BMA in the News 2019-03-12

As supplied by BMA Comms

BMA to support doctors in legal action over pensions

The BMA yesterday wrote to the Health and Social Care Secretary and his counterparts in Scotland and Northern Ireland to inform them that the association intends to support members in suing  their respective governments after doctors were forced to join a pension scheme that the BMA believes will result in huge financial losses when they retire. The action, by the BMA’s legal team, comes in the wake of the Court of Appeal ruling last year which stated that the Government discriminated against judges and firefighters on the grounds of age, race and equal pay in relation to changes to their pension schemes. Although the schemes are different, the BMA believes the underlying legal principles are essentially the same. The outcome of the legal challenges to the judges and firefighters ruling could influence any legal challenge brought on behalf of younger doctors to the legality of the 2015 NHS Pension Scheme.

Dr Trevor Pickersgill, interim BMA treasurer, said: “In 2015, the NHS closed two Sections of the NHS Pension Scheme, moving many NHS staff onto a newer 2015 scheme with less valuable retirement benefits. However, it also allowed some older doctors to stay on the previous schemes until they either retired or they moved to the new scheme at the end of a fixed transition period. The BMA alleges that the failure to allow younger doctors to benefit from these transitions constitutes unlawful age discrimination.”

The story was covered in the Financial Times, FT Adviser, Mail Online, the Daily Mirror, Pensions Expert, Law 360, AOL, Yahoo News, Pulse and GP Online.

Michael Wilks obituary

An obituary of former BMA medical ethics committee chair Dr Michael Wilks, written by his friend Professor Andrew Finlay, has been published in the Guardian. Dr Wilks, who died of prostate cancer aged 69 was on the BMA forensic medicine committee from 1993 to 2014 and was chair of that committee from 2010. He was also on the medical ethics committee from 1993to 2008, and was chair from 1997 to 2006. Professor Finlay writes: “His professional achievements were underpinned by his courage and honesty in confronting his problems with alcohol and he made an outstanding contribution to changing attitudes towards addiction.”

Brexit ‘harmful to health’

German newspaper Arzte Zeitung reports in its Der Brexit Blog on contingency planning in healthcare as Parliament prepares for tonight’s vote. It references a [translated] quote from a BMA spokesperson, who said: “Brexit is definitely harmful to health care in the UK and a chaotic Brexit would be the worst.” The blog reports that the BMA has appealed to politicians to exercise reason and to reject at least a chaotic Brexit.

GP appointment data

There was further regional coverage of recent GP appointment data released by NHS digital, which shows that January 2019 saw an increase of more than one million face-to-face appointments with GPs in England compared to the year before. It also found that the percentage of people attending an appointment more than 28 days after booking rose by 1.4 percentage points from 2.3 per cent to 3.7 per cent over the same time period. Dr Richard Vautrey, BMA GP committee chair, was quoted in the Birmingham Mail. He said: “While we know that many patients are frustrated at having to wait too long to be seen, this data shows that the largest proportion of appointments continue to be made and attended on the same day, while the majority are seen within a week of booking. And though these figures show some patients being seen more than 28 days after making their appointment, it is important to note that many of these will be appropriately booking ahead for return visits or regular check-ups.”

Other news

NHS England yesterday launched plans to drop the four-hour A&E target, as well as changes in targets for cancer, mental health and planned operations. BBC News, The Independent, FT and Metro all report on the plans. The proposals, which will be piloted before an intended introduction In 2020, include a target of one-hour treatment for patients arriving with heart attacks, acute asthma, sepsis and strokes. You can read the BMA’s response to the proposals here.

The Daily Telegraph reported on claims that Google plans to analyse the over one billion health questions internet users type into its search engine. Against a background of negative publicity over Google disseminating erroneous health advice and ‘fake news’, in the same piece the Royal College of General Practitioners advised people to use reputable, unbiased UK websites, such as NHS.uk, to access safe and reliable health advice.

