relatively few reported complications in the literature. The introduction of new procedures into clinical practice to improve patient care may have unintended consequences. Policy should be in place to ensure that new procedures are undertaken with an appropriate level of monitoring.
OAA and SALG Evaluations of Neuraxial Connectors
In partnership with the Obstetric Anaesthetists Association, SALG advocate local evaluation of new neuraxial devices introduced following the NPSA Alert (www.nrls.npsa.nhs.uk/resources/type/ alerts/?entryid45=132897). A form for this is downloadable from the OAA website (www.oaa-anaes.ac.uk/ content.asp?contentid=449). Data from local evaluations is requested for large scale analysis by the SALG Data Analysis Group. This analysis will take place when a significant body of data has been collected. Now, we are also requesting that reports of incidents arising from use of the new equipment are submitted for analysis and sharing. A specific form to capture these incidents is available to download from the OAA website (www.oaa-anaes.ac.uk/content.asp?contentid=449). Completed forms should be returned to spinal@rcoa.ac.uk. Any comments or queries on the topic are also welcomed to this email address.
Tracheostomy Safety Project
SALG would like to advocate the Resuscitation Councils National Tracheostomy Safety Project and in particular, the algorithms Patent Upper Airway (www.resus.org.uk/newsletr/nl12Wal1.pdf) and Laryngectomy (www.resus.org.uk/newsletr/nl12Wal2.pdf). Please share these with your colleagues and consider displaying them in your work area.
References and further reading 1 Webster CS et al. The frequency and nature of drug administration error during anaesthesia. Anesth Int Care 2001;29:494 500. 2 Cousins D, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England over six years (20052010). Br J Clin Pharmacol, 22 December 2011. Accepted article: doi: 10.1111/j.13652125.2011.04166.x. (Epub ahead of print). 3 Merry AF et al. Multimodal system designed to reduce drug errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ 2011;343:d5543 (doi: 10.1136/bmj.d5543). 4 Mahajan R. Medication errors: can we prevent them? BJA 2011;107:35. 5 Jensen LS et al. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004;59:493504.
AsWeWere
e-Learning Anaesthesia
Integrated Anaesthesia Learning Portal
(Pr)e-learning Anaesthesia for undergraduate anaesthesia medical student training

Dr B Howes, Dr F Forrest, Dr C Bourdeaux and Dr A McIndoe, Bristol Royal Infirmary Dr E Hammond, Royal Devon and Exeter Hospital
Medical students at the University of Bristol learn anaesthesia as part of the Applied Clinical Sciences (ACS) module in their fourth academic year. The aims of the clinical attachment are geared primarily towards producing wardcompetent foundation doctors. Students are expected to: 1 Encounter real and simulated sick patients in ITU and the operating theatre. 2 Develop important procedural skills, such as mask ventilation and intravenous cannulation. 3 Use basic sciences to interpret clinical observation and to guide treatment. 4 Experience the career options in anaesthesia-related disciplines. The student year is divided into four groups. Each group receives a morning of introductory lectures, followed by a three-week clinical attachment in anaesthesia. More detailed anaesthesia theory is delivered during the clinical attachment in the form of additional tutorials and informal personal study. In the academic year 2011/2012 we started offering Bristol medical students access to e-Learning Anaesthesia (e-LA). e-LA has been available since 2008 as an online resource designed to support the specialist trainee curriculum. Each session takes about 20 minutes to study and usually includes an element of self-assessment. Students were encouraged to use e-LA to supplement core lectures, in-theatre teaching and tutorials. We selected 21 e-learning sessions from the existing 750 sessions available on the system, and presented them as a prelearning package. This was offered as a learning pathway on the e-Learning Anaesthesia system. The material was chosen to equip the students with the background knowledge needed to get the most out of their clinical attachment, and to hit the ground running. We also allowed students to access any other e-LA sessions they felt were relevant to their studies. Results 259 Bristol students were initially registered to use e-Learning Anaesthesia. The Learning
Table 1 The 21 e-LA sessions included in the undergraduate anaesthetic pre-learning package (titles and QuickLink ID codes) ranked by number of accesses recorded by the cohort of students during their fourth academic year
Search Code
Session Title
Accesses
0010004 0010007 0010008 0010617 0010011 0010010 0010023 0010024 0010009 0010013 0010057 0010067 0010045 0010002 0010046 0010076 0010033 0010032 0010260 0010034 0010054
Anatomy of the airway Cardiovascular system Respiratory system Body water and compartments 1 Autonomic nervous system Neuromuscular junction History and examination ASA grading and preop investigations Oxygen transport and consumption IV induction agents Analgesia and anti-emetics Basic monitoring: ECG, SpO2, and BP Intravenous cannulation Preparation and usage of equipment and drugs Pre-oxygenation Principles of ALS Airway maintenance: cLMA Airway maintenance: facemask Central venous pressure monitoring Airway maintenance: tracheal tube 1 Slow/failed recovery
587 469 414 389 370 357 357 354 352 346 334 326 315 301 298 297 281 272 262 257 232
www.e-LA.org.uk
Dr A McIndoe and Dr E Hammond, Joint Project Leads
Management System (LMS) was able to record all student online learning activity. During the 20112012 academic year 249 students actually registered activity on the LMS, accessing 7,701 sessions and spending a total of 4,797 hours studying online material. The median student accessed 31 sessions (interquartile range: 1841). Anatomy of the airway was by far the most popular session. Half the recommended sessions covered application of basic sciences and half were predominantly clinical in content. Of note, the six most frequently accessed sessions were basic science subjects. 93% of the sessions utilised were drawn from the learning pathway. Students also chose to access 161 alternative sessions outside the learning pathway. Most popular amongst these were:

aims of the curriculum, and time during the anaesthesia attachment is limited. We feel that students should focus on gaining hands-on experience and maximising clinical exposure to patients under direct consultant supervision. e-Learning Anaesthesia provides a knowledge base to support the undergraduate clinical curriculum. However, e-LA is designed to cater for an extensive postgraduate specialty trainee curriculum. Providing undergraduates with a learning pathway prevents overwhelming them with the entire postgraduate curriculum. Students are able to access the material at their own pace and in their own time. Subsequently, many have returned to the material as a revision aid at the end of the academic year, and we have no reason to believe that this self-directed learning model could not be extended to other medical schools and other elements of the undergraduate curriculum.
How we set up a University student prelearning programme on e-LA

1 Learning pathway designed by expert consensus incorporating 21 sessions. 2 Approval granted by Undergraduate Dean to make changes to the lecture programme. 3 Learning path published on e-LA Learning Management System. 4 Registration of the entire student year validated by university email address. 5 Log-in instructions and user handbook posted to University student web. 6 E-LfH individually emailed each student with a username and password for e-LA.
Inhalational anaesthetic agents. IV fluids. Heart and major vessels. The anaesthetist and the theatre team. Premedication. Classification of shock/Assessment and resuscitation of a shocked patient.
Figure 1 The number of e-LA sessions accessed per month recorded by the cohort of students during the academic year 20112012
We observed increased use of e-LA in June, coinciding with the fourth year university examination in anaesthesia at the end of the academic year. 61% of the online activity took place in normal working hours, meaning that the students viewed 39% of sessions during evenings or weekends. Conclusions The aim of the clinical attachment in anaesthesia and critical care is to produce ward-competent foundation doctors. We believe the lecture format is poorly suited to delivering the
Report of Council
At a meeting of Council on Friday, 18 May 2012, the following appointments/re-appointments were approved (re-appointments marked with an asterisk):
Regional Advisers
There were no appointments or re-appointments for Council to consider.