News Items from BMA Comms 2019-03-07

News Items supplied by BMA Comms

North Middlesex Hospital Trust

Has appointed Peter Carter, ex RCN Chief Executive, as the new interim Chair, replacing Dusty Amroliwala. Since stepping down from the RCN in 2015, Mr Carter has served as interim chair at Medway Foundation Trust and East Kent Hospitals University Foundation Trust. Before joining the RCN he was chief executive of Central and North West London Mental Health Trust. Mr Carter’s appointment is the second interim chair appointment made by the joint NHS Improvement and NHS England London regional team since new director Sir David Sloman took up his post. Sir David’s office last week announced the appointment of Guy’s and St Thomas’ Foundation Trust chair Sir Hugh Taylor as interim chair of neighbour King’s College Hospital Foundation Trust.

GP@Hand

Hammersmith and Fulham Clinical Commissioning Group, which hosts GP at Hand, received confirmation from NHS England London that a solution had been found to previous concerns about GP at Hand integrating with local screening and immunisation services. The decision clears the way for the digital practice to expand outside of London for the first time and potentially makes it easier to set up in other cities in the future. GP at Hand is a single practice based in Fulham, but is effectively run by digital primary care company Babylon Health. It is an NHS GP practice which uses video consultation via the patient’s smartphone and heavy advertising to attract new patients from outside its immediate practice catchment. Since November 2017, the patient list has grown from about 4,000 to more than 44,000, most of them from outside Hammersmith and Fulham. But its rise has faced strong opposition from GPs, who have accused it of cherry-picking healthy patients and destabilising the NHS primary care model. Its expansion has caused severe financial problems for the CCG and been subject to regulatory intervention. The expansion into Birmingham will mean, for the first time, a London-based practice will be registering patients remotely in another city. GP at Hand will have a physical clinic in Birmingham but most of the care will be delivered digitally.

 

Pathology services

Last September, the South East London pathology programme board launched a procurement process to provide pathology services up to eight trusts; Guy’s and St Thomas’ FT; King’s College Hospital FT; East Sussex Healthcare Trust; Epsom and St Helier University Hospitals Trust; Oxleas FT; South West London and St George’s Mental Health Trust; South London and Maudsley FT; and Royal Brompton and Harefield FT. The 10-year contract is worth up to £2.2bn. It was tendered amid a push from NHS Improvement for all trusts to form networks by 2021. The winning bidder will start providing its service from September 2020, when Viapath’s contract expires. It was reported by HSJ that it was understood there are three shortlisted bids:

  • Health Services Laboratories (a joint venture between the Royal Free London Foundation Trust, University College London Hospitals FT, and The Doctors Laboratory);
  • Synlab Group, through one of its UK subsidiaries (an international medical diagnostics provider with laboratory services for human and veterinary medicine); and
  • Incumbent provider Viapath (a joint venture between Guy’s and St Thomas’ FT, King’s College Hospital FT, and Serco).

 

Royal Free Trust

Caroline Clarke has stepped into the Chief Executive role, after Sir David Sloman became the new joint new joint NHS England and Improvement London regional director. Ms Clarke, whose new role begins with immediate effect, was deputy chief executive at the large teaching trust for the past seven years. For most of that time, she was also chief finance officer. The Royal Free London group is one of four hospital group vanguards in England, new models of acute provision where several hospitals combine to share services. It is made up of Barnet Hospital, Chase Farm Hospital and the Royal Free Hospital and has a turnover of over £1bn.

 

A & E Dept performance

Official accident and emergency performance data found 17 trusts reported a deterioration of 10 percentage points or more on their type 1 four-hour performance between January 2017 and January 2019. In the Capital, Croydon Health Services Trust’s 29 percentage point slide was the largest drop. The trust reported 49.1 per cent type 1 performance in January – the worst in the NHS, and 27 points behind the 76.1 per cent average; Barking, Havering and Redbridge University Hospitals Trust was also a poor performer. Two Trusts in the capital were reported to have made improvements; London North West and Chelsea & Westminster (both in NW London area).

As ever A&E performance is a barometer for the health and care system as a whole and these figures highlight the need for sufficient investment in services which keep people well in the community and prevent them presenting at A&E in crisis or once their conditions have deteriorated, as well as in accident and emergency care.

 

BMA 2019 Consultants Conference

The Annual Consultants Conference took place at BMA House on Wednesday 27th February after the usual introduction and preliminaries by Chair of conference (Steve Austin)  Dr Gary Wannan acting Consultants Committee Chair gave a speech. The whole speech can be found at

Acting Chair of UKCC Speach

Some points he made

  • In a recent BMA survey 90% of doctors believe the system prevents giving safe patient care.
  • Why do consultants deserve just an 0.75% uplift offer by DHSC, lowest in the NHS = £6 per week after tax.
  • There has been 24% reduction in take home pay in last 10 years
  • Consultants work harder and work more with up to 5 hrs a week of unpaid work
  • There is only so much one can be put up with or leave the service
  • Simon Stevens stated a&e targets are to be abandoned it is easy to let patient care suffer
  • Politicians are giving up on patients but the consultants are not.
  • Consultants are still there under the pressure but without the leadership the NHS will fail
  • There are now even more boxes to tick.
  • Trainees expected to spend hours with patient not minutes.
  • The value of consultants bring is being overlooked
  • Consultants are receiving unexpected of tax bills for covering colleague’s absence
  • 60 % of consultant want to retire before 60 – main cause life time allowance
  • More early retirement and reduction in work by doctor is expected
  • Letter to the chancellor on these issues has had no response.
  • The government does not appear to care about the consultants.

 

The following motions where debated and passed

Healthcare policy and commissioning

5 H1053 Motion BY SCOTTISH consultants committee This conference calls on the Scottish Government to ensure that the implementation of its new healthcare waiting times improvement plan does not distort clinical priorities or disadvantage patients awaiting review appointments.

6 H1062 Motion BY NORTHERN IRELAND consultants committee That this conference calls on the Secretary of State for Northern Ireland, Karen Bradley, in the absence of a Health Minister, to prioritise health and particularly transformation and take the key decisions needed to progress the actions set out in Health and Wellbeing 2026.

7 H1035 Motion BY NORTH WEST RCC That this conference supports many of the ambitions contained within the NHS Long Term Plan and asks the BMA to continue to press for an adequate funding settlement without which those ambitions will remain largely unachievable

Workforce

11 H1013 Motion BY LONDON SOUTH RCC. This meeting calls upon BMA council to lobby that, for the purposes of immigration, all doctors should be placed on the equivalent of the ‘Shortage Occupations List’ in the event of the UK’s leaving the European Union.

12 H1040 Motion BY NORTH WEST RCC. That this conference believes that the health surcharge imposed on doctors arriving from non-EU countries is having a deleterious effect on recruitment. It asks the BMA to find a solution by working with NHS Employers and other stakeholders, that will remove this burden from staff who are urgently needed to address the crisis in medical recruitment and retention.

13 H1041 Motion BY NORTH WEST RCC. That this conference urges the BMA to demand that the Departments of Health and the GMC make a more concerted effort to retain senior doctors in the NHS.

16 H1007 Motion BY NORTH WEST LONDON RCC. That this conference believes that the government’s stated intention of training more doctors to be ‘generalists’ and fewer to be ‘specialists’ is contrary to the direction of travel in a world where knowledge is increasing exponentially. A combination of adequately resourced primary care and systems that support collaboration between specialists within secondary care will provide the best outcomes for patients.

 Wellbeing

17 H1038 Motion BY NORTH WEST RCC. That this conference notes that there is a surfeit of evidence that the mental health and well-being of doctors is being undermined by the pressures of professional practice. It welcomes the evidence that the Association and others have already gathered, but now insists that this is translated into a systematic, tangible plan of action, by taking a lead on the coordinated engagement of all relevant stakeholders.