Deputy Regional Advisers
Council noted recommendations made to the GMC for approval, that CCTs/ CESR (CP)s 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.
Severn/Bristol Dr Yelisava Horswill Dr Tessa Bailey Dr Rachel Alexander Dr Mala Cathiavadi Greamspet Dr Benedict Huntley Dr Christopher Marsh Dr Nicholas Preston South West Peninsula Dr David Pappin Tri-Services Dr David Beard Dr Edward Allcock Wessex Dr Frances Haigh Dr Richard Isaacs Dr Elizabeth Shewry
Birmingham

College Tutors
Anglia Dr Sabita Sreevalsan Dr John Mitchell North Central Dr Kathryn King Dr Nicholas Schofield Dr Ganga Liyanage Barts and The London Dr Fauzia Mir * Imperial Dr Rebecca Hull Kent, Surrey, Sussex Dr Peter Isherwood Mersey Dr Elizabeth Clark Dr Benjamin Chandler Dr Vyacheslav Seppi North West Dr Cally Burnand Dr Keirarash Kazemi-Jovestani Dr Stephen Clements Dr Lucy Bates * Dr Darshan Boregowda Dr Daniel Cottle * Dr Mruthunjaya Narayana Swamy Dr Shreekar Yadthore Dr Daniel Mallaber Dr Jamila Mulla Northern Ireland Dr Martin Duffy * Dr Omair Malik Oxford Dr Simon Raby *
West Yorkshire Dr D Odedra, St Jamess University Hospital (in succession to Dr J I L Jones) North Thames Central Dr M S George, Great Ormond Street Hospital (in succession to Dr D G Williams) North Thames East Dr F M L Dancey, Barts Health NHS Trust (in succession to Dr S Nikolic) (Acting Tutor) East of Scotland Dr U S Mok, Perth Royal Infirmary (in succession to Dr E D Ritchi) Heads of Schools There were no appointments for Council to note.
Dr Hugo Hunton Dr Colin Morton Dr Michael Clarke
Warwickshire Dr Rachel Lawton South East Scotland Dr Harinda Goonesekera Dr Anhish Satapathy Dr Marc Janssens Dr Matthew Royds North Scotland Dr Andrew Bayliss West Scotland Dr Katherine McDowall * Dr Nicholas Crutchley Dr Timothy Geary Dr Hari Kalagara Dr Vishal Uppal # Dr Andrew Harvey Dr Wesley Edwards Dr Satyawan Bhat Dr Simone Rowell Dr Tom Pettigrew Dr Philip Rae Dr Rachel Kearns Dr Shubhranshu Gupta Dr Pravin Dandegaonkar Dr Zoey Dempsey
West Yorkshire (Leeds/Bradford) Dr Sarah Sherliker Dr Anurag Vats South Yorkshire (Sheffield) Dr Olena Mateszko Dr Michael Moncreiff Dr Mark Smith * Dr Martin Diacon
*Joint CCTs in Anaesthetics and ICM #Trainees recommended for a CESR (CP)
The following appointments/ re-appointments were approved (re-appointments marked with an asterisk):
Regional Adviser
*Dr M A Staber, Inverclyde Royal Hospital Dr G A Gallagher, Glasgow Royal Infirmary (in succession to Dr S M Geddes)
Leicester and South Trent Dr N A Leslie, Leicester General Hospital (in succession to Dr C Leng)

College Tutors
Wessex Dr S A Townley, Royal Hampshire County Hospital (in succession to Dr R C Thomas) *Dr J Chambers, Dorset County Hospital *Dr I R Taylor, Queen Alexandra Hospital South West Peninsula *Dr E Hartsilver, Royal Devon and Exeter Hospital South Thames West *Dr S Dhileepan, University Hospital of Croydon
Heads of Schools
At a meeting of Council on Wednesday, 20 June 2012, Dr H M Jones and Dr D Nolan were elected Vice-Presidents of the College for the year 20122013.
Admission to the Board of Examiners
The following Fellows were admitted to the Board of Examiners: Dr Philip Bolton, Royal Hospital for Sick Children, Glasgow Dr John Greer, Manchester Royal Infirmary Dr Andrew Hall, Leicester General Hospital Dr Prashant Kakodkar, Northampton General Hospital Dr Jamie Macdonald, Aberdeen Royal Infirmary Dr Alan McGlennan, Royal Free Hospital, London Dr Cyprian Mendonca, University Hospital Coventry
Oxford Dr C M Skinner, Royal Berkshire Hospital (in succession to Dr A Gregg) Northern *Dr P Krishnan, Darlington Memorial Hospital *Dr J Morch-Siddall, Royal Victoria Hospital *Dr E M E Rodger, Sunderland Royal Hospital *Dr M K Varmar, Newcastle General Hospital East Yorkshire *Dr J D Pettit, Hull Royal Infirmary Northern Ireland *Dr G Turner, Belfast City Hospital North Thames Central Dr R K Verma, University College Hospital (in succession to Dr S Chieveley-Williams) Dr R Sethuraman, Princess Alexandra Hospital (in succession to Dr A K Krishnamurthy) *Dr L Zsisku, Colchester General Hospital Mersey Dr S H McClelland, University Hospital Aintree (in succession to Dr D A Raw) *Dr T G Mahalingham, The Walton Centre for Neurology and Neurosurgery West of Scotland *Dr K Morley, Victoria Infirmary
Dr Helen Drewery, Barts and the London School (in succession to Dr EMcAteer)
Dr Eluned Wright, Wales (in succession to Dr C Callander)
Council noted recommendations made to the GMC for approval, that CCTs/ CESR (CP)s 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.
Board of Examiners, June 2012
Anglia Dr Ashwani Gupta Dr Rachel Morris Dr Ram Adapa Dr Jonathon Francis Dr Anjalee Brahmbhatt Dr Ashish Shetty Dr Owain Evans Dr Srinivas Jakkula Dr Awanee Kumar North Central Dr Omaima Glesa
Barts and The London
Dr Edward Breeze Dr Nadir Sharawi
Mersey Dr Neil Sahgal North West Dr Judith Young Dr Alice Arch Dr Nitin Arora Dr Vimmi Oshan Dr Sarah Wood Dr Wendy Aubrey * Dr Kailash Bhatia Severn/Bristol Dr Sara-Catrin Cook * Dr Andrew Georgiou * Dr Robert Jackson * Dr Thomas Martin Tri-Services Dr Timothy Hooper * Wessex Dr Andrew Leitch * Wales Dr Alexandra Ford Scotland Dr Sharon Hilton-Christie * South East Scotland Dr Binu Arthur Dr Nicola Alexander West Scotland Dr Brenda Daly Dr Julia Robertson Dr Nithin Roy Dr Richard Appleton * Dr Philip Lucie Dr Shebeen Hamza West Yorkshire (Leeds/Bradford) Dr Meyyappan Nachiappan Dr Bobby Daniel Dr Matthew Devall Dr Sarah Marsh * Dr Sumit Gulati East Yorkshire (Hull/York) Dr Christopher Smith Dr Mariappan Sivakumar Dr Rohit Garkoti Dr Rajeev Jha * Dr Uthappa Belliappa
South Yorkshire (Sheffield) Dr Prashanth Sadhahalli Dr Allen Pinto Dr Juliette Fraser Dr Jabulani Moyo
* Joint CCTs in Anaesthetics and ICM
The following appointments/ re-appointments were approved (re-appointments marked with an asterisk):
Regional Advisers