18 H1043  P Motion from specialty lead for emergency medicine:

NHS consultants are working harder than ever before to deliver safe and high-quality emergency care in a system that is being pushed to breaking point by a combination of rising demand and inadequate funding from the government. This conference:

  1. recognizes that this is unsustainable and that ‘burnout’ and ill-health are inevitable consequences of working under this pressure
  2. calls on the BMA to demand that the government take seriously the need for future consultant working patterns to be sustainable and contain safeguards to ensure the wellbeing of consultants
  3. insists that any new consultant contract must contain safeguards that adequately protect all consultants from working excessive antisocial hours
  4. insists that any new consultant contract ensures that those consultants who work the most antisocial hours receive enhanced time in which to rest and recuperate.

 

20 H1001 Motion BY WELSH consultants committee This conference expresses concern that insufficient progress appears to have been made in enhancing the provision of occupational health services for NHS Wales staff since the publication in 2012 of the recommendations of a review undertaken by Professor Sir Mansel Aylward on behalf of the Welsh Government, and in particular expresses concern at the on-going lack of occupational health consultants in Wales.

This conference therefore calls on the Welsh Government, Welsh NHS employers and Health Education and Improvement Wales (HEIW) to look at undertaking specific initiatives to tackle such recruitment difficulties and to increase the number of training places in Wales for occupational health consultants.

Mental Health

21 1065 Motion BY AGENDA COMMITTEE (OXFORD RCC PROPOSING) That this conference calls upon the Department of Health and Social Care to commit to:

  1. increasing mental health funding incrementally over the period of the 10 Year Plan to reach a minimum of 25% of overall budget in line with mental health treatment need and activity levels.
  2. parity of resource, access, and outcome for mental and physical health services rather than esteem.
  • Requiring those commissioning local services to allocate adequate, ring fenced funds for mental health promotion and prevention in line with the 10 year plan

25 H1060 Motion BY NORTHERN IRELAND consultants committee That this conference recognises the unacceptably high suicide rate in Northern Ireland, with more people having died by suicide since the Good Friday Agreement 1998 than the total number of lives lost due to the Troubles and calls on the government to fund mental health services and other stakeholders adequately, in order to address this.

Quality and patient safety

27 H1002 Motion BY WELSH consultants committee This conference notes:

  1. the introduction in 2016 of Freedom to Speak Up Guardians within the NHS in England following a review undertaken in 2015 by Sir Robert Francis which advised on the need to create an appropriate culture so that raising concerns becomes part of normal routine business and that staff feel able to do so in a culture that is free from bullying and other oppressive behaviours.
  2. that the role of Freedom to Speak Guardian has not so far been introduced within the NHS in Wales.

Recognising the importance of facilitating NHS staff to feel safe in raising concerns, and to have greater confidence that their concerns will be listened to and acted upon, this conference calls on the Welsh Government and Welsh NHS employers to introduce a similar role of Freedom to Speak Guardian within the NHS in Wales.

 Regulation

29 H1050 Motion BY SCOTTISH consultants committee This conference recognises that the revalidation burden remains significant and there is a lack of evidence to support its efficacy and calls for the revalidation cycle to be extended to 10 years.

 Education and training

31 H1046 Motion BY LONDON NORTH EAST RCC That this conference Motion from Northeast London RCC:

The vast majority of post mortems (PMs) are performed in England and Wales under the jurisdiction of Her Majesty’s Coroner. The Coroner PM examination and the storage of tissue removed during PM examination do not require consent from the family of the deceased. However, once the coroner’s authority has ended, consent is required from the deceased relatives to retain the slides and tissue. In practice this results in most histology slides and paraffin blocks of tissue taken at Coroners PMs are disposed of and are lost for teaching, educational and audit purposes. This conference

  1. Believes this a loss to medical education and maintaining good medical practice.
  2. Asks the BMA to discuss with the Royal Colleges, Coroners Society and other stakeholders the need to change the rules.
  3. Asks the BMA to lobby for a change in the Human Tissue Act and Coroner Rules in England and Wales to facilitate retention of the histology slides and paraffin blocks taken at Coroner’s autopsy for teaching, education and audit without the need of deceased relatives’ consent.