At a meeting of Council on Wednesday, 18 July 2012 the following Fellows were admitted to the Board of Examiners: Dr Jo Budd, Worcestershire Royal Hospital Dr Dharshini Radhakrishnan, Whipps Cross University Hospital, London Dr Asius Rayen, City Hospital, Birmingham Dr Emily Simpson, Southend University Hospital Dr Carl Stevenson, Hereford Hospital NHS Trust Dr Christopher Taylor, National Hospital for N&N, London Dr Mritunjay Varma, Royal Victoria Infirmary, Newcastle Dr Simon Vaughan, Blackpool Foundation Hospital NHS Trust
Mersey Dr P M Mullen, Countess of Chester Hospital (in succession to Dr N M Robin) South East Scotland Dr J A Wilson, Royal Infirmary of Edinburgh (in succession to Dr Dr K G Stewart)
College Tutors
Anglia *Dr S G H Rao, Queen Elizabeth Hospital, Kings Lynn *Dr A A Klein, Papworth Hospital West Yorkshire Dr B S Ghoorun, Calderdale and Huddersfield NHSFT (in succession to Dr M R Beadle) North Thames West *Dr M A Stevens, Hillingdon Hospital North Thames Central *Dr M Sivarajaratnam, North Middlesex Hospital North Thames East Dr K R Reid, Broomfield Hospital (in succession to Dr H Jones) Mersey Dr K E J Palmer, Liverpool Heart and Chest Hospital (in succession to Dr O Al-Rawi) Dr A M Troy, Countess of Chester Hospital (in succession to Dr P M
Mullen)
Board of Examiners, July 2012
*Dr M Diwan, Royal Liverpool University Hospital
North West Dr A W Monks, Blackpool Victoria Hospital (in succession to Dr S T A Vaughan) Dr S Sharma, Lancashire Teaching Hospitals NHS Trust (in succession to Dr F Sloss) West of Scotland Dr L A McGarrity, Crosshouse Hospital (in succession to Dr C H Whymark from December 2012) KSS Dr M G Way, Royal Surrey County Hospital (in succession to Dr V Nataraj) Wales Dr S H Burnell, Ysbyty Gwynedd (in succession to Dr J D Walker)
Head of Schools
There were no appointments for Council to note. Council received and approved the list of Fellows by Examination from June 2012:
Abdelghani Mowafak Ahmad Hassan Aldamluji Niamat Ali Syed
Ibrahim
Shahood Fenwick Al-Shather Husham Sami Mahdi Anderson Fiona Jean Anderson Thomas Russell Aron Jonathan Paul Arora Sunil Artis Heidi Arunachalam Subha Aseri Salmin Saleh Babic Adele Bampoe Sohail Barker Ian Richard Bassett Michael Graham Bawdon Hannah Baxter Sebastian John Bedekar Amruta Vijay Bell Daniel James Bellchambers Emma Louise Biswas Suman Boney Oliver Caleb
Allen Jonathan
William Briggs Jessica Frances Bryden Emma Capek Adam Lee Chacko Cyril Jacob Chana Avninder Singh Chapman Eleanor Elizabeth Chillingworth Simon Cochrane Anthony David Lewis Collins Jonathan Peter William Conway Morris Andrew Roderick Mulutanyi Cooper Mariese Ginette Craven Thomas Henry John Crewdson Kate Czech Alexander James Dalton Andrew John Daniel Sonya Francesca De Silva Samanthi Sumudi Delroy-Buelles Ilana Josephine Devlin Aidan Patrick Dhanancheyan Ramkumar Dickson Anne-Louise Dixon Michael John Dixson Tobias Matthew Do Thy Bao Thuy Dodwell Richard Doris Thomas Edward Douglass Jamie Alistair Duffin-Jones Victoria Lee Ehsan Muhammad Faisal El-Boghdadly Kariem Elliott Kerry Ann Elizabeth Elsissi Amr Madih Rashwan Evetts George Edward Fairbairns Chloe Faulkner Thomas Evelyn Feizerfan Alireza Fenton-May Llewellyn Thomas Ferns Janis Mei Fitzpatrick Graeme Forshaw Natalie Chantelle Claire Frank Peter David Franklin Danielle Kerry Frost Louise Ann Gallagher Sarah Elizabeth Gemmell Lisa Karen Girotra Vandana Gordon Helen Louise Gould Carla Louise Govenden Daniel
Brand Jonathan
Grant Andrew Gray James Green Alice
Julius Rose Green Angela Jane Gresoiu Mihaela Gratiela Grimshaw Roger Nicholas
Gunasekera Dassanayake
Vihara
Henadirage Erangika Hague Ashley John Godwin Halligan Claire Louise Harris Benjamin Nicholas Harris James Colyn Harvey Laura Catherine Harvey Orla Hayward Elizabeth Hepburn David Paul Heyhoe Vivienne Hobbs Amy Louise Hodson Emma Jane Holder Andrew Denne Holley Amy Louise Honnesh Smitha Hormaeche Sebastian Estenio Horner Katherine Celia Hoy Christopher Walter Huntley Martin Paul Ibrahim Mark Jackson Laura Evelyn Jackson Robert Edward Jacobs Toby Jappie Roxaan Jayabalan Magesh Jeyanathan Jeyasangar Jeyarajah Jeyanjali Johnson Emily Elizabeth Johnson Mae Susan Johnstone Craig Robert Jones Rhidian Mark Jones Simon James Jones Sarah Elizabeth Meredith Juknevicius Gediminas Kannan Govindaswamy Arun Chakkravarthy Karmali Anil Karunasekara Niroshini Samantha
Kashimutt Narayanaswamy
Shivanandaswamy Kasi Vigneshwaran Khan Mehnaz King Adele Elizabeth Kingston Elizabeth Victoria
Gurunath Ladele Abiola Olaitan Lamb Conor Langdon Andrew Laver Kathryn Sarah Lear Emily Grace Leslie David Lester Vicky Louise Li Lawrence Lok man Liddle Samuel Gordon Loveridge Robert Peter Low Adam Edward Magham Srinivas Marimuthu Muthuraja Marshall Cara McCawley Declan Eamon McConville Barry Declan McCrossan Roopa McIntosh Euan James McKinlay James Greig Buchanan McKnight Angus Charles McMullan Victoria Mehta Madhur Mesbah Ahmed Mostafa Kamel Miller Becker Marni Milligan Pamela Joanne Sandra Mills Jane Catherine Miskovic Alice Mary Modha Jignasa Mohammed Rafi Kambasi Mohamed Meera Mon Wint Monks Stephanie Clare Monro Somerville Thalia Sheleigh Monteiro Roisin Shalini Moore Rachel Mordecai Luke Mullen Gemma Louise Mullington Christopher John Murray Helen Frances Naithilath Sriram Nandasena Deepani Priyanka Nandhabalan Prashanth Nathwani Rajen Vinodkumar Newell Christopher Paul Ng Yuet Meng Andy Nickell Katherine Jane Nour Sarah Mohamed Nowicka Aleksandra Magdalena Odor Peter Oldridge Jennifer Claire
Kulkarni Sudhindra
Oliver Charles
Matthew Olowosale Isiaka Adegoriola Onwochei Desire Nkechinye Nwamaka Ovenden Zoe Claire Paolineli Alexia Patel Pradip Patle Vidhi Rochin Pawson Helen Elizabeth Pearson Annabel Mary Elizabeth Pegg David Michael Pennington James Martin Perry Laura Petsas Anna Phylactides Leonidas Pidgeon Rebecca Katy Pierson Anna Louise Pietroni Oliver Thomas Pipe Georgina Elizabeth Margaret Quinn James Gerard Patrick Rahman Nipa Suehana Rahman Shaheedur Ramkumar Asha Ranade Gouri Ratnam Shobana Arathi Reed Isabelle Alice Riddell Joseph Roger Roberts Gareth Huw Meirion Rodda Bruce Rungta Aditya Salib Samuel Youssef Makram Sandu Ravinda Sans Solachi Emma Sathananthan Christine Sharmilla Sathyaseelan Ratnamma Vineetha Scott Alexander William Sellers Daniel Shah Nirav Shah Sonia Shammas Kathy Shaw Michael William Sherratt Kate Mary Simpson Anna Katherine Sogbodjor Lisa-Jean Amaki Stead Amy Charlotte Stephens Miriam Stewart Darryl George James Steynor Martin Peter Anthony Stoddart Richard Charles Stone Jeannine Odette Sturgess Holly Rebecca Surah Amit
Tay Anne
Tuan Leng
Thirugnanam Madan Tupprasoot Raksa Turner Mark
Aubrey Tweed Nathan John Uren Sophie Joanna Vallance Vanessa Jane Veitch Jonathan David
Vellalapalayam Sathyamoorthy
Mohan Kumar Vincent Laura Jane Walker Eleanor Mary Kate

Wanigasundara Mudiyanselage
Susantha Dammika Chandrasiri Ward Patrick Alexander Ward Jones Michael Peter Webster Jessica Ruth West David Thomas Edward Wild Carol Wild Kim James Williams Jessica Laura Rhonwen Wilson Anthony Joseph Wingate Robin Maurice Woodman Natasha Therese Wrigley Hannah Katharine Yatiwelle Niranjali Young Lorna Grace Young Louise Claire
FRCA Examinerships 20132014

The College invites applications for vacancies to the Board of Examiners in the Fellowship of the Royal College of Anaesthetists, from the academic year 20132014. Examiners will be recruited to the Primary examination in the first instance. The number of Examiners required will reflect the number of retirements from the current Board of Examiners. Applicants shall be assessed against the following person specification: aEssential 1 Shall normally be a Fellow by Examination, but a Fellow ad eundem, or a Fellow by election of the Royal College of Anaesthetists will also be considered. 2 Shall be in good standing with the College. 3 Applicants must be able to demonstrate that they have the competence, confidence and credibility to assess the next generation of consultants 4 Shall currently be active in clinical practice in the NHS or a comparable post. 5 On 1 September 2013 shall have the expectation of completing ten years as an examiner whilst filling a Specialty Doctor/SAS grade or Consultant appointment in the NHS, or comparable post. 6 Can demonstrate active involvement in the training and assessment of trainees. 7 Good written and verbal communication skills. 8 Ability to work as part of a team. 9 Documentary evidence of satisfactory completion of Equal Opportunities training in the last five years. 10 Able to commit to long-term and active involvement to examiner duties including the ability to devote a minimum of 15 days per academic year to the role. This includes both the delivery and development of the examinations. bDesirable 1 Shall demonstrate a special interest(s) directly relevant to the balance of expertise required in the Board of Examiners. 2 Within the past five years shall have visited a Primary or Final FRCA examination. Application forms and information for applicants can be downloaded from the examinations section of the College website (www.rcoa.ac.uk/ examinations). Or can be obtained from Miss Chloe Scrivener, Training and Examinations Directorate (020 7092 1525 or cscrivener@rcoa.ac.uk).
Appointment of Members, Associate Members and Associate Fellows