This motion was proposed by me. My 3 minute speech is given below

“ Chair Conference. Daniel Defoe said there is nothing more certain than death and taxes. And if the government increases probate fees soon and adds a death tax of £100 in a couple of years expect more taxation after death.Conference each year more than ½ million deaths occur in England and Wales .  40% of the deceased are referred to Her Majesty’s Coroner  and about 90,000 have a coroners post mortem.  The implementation of the Medical Examiner of Cause of Death is likely to have only a small effect on these numbers though. We all know the Human Tissue Act was passed as a response to the organ retention issues particularly of paediatric cases that came to light in the 1990s . In life patients are given the opportunity to refuse permission for tissue to be taken from them during surgery or the tissue to be used for research purposes. The Act allows material taken from the living for any reason to be stored and used without consent for the clinical audit, workforce development, performance assessment and public health monitoring. This persists after the patient has died. The Human Tissue Act does not cover the taking of and reporting on tissue under the jurisdiction of the coroner but does require relative consent for retention after the jurisdiction of the coroner has ceased. This results in most histology slides and paraffin blocks of tissue taken at Coroners PMs are disposed of and are lost for teaching, education and audit . This a loss to both medical education and maintaining good medical practice. Conference I would not have considered putting forward this motion at all if not for the likely passing of the Organ Donation (Deemed Consent) Bill currently going through parliament.

This states that a deceased is deemed to have consented to the organ donation unless a relative provides information that the deceased would not have consented. This motion is not talking about whole organs but very small pieces of tissue and slides in adults. Bizarrely histology slides can be scanned and retained without consent as they do not come under the Human Tissue Act. Conference we need to give the appropriate BMA committees and representatives the incentive to discuss with the Colleges,  Societies and others  the need to change the rules and ask the BMA to lobby for a change in the Human Tissue Act and Coroner Rules in England and Wales to facilitate retention of the slides and  blocks taken at Coroner’s autopsy. Conference I move.”

34 H1063 Motion BY NORTHERN IRELAND consultants committee That this conference recognises the benefits of study leave to enable consultants to remain up to date on best practice and support them in delivering the best high quality, evidence-based care. We call upon the Department of Health and the employing Trusts to look at funding for study leave, which has frozen – while the cost of accommodation, travel and conferences has increased. It is important that consultants in Northern Ireland have access to the same high-quality educational opportunities as their colleagues in the rest of the UK.

 Pensions

36 H1062 Motion BY CONFERENCE AGENDA COMMITTEE (NORTHERN RCC TO PROPOSE). That this conference notes the significant numbers of consultants who are subject to both the lifetime and complex annual allowance tax charges and calculations with the resultant damaging effect on the retention of NHS consultants noting that many consultants are no longer taking on additional work due to punitive effective rates of taxation and therefore demands that:

  1. the NHS Business Authority should routinely issue pension statements relating to pension growth and potential annual allowance charges on an annual basis to all doctors.
  2. the BMA should lobby HMRC, DHSC and the Treasury (and the respective departments within the devolved Nations) to alter the annual allowance calculation so that high earning public sector workers are not subjected to excessive rates of taxation.
  3. all NHS employers should pay the employers pension contributions to employees who have opted out of the NHS pension scheme due to annual allowance or lifetime allowance tax charges, as part of the ‘Total Reward Package’
  4. the BMA note the successful legal action by judges and fire fighters against some of the deleterious changes to their pensions;
  5. the BMA fully support, including with any external legal or analytical support required, the consultants committee in mounting such legal action as is determined by the consultants committee to be necessary against deleterious changes to consultants’ pensions.