The College congratulates the following who have now been admitted accordingly: Associate Fellows June 2012 Dr Oghogho Nosakhare Jude Oronsaye Dr Babasey Oyedele Oyesola Dr Martin Urban Member June 2012 Dr James Lloyd Garwood Associate Members June 2012 Dr Dora Eszter Pappne Dr Paal Dr Tariq Rasheed Chaudhari Dr Kootharajan Kamaraj Dr Dominika Palcovicova
Deaths
It is with regret that the College records the deaths of those listed below. Dr A Kilpatrick, Lancashire Dr P Natarajan, London Dr F Rasool, Leicestershire Dr A J Richardson, Hampshire Dr Michael G Rolfe, Exeter Dr C F Scurr, London Dr B Wells, Northamptonshire Dr J White, Northamptonshire The College is able to receive brief obituaries (of no more than 500 words), with a photo if desired, of Fellows, Members or Trainees. These will be published on the College website (www.rcoa.ac.uk/obituaries). Please email your text and any photo to: website@rcoa.ac.uk.
The closing date for receipt of completed application forms is Monday, 15 October 2012.
FACULTY OF PAIN MEDICINE

of the Royal College of Anaesthetists
RCSEd launches Diploma in Retrieval and Transfer Medicine

The Royal College of Surgeons of Edinburgh is to become the first royal college in the UK to offer a diploma in retrieval and transfer medicine.

THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH
The first diet of the Postgraduate Diploma in Retrieval and Transfer Medicine (DRTM) is to take place over two days in September and is open to doctors, nurses and paramedics who are fully registered in the UK. Dr Stephen Hearns, Consultant in Emergency and Retrieval Medicine and project lead for the exam, said: We are very excited to be launching the new qualification, which has been developed by the RCSEds Faculty of Pre-Hospital Care and is set at a standard necessary to be a safe and effective member of a critical care retrieval team. With an increasing number of doctors, nurses and paramedics from a range of backgrounds undertaking high-risk critical care retrievals, there is a need to develop a benchmark assessment of skills, knowledge, attitudes and experience. Through its Faculty of Pre-Hospital Care, RCSEd has considerable experience in hosting the Diploma in Immediate Medical Care and so is ideally placed to host the UK Diploma in Retrieval and Transfer Medicine. The DRTM will focus on assessment of candidates experience of secondary and tertiary retrieval. Clinical knowledge and skills will also be assessed. When working in demanding, diverse and time-critical situations with a variety of unfamiliar team members, excellent communication and team resource management skills are vital for a retrieval practitioner. Assessment of these skills will also be part of the exam. Announcement of the new qualification comes as retrieval and transfer medicine is becoming increasingly important, both in civilian and military settings. The establishment of trauma care networks in England will lead to formalised primary retrieval teams for pre-hospital trauma management and will necessitate the introduction of rapidly responsive secondary retrieval systems to transfer patients from trauma units to trauma centres. Increasingly, secondary-to-tertiary care transfer and international repatriation of the critically ill between facilities is recognised as a high-risk activity but practice remains unregulated. The skill set required for all types of retrieval is very similar and many clinicians will undertake all categories of retrieval within single services. The first diet of the examination will take place on 67 September 2012. A detailed syllabus, candidate guide and a guide to educational resources are available at www.rcsed.ac.uk
Election to Faculty of Pain Medicine Board 2012

Details of elections to the Board of the Faculty of Pain Medicine of the Royal College of Anaesthetists are now available on the FPM website. Fellows and Members eligible to stand for election will be sent via the post a letter and Form of Notice of Intention to Stand and Form of Nomination on Friday, 24 August 2012. All papers will be sent to the address our Fellows and Members have registered with the College. Completed Notices of Intention to Stand must be received by the FPM Secretariat no later than 5.00 pm on Thursday, 20 September 2012. Any forms received after this date will not be accepted. The names of the candidates and whom they have been nominated by will be published on the FPM website on Friday, 28 September 2012. Ballot papers will be sent by post by Monday, 1 October 2012 to the address registered at the College. Ballot papers must be returned to the College by 5.00 pm on Thursday, 25 October 2012 and the election results will be declared as soon as possible after the election on Friday, 2 November 2012 via the Faculty and College websites and will be published in the College Bulletin in due course.
www.fpm.ac.uk
Appointment of Fellows to consultant and similar posts
Policy for badging, endorsement and support

The Association of Anaesthetists of Great Britain and Ireland and Royal College of Anaesthetists are often asked to participate in joint publications with other organisations, or to support publications produced by other organisations that have already been prepared. More recently, this has extended to include requests to develop or support electronic media, such as mobile applications (apps). The following taxonomy is proposed for both printed and electronic publications. This does not apply to links with commercial organisations or industry. Each Council reserves the right to apply this process flexibly (e.g. the WHO Safer Surgery Checklist).
The College congratulates the following Fellows on their consultant appointments: Dr K Bhatia, St Marys Hospital, Manchester Dr A E G Clyde, Crosshouse Hospital, Kilmarnock Dr S D Clements, Gwyneth Hospital, Bangor Dr C Farrell, South Eastern Trust, Northern Ireland Dr F Franco, Chase Farm and Barnet Hospitals NHS Trust Dr R Garkoti, Queen Elizabeth Hopsital, Gateshead Dr S Gohil, South Warwickshire NHS Foundation Trust Dr T R Geary, Crosshouse Hospital, Kilmarnock Dr A Gupta, Queen Elizabeth Hospital, Gateshead Dr S Hamza, Queen Elizabeth Hospital, Gateshead Dr R Hawes, Royal Victoria Infirmary, Newcastle-upon-Tyne Dr T Hooper, Frenchay Hospital, Bristol Dr M C Janssens, Royal Infirmary, Edinburgh Dr A Leitch, Royal London Hospital Dr S Liu, Guys and St Thomas Hospital NHS Trust Dr M B Muthuswamy, Royal Gwent Hospital, South Wales Dr S K Natarajan, Queen Elizabeth Hospital, Birmingham Dr S D Reddy, Princess of Wales Hospital, Bridgend Dr R Shanmugam, South Warwickshire NHS Foundation Trust Dr C Smith, Dr Grays Hospital, Elgin
Joint publications
The organisation was involved from the start of the project and was represented throughout the preparation of the publication. A Service Level Agreement will often have been in place. The organisation has had the chance to comment on the final document and make suggestions for change. The final draft has been approved by Council.* The final document or electronic media will bear the badge of the organisation.
Endorsement
The organisation is asked to review a finished document or electronic media from another source, without the opportunity to influence/change it. Notwithstanding this, the organisation believes the document is valuable and no significant reservations are expressed by Council.* The final document or electronic media will say it has been endorsed, but will not bear the badge of the organisation.
Support
The organisation is asked to review a finished document or electronic media from another source, without the opportunity to influence/change it. The organisation believes the general principles are of value, but may have reservations about the scope, relevance, or method. The final document or electronic media will say it is supported, but will not bear the badge of the organisation.
Not supported
The organisation is asked to review a finished document or electronic media, but does not agree with one or more of its scope, relevance, method or recommendations. The document or electronic media is not supported.
*The process for final approval may vary between AAGBI and RCoA.
THE EVENTS DEPARTMENT
events@rcoa.ac.uk
020 7092 1500
www.rcoa.ac.uk/events
PROGRAMME OF EVENTS 20122013

Scan the code to visit the online Events calendar
Advanced central venous access for anaesthetists

21 September 2012 (code: F35) RCoA, London Registration fee: 235 (175 for RCoA registered trainees and affiliates)
Ultrasound workshop
16 October 2012 (code: D09) RCoA, London Registration fee: 235 (175 for RCoA registered trainees and affiliates)
Current concepts symposium

12 November 2012 (code: B05) RCoA, London Registration fee: 435 (325 for RCoA registered trainees and affiliates)
CPD study days

1718 October 2012 (code: A99) RCoA, London Registration fee: 350 (265 for RCoA registered trainees and affiliates)
UK training in emergency airway management (TEAM) course

2728 September 2012 (code: D29) RCoA, London Registration fee: 415
Continuing professional development day (formerly known as CME day)

3 November 2012 (code: A76) RCoA, London Registration fee: 235 (175 for RCoA registered trainees and affiliates)
Children in the district hospital: essential care

1 October 2012 (code: D95) RCoA, London Registration fee: 195 (150 for RCoA registered trainees and affiliates)
Professional Standards Patient Safety Conference, Glasgow

23 October 2012 (code: C03) RCPS, Glasgow Registration fee: 205
**REDUCED RATE**
Current concepts symposium 2012/Continuing professional development day 2012 A reduced rate of 570 (430 for RCoA registered trainees and affiliates) is available for those attending both the Current concepts symposium and the Continuing professional development day. Places for the events will be offered on a first come, first served basis.
Leadership and management for anaesthetists: personal effectiveness

2 October 2012 (code: A71) RCoA, London Registration fee: 215
Faculty of Pain Medicine Study day: managing the pain service

24 October 2012 (code: A78) RCoA, London Registration fee: 160 (130 for RCoA registered trainees and affiliates)
CPD study day, Belfast

3 October 2012 (code: C97) The Waterfront, Belfast Registration fee: 195 (150 for RCoA registered trainees and affiliates)
UK training in emergency airway management (TEAM) course

2425 October 2012 (code: B75) Edinburgh Royal Infirmary Registration fee: 415
A career in anaesthesia
6 November 2012 (code: C49) RCoA, London Registration fee: 35
Airway workshop, Glasgow

10 October 2012 (code: C40) Teacher Building, Glasgow Registration fee: 255 (190 for RCoA registered trainees and affiliates)
Faculty of Pain Medicine/British Pain Society Developing a UK clinical research forum for pain
1 November 2012 RCoA, London Registration fee: 35
Anaesthetists as educators: an introduction

7 November 2012 (code: A12) RCoA, London Registration fee: 215 (160 for RCoA registered trainees and affiliates)
CPD Matrix codes
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2012

Joint Scottish winter meeting
A joint meeting with the Scottish Society of Anaesthetists 1516 November 2012 (code: C22) West Park Conference Centre, Dundee Registration fee: 270 (205 for RCoA registered trainees and affiliates)
events@rcoa.ac.uk
Airway workshop
020 7092 1500
12 December 2012 (code: C65) RCoA, London Registration fee: 255 (190 for RCoA registered trainees and affiliates)
ANNIVERSARY MEETING 2013

PERIOPERTIVE MEDICINE AND THE FUTURE ROLE OF THE ANAESTHETIST
Date and venue: 1314 March 2013 (code: A03) The Mermaid Conference and Events Centre, Puddle Dock, Blackfriars, London Registration fee: 435 (325 for registered trainees and affiliates) Approved for 10 CPD credits Event organisers: Dr R Moonesinghe and Dr A Cooper
Joint clinical directors day

16 November 2012 RCoA, London By invitation only
Leadership and management: working well in teams and making an impact

13 December 2012 (code: A93) RCoA, London Registration fee: 215
Anaesthetists as educators: teaching and training in the workplace

1920 November 2012 (code: C80) RCoA, London Registration fee: 415 (310 for RCoA registered trainees and affiliates)
Final FRCA course

2125 January 2013 (code: A82) RCoA, London Registration fee: 360
Airway workshop
31 January 2013 (code: B53) RCoA, London Registration fee: 255 (190 for RCoA registered trainees and affiliates)
Research methodology workshop

20 November 2012 (code: C43) RCoA, London Registration fee: 145
Faculty of Pain Medicine annual meeting: recent advances in pain medicine, neurobiology and management
22 November 2012 (code: B08) RCoA, London Registration fee: 180 (130 for RCoA registered trainees and affiliates)
Recent advances in anaesthesia, critical care and pain management

68 February 2013 (code: C68) RCoA, London Registration fee: 480
Topics featured:
Working with other specialities to improve perioperative outcomeelderly care, primary care and surgery. Hearts and minds delerium, exercise testing and echocardiography in perioperative practice. The perioperative pain physician long term outcome of perioperative pain, regional anaesthesia, multimodal analgesia to improve perioperative outcome. How anaesthetists work at home and abroad: US and European perspectives; a futuristic look at UK anaesthesia practice. Developing the evidence base: systematic reviews and randomised controlled trials in perioperative medicine. Health services research centre session: Emergency laparotomy;
CPD study day: paediatric anaesthesia

13 February 2013 (code: F38) RCoA, London Registration fee: 195 (150 for RCoA registered trainees and affiliates)
Primary FRCA masterclass

2629 November 2012 (code: D70) RCoA, London Registration fee: 285
Recent advances in anaesthesia and pain management, Bath

35 December 2012 (code: C11) The Assembly Rooms, Bath Registration fee: 480
Anaesthetists as educators: teaching and training in the workplace

2728 February 2013 (code: C84) RCoA, London Registration fee: 415 (310 for RCoA registered trainees and affiliates)
Anniversary meeting 2013

1314 March 2013 (code: A03) Mermaid Events and Conference Centre, Blackfriars, London Registration fee: 435 (325 for RCoA registered trainees and affiliates) CPD Matrix codes
outcome measures and risk prediction. See website for further details: www.rcoa.ac.uk/node/7131
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Anaesthesia and Critical Care

Date and venue: 12 November 2012 (code: B05) RCoA, London Registration fee: 435 (325 for RCoA registered trainees and affiliates) Approved for 10 CPD credits Event organiser: Dr S Patel
current concepts symposium 2012:
**reduced rate**
Current concepts symposium 2012/continuing professional development day 2012
A reduced rate of 570 (430 for RCoA registered trainees and affiliates) is available for those attending both the Current concepts symposium and the Continuing professional development day. Places for the events will be offered on a first come, first served basis.
Day 1
SESSION 1 Flying first class perioperative updates
SESSION 4 Intensive care medicine MACINTOSH LECTURE
Pain medicine breaking frontiers (3E00) Dr C Bantel, London
Preoperative check in (2A03) Dr G Ackland, London Intraoperative experience (2A04, 2A05, 2E01) Professor M Mythen, London Postoperative arrival lounge (2A05, 2E01) Dr R Pearse, London
Interactions of volatile anaesthetics and the hypoxic ventilatory response (1A01, 1A02) Professor J Pandit, Oxford
SESSION 7 Samuel thompson rowling oration
Recent advances in intensive care medicine (3C00) Professor M Singer, London ECMO here to stay (3C00) Dr S Finney, London
Generic influences on sepsis, susceptibility and outcome. Where next? Professor C Hinds, London
Presentation of College Prizes debate
SESSION 2 Hot Topics
Day 2
SESSION 5 Specialist Updates
Recent important papers (3J00) Professor R Sneyd, Plymouth Author misconduct (3J00) Dr S Yentis, London
Is it cool to be cool after brain injury? (2F01, 3F01) Professor M Smith, London Paediatric anaesthesia update (3000) Dr S Walker, London Obstetric anaesthesia update (3B00) Dr R Fernando, London
This house believes that roc rocks and sux sucks (3A01, 1B02) Chair: Dr D Levy, Nottingham Dr A McGlennan, London (pro sux) Dr A England, London (pro roc)
SESSION 3 Keep me updated, part 1
SESSION 8 Keep me updated, part 2
Chronic heart failure a perioperative challenge (1A02, 2A12) Dr N Fletcher, London Intraoperative ventilation ... best practice (1A01, 2A04) Dr P Macnaughton, Devon
Novel antiplatelet drugs and their anaesthetic implications (2A12) Dr B Hunt, London Update in nephrology (1A01) Speaker to be advised
SESSION 6 Regional anAesthesia and Pain medicine
Regional anaesthesia ... improving postoperative care (3A09) Dr C McCartney, Toronto, Canada Fascia iliaca block gold standard hip fracture analgesia? (2G02, 3A09) Dr D Kamming, London
CPD Matrix codes
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2012
events@rcoa.ac.uk
020 7092 1500
2012
events@rcoa.ac.uk
020 7092 1500
Continuing Professional Development (CPD) Day 2012

Date and venue: 3 November 2012 (code: A76) RCoA, London Registration fee: 235 (175 for RCoA registered trainees and affiliates) **REDUCED RATE AVAILABLE** (see page 61) Approved for 5 CPD credits Event organisers: Professor C Kumar and Dr R Verma
Introduction for all delegates Dr J-P van Besouw, President-elect, RCoA
Participants are able to choose a total of six lectures, one from each session
Session 1: IMPROVING OUTCOME
A Improving outcome after colorectal surgery Dr S Nimmo, Edinburgh

Session 2: CLINICAL PRACTICE
B Improving care of paediatric emergencies in the DGH Speaker to be advised
C Anaesthesia for non-cardiac surgery in patients with cardiac disease Professor P Fox, Oxford
A Anaesthesia for fractured neck of femur Speaker to be advised

Session 3: recent advances
B Monitoring depth of anaesthesia Professor R Sneyd, Plymouth
C Anaesthesia and burns Speaker to be advised
A Acute pain management and major lower limb surgery Dr B Fischer, Redditch
Session 4: critical incidents
B Advances in nerve location during regional anaesthesia Speaker to be advised
C Recent advances in continuous spinal anaesthesia Professor C Kumar, Singapore
A Accidental awareness Professor J Hardman, Nottingham