 

42 H1022 Motion BY SOUTH WEST RCC. That this conference requires the BMA to develop a fit for purpose pensions calculator to allow members to assess their potential liabilities with respect to the annual allowance charge. Should this fail to have been done by the 2019 ARM then the reasons why must be given to CC.

 

Professor Michael West of Lancaster University and The Kings Fund gave a keynote speech on “Compassionate and Collective Leadership for High Quality Care Cultures”.  Some of the points he made. Patients need to continue to receive high-quality care. But in high turnover and difficulty in recruitment – there is something toxic in the NHS. There is too much stress at work reflected in the NHS workload , the quantity and complexity. The origins of the NHS he said was compassion and inclusion and they are still central. Most leadership development occurs through experience and observing. He described four important behaviours  ; being present, finding the causes of distress, having an empathic response and helping. He discussed the culture of the organisations , how leaders can  deliver. There need to be leadership at every level of the NHS . who are role-modelling . the values and behaviours of compassionate leadership. How optimistic , how cynical. Leaders focus on what we value and in the what they talk about in their behaviour. One needs to seek to know the challenges through dialogue and have a feeling for people. An important skill is listening. Senior leader are sympathetic but nothing changes. There are core characteristics of successful organisation ; clear direction in the organisation, give feedback focused on high quality compassionate care. Focusing on productivity is not what matters. An inspirational vision of high quality care requires leaders to sympathise , have clear objectives, and a clarity of support. There has to be good people management and employee engagement. Creating commitment is surprisingly poor in national organisation. As compassionate leaders they need to be authentic, open honest and acting with humility. There must be continuous learning and quality improvement. He referred to the document Caring to Change by the Kings Fund with leadership across boundaries. The document looks at how compassionate leadership results in a working environment that encourages people to find new and improved ways of doing things. How core cultural value of the NHS  involves compassion,  attending, understanding, empathising and helping. Leadership can stimulate innovation in health care. To have a culture for innovative, high-quality and continually improving care it describes four key elements and what they mean for patients, staff and the wider organisation:

  • inspiring vision and strategy
  • positive inclusion and participation enthusiastic team and cross-boundary working with working cooperation and integration
  • support and autonomy for staff to innovate.

There has to be an openness , humility and compassion. All voices are to be heard with a strong sense of inclusion. Voices for both patients and service users, He emphasized the importance of team work and pointed out research indicating 65% are working in dysfunctional teams with teams often not having time to meet. Whilst teams who take time out to debrief where 38% more productive. Do not allow chronic festering. Valuing difference and ensure every team working with other. Team have to be enthusiastic. Creative positive environments and avoid the “Cultures of accountabilism” creating positive emotional environment. Schwartz rounds are  useful. Seeking a better approach to change the courses are designed to be delivered internally, evidenced based and open source with evidence based methods and tools. He noted that well being is spending quality time with people we love, getting exercise and sleep.

References

https://qualitysafety.bmj.com/content/qhc/23/2/106.full.pdf

https://www.lancaster.ac.uk/media/lancaster-university/content-assets/documents/lums/cphr/quality-safety-nhs-e.pdf

https://improvement.nhs.uk/resources/culture-and-leadership/

Pay

44 H1048 Motion BY SCOTTISH consultants committee This conference deplores the deliberate degradation of UK doctors remuneration by 30% in real terms take home pay over past decade and calls for the governments across the UK to address this urgently.

47 H1010 Motion BY LONDON SOUTH RCC. This meeting calls for hospital consultants to formally pull out of the Doctors’ & Dentists’ Review Body mechanism.

48 H1054 Motion BY NORTHERN IRELAND consultants committee. That this conference deplores the fact that consultants in Northern Ireland are still waiting for the implementation of the DDRB recommendations for 2018-19 and we believe that this is contributing to the recruitment and retention issues in Northern Ireland. We call on the Department of Health, Northern Ireland, to ensure consultants in Northern Ireland are treated equitably compared to consultants in the rest of the United Kingdom.