Session 5: Anaesthetic management
B Roles of RCoA in patients safety Speaker to be advised
C Root cause analysis of major incidents Speaker to be advised
A Management of head injury Speaker to be advised

Session 6
B Management of obese obstetric patient Speaker to be advised
C Anaesthesia for maxillofacial trauma and sepsis Dr J Curran, East Grinstead
A Regional anaesthesia: an update Dr W Harrop-Griffiths, London
B Pain management during labour Dr D Hill, Belfast
C Recent advances in videolaryngoscopy Professor A van Zundent, The Netherlands
3.35 pm Close of meeting
CPD Matrix codes
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CPD study day, Belfast

Date and venue: 3 October 2012 (code: C97) The Waterfront, Belfast Registration fee: 195 (150 for RCoA registered trainees and affiliates) Approved for 5 CPD credits Event organiser: Dr B Darling
children in the district hospital: Essential care

Date and venue: 1 October 2012 (code: D95) RCoA, London Registration fee: 195 (150 for registered trainees and affiliates) Approved for 5 CPD credits Event organiser: Dr M Tremlett
9.00 am Welcome by Dr J-P van Besouw, President-elect, RCoA Safe sedation (2A10) Professor R Sneyd, Plymouth My top ten controversies in anaesthesia Dr C Morris, Derby The i-Robot (2C07, 1G01) Dr C McAllister, County Armagh
9.00 am Registration Welcome Dr M Tremlett, Middlesbrough Consent. What to do when the child says no (2D02) Dr A McLeod, London Management of the anxious child Speaker to be advised Preoperative dilemmas (2D02) Dr N Barber, Cambridge Common paediatric syndromes (2D02) Dr J Purday, Exeter The child in the ED common problems (2D01) Dr F Davies, Leicester Workshops Preparing for transfer of the seriously ill child (2D07) Dr M Entwistle, Lancaster ENT anaesthesia in the district hospital (2D02) Dr M Tremlett, Middlesbrough
Five trainee presentations each lasting five minutes with two minutes discussion
Fluid optimisation of the high risk patient (2A05) Dr C Morris, Derby Performance by the aggregation of marginal gains in hip fracture management (3A08) Dr M McBrien, Belfast A rational approach to chest trauma (3A10) Dr J Hinds, Portadown Neuromuscular conditions and the anaesthetist (2A12) Dr J McConville, Ulster Update on the management of sepsis (2C03) Professor J Bion, Dean, Faculty of Intensive Care Medicine The Faculty of Intensive Care Medicine Professor J Bion, Dean, Faculty of Intensive Care Medicine 4.10 pm Close of meeting by Dr J-P van Besouw, President-elect, RCoA
Your Events, Your Ideas

We would welcome your suggestions for...
ORGANISERS SPEAKERS TOPICS LOCATIONS
Workshops:
1. Vascular access techniques (2D03) 2. Airway emergencies (2D02) 3. Regional Blocks
(2D02 and 2D05)
Peter Murphy Stephanie Bew Graham Bell
4.40 pm Close of meeting
events@rcoa.ac.uk
CPD Matrix codes
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2012
events@rcoa.ac.uk
020 7092 1500
2012
events@rcoa.ac.uk
020 7092 1500
JOINT WINTER SCIENTIFIC MEETING

Date and venue: 1516 November 2012 (code: C22) West Park Conference and Events Centre, Dundee Registration fee: 270 (205 for RCoA registered trainees and affiliates) Approved for 10 CPD credits Event organiser: Dr F Cameron
The Scottish Society of Anaesthetists and the Royal College of Anaesthetists
Are you interested in facilitating a Final FRCA Tutorial Group at the College?
Day 1
Day 2
9.30 am Registration and refreshments 10.25 am Welcome by Dr C Allison, President, Scottish Society of Anaesthetists Treatment options and outcomes in end stage kidney disease (2A12) Dr D Henderson, Dundee Interventions to reduce AKI. Local initiative (2C04) Dr F Millar, Dundee Transplantation opt in or out/nonheart beating/elective ventilation (2A07) Dr S Cole, Dundee Management of major blood loss in the military (2A01, 3A01) Dr S Bree, Plymouth Forensic anthropology cases from the real world (1H02, 3J00) Professor S Black, Dundee UGRA translational studies (2G03, 3A09) Dr G McLeod, Dundee Ultrasound technology: direct neural intervention and other more exciting topics (3A09) Professor S Cochran, Dundee A population in pain epidemiology of chronic pain (2E03, 3E00) Professor B Smith, Dundee
8.30 am Registration and refreshments 9.25 am Welcome by Dr J Colvin, Dundee IAA clinical academic track (3J00) Dr C Weir, Dundee Intolerance of opioid tolerance (1A02, 3E00) Dr F King, Dundee Neurosteroids: endogenous analgesics (1A02, 3E00) Dr S Humble, Dundee Developing translational research in the IAA (3J00) Professor T Hales, Dundee The GABA receptor a target for intravenous general anaesthetics and analgesics (1A02, 3J00) Professor J Lambert, Dundee Quality strategy (1I05, 3J00) Mr D Feeley, NHS Scotland Health improvement/patient safety (1I05, 3J00) Mr G Marr, NHS Tayside Quality improvement and SASM (1I01, 1I05) Dr A Longmate, National Patient Safety Lead, Scottish Government Sepsis collaboration (2C03, 3C00) Professor D Nathwani, Dundee The anaesthetic and A and E interface (2A07, 3A102) Dr B McGuire, Dundee Obstetric admissions to ICU (2B06, 3B00) Dr J Joss, Dundee 5.00 pm Close of meeting
The Gillies Lecture
From school to CCT Selecting and training doctors and specialists for the NHS (3J00) Professor R Sneyd, Plymouth
5.00 pm Close of meeting 7.00 pm Drinks reception at The Vedant Works
CPD Matrix codes
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RECENT ADVANCES IN ANAESTHESIA AND PAIN MANAGEMENT

Date and venue: 35 December 2012 (code: C11) The Assembly Rooms, Bath Registration fee: 480 Approved for 15 CPD credits Event organisers: Dr J Nolan, Dr T Cook and Dr F Kelly
Day 1

CPD study day

Date and venue: 10 December 2012 (code: C79) RCoA, London Registration fee: 195 (150 for RCoA registered trainees and affiliates) Approved for 5 CPD credits Event organisers: Dr B Patel and Dr C Frerk
Preoperative risk stratification (2A03) Dr M Thomas, Bristol Which cardiac output monitor to use perioperatively? (2A04) Dr M Cecconi, London Fluids: whats in and whats out (2A05) Professor M Mythen, London Airway management for major trauma (2A01, 2A02) Dr J Nolan, Bath Early management of severe head injuries: state of the art (2F01, 3F00) Dr A Eynon, Southampton Early management of major haemorrhage in trauma: state of the art (2A02, 3A10) Dr M Parr, Sydney, Australia High risk surgical patients: a quality improvement approach (2A12, 2C01) Dr C Peden, Bath Quality improvement indicators for anaesthetists: which, why and how? (3J00) Dr R Moonesinghe, London Measuring quality in a DGH (3J00) Dr T Cook, Bath Obesity it only gets bigger! (3I00) Dr M Thomas, Bristol
Enhanced recovery for colorectal surgery: evidence or anecdote? (3A03) Dr M Scott, Guildford Awareness: everyday challenge or rare mishap (2A04, 3J00) Dr J Pandit, Oxford
Perioperative arrhythmias and cardiac arrest (2A06) Dr J Nolan, Bath Anaphylaxis (1B01, 2A00) Dr N Harper, Manchester Obstetric emergencies (2B05) Dr D Gabbett, Gloucester
Ultrasound Revalidation Burns management Human factors in trauma teams Major haemorrhage ICU Airway
Day 2
Lessons from NCEPOD about anaesthesia for children (3D00) Dr K Wilkinson, Norwich Stabilising the critically ill child (2C01) Dr P Weir, Bristol Managing the anxious or unco-operative child (3D00) Dr R Beringer, Bristol Videolaryngoscopes: a critical analysis (2A01, 3A01) Dr M Kristensen, Denmark Implementation of NAP4 in a DGH (3A01) Dr F Kelly, Bath CICV be prepared (2A01, 3A01) Dr T Cook, Bath Beta blockers, statins and stents in peri-operative care: what to do in 2013? (1A02, 3G00) Professor P Fox, Oxford Statins: an update Dr D Brealy, London Drugs affecting clotting and regional anaesthesia (2G04, 3A09) Dr W Harrop-Griffiths, London
Day 3
CPD study day:
Ultrasound-directed nerve block (2G03, 3A09) Dr M Coupe, Bath Ultrasound-directed nerve block (2G03) Dr M Coupe and Dr M Thornton, Bath Is there anything new in PNB? (3A09) Dr J Barcroft, London Why the ageing population matters to all doctors (2A07) Dr D Oliver, Reading Perioperative care of the acute elderly laparotomy patient (3A03) Dr S Varley, Manchester Gabapentin, Pregabalin, Clonidine... what to do? (1A02, 3E00) Dr A Souter, Bath NSAIDS: who, when, what and why? (1A02, 3E00) Dr B Brock, Bristol Opioids: modern day issues and ideas on management (3E00) Dr C Stannard, Bristol
Paediatric ANAESTHESIA
Date and venue: 13 February 2013 (code: F38) RCoA, London Registration fee: 195 (150 for registered trainees and affiliates) Approved for 5 CPD credits Event organiser: Dr N Morton
PROGRAMME SUBJECT TO CHANGE
Care of the surgical neonate: lessons from NCEPOD 2012 How to implement guidelines for safe sedation of children A practical guide to TIVA in children Does awareness occur in children and should we measure depth of anaesthesia in children? A systematic approach to paediatric airway problems New devices for the normal and abnormal paediatric airway Pain management in children: what is the latest evidence? Improving pain at home after surgery in children
CPD Matrix codes
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2012
events@rcoa.ac.uk
020 7092 1500


events@rcoa.ac.uk 020 7092 1500 www.rcoa.ac.uk/events

Faculty of Pain Medicine Study Day Faculty of Pain Medicine/British Pain Society Faculty of Pain Medicine Annual Meeting
Managing the Pain Service

Date and venue: 24 October 2012 (code: A78) RCoA, London Registration fee: 160 (130 for RCoA registered trainees and affiliates) Approved for 5 CPD credits Event organiser: Dr S Gupta
Developing a UK Clinical Research Forum for Pain

Date and venue: 1 November 2012 RCoA, London Registration fee: 35 CPD credits applied for Event organiser: Professor D J Rowbotham
Session 1 Background

Recent Advances in Pain Medicine: Neurobiology and Management

Date and venue: 22 November 2012 (code: B08) RCoA, London Registration fee: 180 (130 for RCoA registered trainees and affiliates) Approved for 5 CPD credits Event organiser: Dr S Gupta
Pain specialists perspective of clinical commissioning groups and pain service what should we know and what can we do? GP perspective of clinical commissioning groups and pain service how can we collaborate? Difficult interactions with patients views from the defence organisation How to avoid complaints in clinical practice? The hidden costs of pain and the wider benefits of pain management PROMS The dilemma of diagnosis in pain clinic we have a responsibility to diagnose patients in the pain clinic
Introduction and aims of the day National research agenda: National Institute for Health Research Scottish Pain Research Community National Institute of Academic Anaesthesia (NIAA): contribution to pain research NIAA Health Service Research Centre Research and the British Pain Society What are Comprehensive Local Research Networks (CLRN) The CLRN anaesthetics, perioperative medicine and pain speciality group
Recent advances: neural inflammation and pain Imaging and nociception QST and central sensitization: what does it mean? Patrick Wall Lecture Trainee publication prize Recent developments: pain pathways Pain pathways musculoskeletal pain What is new or different since CG88? Recent advances: cancer pain management FPM developments
Session 2 Learning from others

Perioperative medicine Why get involved with commercial research? Discussion and introduction to group working
Session 3 Group working and next steps

Group working Feedback from group and next steps

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CPD Matrix codes
events@rcoa.ac.uk
020 7092 1500
APPLICATION FORM
Your details
Full name: College Reference Number (CRN): GMC Number: Address:
For CPD DAY please select your lecture choices:

Session 1 A Session 3 A Session 5 A B C B C B C Session 2 A Session 4 A Session 6 A B C B C B C
Postcode: Please ensure you complete your full postal address. Is this your main mailing address? Telephone: Email: Hospital:
Terms and conditions
Yes
No

Additional copies of this form can be downloaded from www.rcoa.ac.uk/event-application-form. Members of the Senior Fellows Club can attend events at half price. Bookings will be accepted on a first come, first served basis. Please be aware that programmes are subject to change and you should check the College website for regular updates. Our events are open to all grades of anaesthetists, unless specifically stated otherwise. When an event is full, this will be publicised on the website. To be placed on a waiting list, please contact the Events Department on 020 7092 1670. We will then contact you as soon as a place becomes available. All of our events have CPD approval of five credits for a full day and three credits for a half day, with the exception of FRCA revision courses, which carry a maximum of 15 credits, for non-trainees only. Lunch is included in the registration fee unless otherwise indicated. If you have any dietary requirements, please contact the Events Department (events@rcoa.ac.uk). Bookings will be accepted by post or fax only on a first come, first served basis. Bookings will not be accepted unless the appropriate fee and application are received together. Please note that places are not reserved until payment is received. Confirmation of a place will be sent to you within 14 days of payment being received. If you do not receive this, please contact the Events Department. Notice of cancellation must be given in writing to the Events Department or by email to: events@rcoa.ac.uk at least ten working days prior to the event to qualify for a refund. All refunds are made at the discretion of the College and are subject to the deduction of an administration fee. Delegates cancelling less than ten days before the event will not be entitled to a refund. The College will accept name changes for attendees; please inform the Events Department seven days prior to the event.
Event details
Date: Event Title: Registration fee: A reduced rate of 570 (430 for RCoA registered trainees and affiliates) has been introduced for those attending both the Continuing Professional Development Day and the Current Concepts Symposium. I would like to register for: Current Concepts Symposium: CPD Day 2012: Both events:

Code:
Booking and payment
Payment details (please use BLOCK CAPITALS)

A cheque is enclosed made payable to The Royal College of Anaesthetists. I wish to pay by the following debit/credit card:
Cancellation policy
Cardholders name: Signature: Card number: Valid from: Issue number: Expiry date: Security code:
Please complete this form in BLOCK CAPITALS and return to the Finance Department at the RCoA or via fax (020 7092 1733).
Follow @rcoa_events
12th Annual Education Day Paediatric Anaesthesia

TRUTH AND MYTH IN PAEDIATRIC ANAESTHESIA
Surgical Safety Week

2428 September 2012
Patient Safety First is holding a Surgical Safety Week during the week commencing 24 September. The Safe Anaesthesia Liaison Group (SALG) are encouraging all anaesthesia departments to hold an M&M meeting this week and a new toolkit for M&M meetings will be accessible on the College website. A series of webinars and other activities will also be taking place. Details are available on the RCoA and Patient Safety First websites. www.rcoa.ac.uk/salg www.patientsafetyfirst.nhs.uk
Surgical Safety Week is a collaboration between Patient Safety First and the Clinical board for Surgical Safety (CBSS). Both CBSS and SALG include representatives from the RCoA and AAGBI.
Tuesday, 13 November 2012 St Bartholomews Hospital, London EC1

A day of lectures, short presentations and debates for anaesthetists and allied professionals with an interest in paediatric anaesthesia and critical care. Awarded 5 CPD credits by the RCoA Fee: 120 (medical); 20 (non-medical); including lunch and refreshments
Programme

Drug trials and publications FEAST trial IV fluids in paediatric resuscitation Peri-operative anxiety PICU the evidence base Desert island papers Chronic pain in children Guidelines friend or foe? Professor Kath Maitland, Professor of Tropical Paediatric Infectious Disease, Imperial College, London Dr Mark Schreiner, Head of IRB and Associate Professor of Pediatrics, Anesthesiology and Critical Care at the Childrens Hospital of Philadelphia Professor Zeev Kain, Professor of Anesthesiology, University of California, Irvine Dr Kathy Wilkinson, Consultant Paediatric Anaesthetist, Norwich, President APA Dr Suellen Walker, Clinical Senior Lecturer in Paeditaric Anaesthesia and Pain Medicine, UCL Institute of Child Health Dr Jane Lockie, Consultant Paediatric Anaesthetist, UCLH Dr David Inwald, Consultant Paediatric Intensivist, Imperial Health, London Dr Anil Visram, Consultant Paediatric Anaesthetist, Barts and the London Childrens Hospital Dr Lionel Davis, Consultant Paediatric Anaesthetist, Barts and the London Childrens Hospital Dr Barry Clifton, Consultant Paediatric Anaesthetist, Barts and the London Childrens Hospital
Faculty
Application forms and further details from: Salma Akhtar, Course Administrator Paediatric Anaesthetic Education Day, Medical and Dental Education Department, Postgraduate Centre, 48 Ashfield Street, Royal London Hospital, London E1 2AJ tel 020 7377 7760 fax 020 7377 7187 salma.akhtar@bartshealth.nhs.uk
BULLETIN ADVERTISING
The RCoA Bulletin is published bi-monthly and distributed to over 15,000 anaesthetists worldwide, the vast majority being in the UK. Being so widely distributed, it is obviously seen by many other professionals who work alongside anaesthetists. 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. Advertisements must fit with the aims and aspirations of the RCoA, be related to anaesthesia, critical care and pain medicine and will be accepted at the discretion of the Editor or Editorial Board. Non-commercial advertising rates are listed below. Please see the Bulletin pages of the website for specific commercial rates, deadlines and further information on discounts available.
Quarter page (85 mm by 124 mm) 265 +VAT Half page (85 mm by 252 mm) 525 +VAT Full page (175 mm by 252 mm) 840 +VAT
www.rcoa.ac.uk/bulletin
Primary OSCE/Viva crammer

1214 September 2012 1214 December 2012 1719 April 2013
Fee: 395.00 for full course
250.00 for VIVA only 200.00 for OSCE only
Final FRCA crammer courses

56 November 2012 (Viva) 2830 January 2013 (MCQ/SAQ) 1314 May 2013 (Viva)
Fee: 250.00 VIVA
300.00 MCQ/SAQ Programme includes full mock MCQ and SAQ exam plus tutorials. Viva course includes intense and realistic formal Viva practice under exam conditions with Consultant mock examiners. Candidates receive personalised one-to-one feedback on techniques. For an application form, please contact: The Department of Academic Anaesthesia, Cheriton House, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW
Intense three-day course for Primary examination. Candidates will attend nine viva and 32 OSCE stations. Intense coaching in OSCE and Viva technique via interactive tutorials. For an application form, please contact: The Department of Academic Anaesthesia, Cheriton House, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW
claire.thornley@stees.nhs.uk
01642 854601
claire.thornley@stees.nhs.uk
01642 854601
PLACES ARE LIMITED
PLACES ARE LIMITED
The Primary FRCA and FCAI Examinations

Primary Selective Course Primary MCQ/SBA Courses Primary OSCE/Orals Course Primary Viva Weekend Course Primary OSCE Weekend Course 5 days 6 days 7 days 21/2 days 21/2 days Two per year Three per year Three per year Three per year Three per year
The Final FRCA and FCAI Examinations

Final (Booker) Revision Course Final MCQ/SBA Course Final SAQ Weekend Course Final Viva Revision Course Final Viva Weekend Course 5 days 6 days 21/2 days 6 days 21/2 days Two per year Two per year Six per year Two per year Two per year
Plus
The Final SAQ and E&SAQ Writers Club Creditable first time success rate Single membership fee remains valid until success Free admission to SAQ Weekend Courses.
NOTE
Trainees planning to sit the Final Examination in MARCH or SEPTEMBER 2013 Are seriously advised to join The Writers Club sooner rather than later for the greater benefit at least six months ahead of the examination. For details, applications, protocols and procedures: www.msoa.org.uk
Contact information
Chief Executive Deputy Chief Executive and Director of Professional Standards Director of Education Director of Training and Examinations Kevin Storey Charlie McLaughlan Sharon Drake Richard Bryant 020 7092 1612 020 7092 1613 020 7092 1613 020 7092 1613
Chief Executives Office

Facilities Manager, Martin Bennetts Finance Manager, Roger Smith IT Manager, Richard Cooke Membership and subscriptions facilities@rcoa.ac.uk finance@rcoa.ac.uk support@rcoa.ac.uk subs@rcoa.ac.uk 020 7092 1510 020 7092 1585 020 7092 1712 020 7092 1701/1702/1703
Education Directorate
Continuing Professional Development e-Learning Anaesthesia Faculties Manager, Daniel Waeland (FPM & FICM) Human Resources Manager, Isma Adams Meetings and Events National Institute of Academic Anaesthesia cpd@rcoa.ac.uk e-LA@rcoa.ac.uk fpm@rcoa.ac.uk hr@rcoa.ac.uk events@rcoa.ac.uk info@niaa.org.uk 020 7092 1729 020 7092 1542 020 7092 1727 020 7092 1542 020 7092 1670 020 7092 1680
Professional Standards Directorate

Professional Standards Manager, Bob Williams Revalidation Project Manager, Don Liu Advisory Appointments Committees Anaesthesia Review Teams Bulletin Media Advisor Patient Safety Presidential Secretariat Website standards@rcoa.ac.uk revalidation@rcoa.ac.uk aac@rcoa.ac.uk art@rcoa.ac.uk 020 7092 1694 020 7092 1699 020 7092 1571 020 7092 1572
bulletin@rcoa.ac.uk 020 7092 1693 simonandrewscott@hotmail.co.uk 07730 989692 salg@rcoa.ac.uk president@rcoa.ac.uk website@rcoa.ac.uk 020 7092 1574 020 7092 1600 020 7092 1692/1693
Training and Examinations Directorate

Examinations Manager, Graham Clissett Training Manager, Claudia Moran e-Portfolio Project Manager, Lorna Kennedy Equivalence Intensive care medicine (adult and paediatric) International Programme Regional Adviser and College Tutor appointments SAS and Specialty Doctors Quality Assurance cgc@rcoa.ac.uk exams@rcoa.ac.uk training@rcoa.ac.uk e-portfolio@rcoa.ac.uk equivalence@rcoa.ac.uk ficm@rcoa.ac.uk ip@rcoa.ac.uk 020 7092 1525/1526 020 7092 1552/1553/1554 020 7092 1551 020 7092 1651/1653 020 7092 1651 020 7092 1552 020 7092 1573 020 7092 1552 020 7092 1652
The Royal College of Anaesthetists

Churchill House 35 Red Lion Square London WC1R 4SG 020 7092 1500 www.rcoa.ac.uk info@rcoa.ac.uk

CSQ Bulletin75

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The Royal College of Anaesthetists

Issue 75 | September 2012

Page 2 | Bulletin 75 | September 2012

of The Royal College of Anaesthetists

Design and layout by The Royal College of Anaesthetists

Views & opinions

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

Page 3 | Bulletin 75 | September 2012

From the Editor

Dr Anne Thornberry, Editor

Page 4 | Bulletin 75 | September 2012

The Presidents Statement

The times they are a-changin

Page 5 | Bulletin 75 | September 2012

The Presidents Statement

Final FRCA course

National Emergency Laparotomy Audit (NELA)

Page 6 | Bulletin 75 | September 2012

Setting standards: the RCoA accreditation programme

Getting them on our side

Page 7 | Bulletin 75 | September 2012

Where are we now?

Page 8 | Bulletin 75 | September 2012

Page 9 | Bulletin 75 | September 2012

Page 10 | Bulletin 75 | September 2012

SAS and Specialty Doctors | CGC@rcoa.ac.uk | www.rcoa.ac.uk/sas

SAS Bulletin Articles Needed!

Recognition of career grade doctors as trainers

Proposed criteria for trainers/ assessors

Page 11 | Bulletin 75 | September 2012

SAS and Specialty Doctors | CGC@rcoa.ac.uk | www.rcoa.ac.uk/sas

Page 12 | Bulletin 75 | September 2012

Revalidation for anaesthetists | revalidation@rcoa.ac.uk | www.rcoa.ac.uk/revalidation

The role of reflection in CPD and revalidation

How much and at what level?

Academy reflective template

Observation is not reflection

Page 13 | Bulletin 75 | September 2012

Revalidation for anaesthetists | revalidation@rcoa.ac.uk | www.rcoa.ac.uk/revalidation

Description of activity or event What have you learned?

How has this influenced your practice?

Looking forward, what are you next steps?

Page 14 | Bulletin 75 | September 2012

NIAA Health Services Research Centre | hsrc@rcoa.ac.uk | www.niaa-hsrc.org.uk

National Emergency Laparotomy Audit contract awarded

Page 15 | Bulletin 75 | September 2012

The Faculty of Pain Medicine | fpm@rcoa.ac.uk | www.fpm.ac.uk

News from the FPM

Page 16 | Bulletin 75 | September 2012

The Faculty of Intensive Care Medicine | ficm@rcoa.ac.uk | www.ficm.ac.uk

Page 17 | Bulletin 75 | September 2012

Patient Perspective | plg@rcoa.ac.uk | www.rcoa.ac.uk/plg

My first year as Chairman

Ignorance and choice

When we are old

Page 18 | Bulletin 75 | September 2012

Patient Perspective | plg@rcoa.ac.uk | www.rcoa.ac.uk/plg

Working with Council

Page 19 | Bulletin 75 | September 2012

Annual Review of Competence Progression the ARCP

Making them successful

Basic principles and rules

Page 20 | Bulletin 75 | September 2012