49 H1049 Motion BY SCOTTISH consultants committee. Scotland has a worsening exodus of frontline consultant medical staff due to declining remuneration, increasing workload and a sense of being devalued. This conference

  1. deplores Scottish Government’s 2018 real terms pay cut for consultants
  2. regrets the breach of trust by Scottish Government in its failure to implement even the modest recommendations of the DDRB in 2018 for the second year running
  3. calls upon the Scottish Government to restore pay and conditions for its frontline consultant staff or be honest with the public about the consequences.

 

Terms and conditions of service

54 1064 Motion BY AGENDA COMMITTEE (NORTHERN IRELAND CONSULTANTS  COMMITTEE PROPOSING) That this conference notes the positive impact that flexibility and annualization can have on work-life balance but demands that:

  1. Consultants using annualised job plans must be protected to prevent short notice alterations to regular commitments not specifically agreed by the consultant
  2. the BMA ensures that LNCs have robust policies in place to prevent short notice alterations to regular commitments occurring

 

57 H1027 Motion BY NORTH WEST RCC. That this conference demands that the BMA produces clearer guidance as to what work constitutes Supporting Professional Activities within job planning.

58 H1029 Motion BY NORTH WEST RCC. That this conference believes wholeheartedly in nationally recognised terms, conditions and medical job titles. It condemns the use of confusing and arbitrary terms like ‘associate consultant’ and calls on the BMA to lobby against posts without national recognition.

59 H1052 Motion BY SCOTTISH consultants committee This conference calls on all 4 nation’s departments of health to recognise their obligation to provide safe parking or taxis for their staff to get to/from work

  1. when their hours frequently but unpredictably extend beyond the working day or
  2. involve transit during hours where there is no appropriate public transport option or
  3. where the employee is expected to have their car available for the employer’s benefit (ie inter-site transit).

BMA structure and function

62 H1042 Motion BY NORTH WEST RCC. That this conference regrets that there are no national minimum standards for facilities time and remuneration for LNC chairs and members. It therefore asks the BMA to work in conjunction with NHS Employers and other stakeholders to produce suitable guidance that can be disseminated to organisations and their LNCs.

63 H1028 Motion BY NORTH WEST RCC. That this conference understands that hospital mergers can increase the workload of their LNCs to a large extent. It calls upon the BMA to review the terms of reference for the annual LNC conference, enabling proportional representation. (as a reference)

 

2019-01-31 Trade Union Duties this week

Having become a member of the Royal Free Group staff Local Negotiating Committee I attended my first GJNCC and LNC. To give BMA members an idea of what function these have I give a short summary.  Formal request  for information on what was discussed would be through the appropriate official channels.

GROUP JOINT NEGOTIATION AND CONSULTATIVE COMMITTEE  (GJNCC)

This took place on 29th January 2019. This meeting is attended by and chaired by management with representatives of all the union recognised by the Trust for the purpose of negotiations concerning all employees. Policies and documents which relate to all employees are discussed and ratified. I attended as a BMA representative. At this meeting no documents were submitted for approval. Updates were given on the following items :-

  • Financial position of the Trust
  • Operational/Performance of the Trust
  • Workforce performance of the Trust
  • HRBP consultation
  • Reports were given on the following
  • Job matching at the Trust
  • Contract of employment vs updated polices
  • Expenses policy

A request for recognition by another union will be brought to the next GJNCC in the form of an amendment to the Trade Union Recognition Document.

There was a discussion of the potential use of Skype for business for future meetings

 

LOCAL NEGOTIATING COMMITTEE

The staff side Local Negotiating Committee of the Royal Free Group took place on 31st January 2019 for an hour prior to the joint LNC meeting after a number of policies new members (including myself) where introduced and welcomed. There was a discussion in advance of the items for discussion at the jLNC  The eight new members of the sLNC will be circulated by the usual channels. After this the management side entered and as part of the rotation of the chair of the meeting, chaired this meeting.

As well as the forum for the trust to seek views of matters relevant to medical staff the role of the jLNC is to negotiate the following with respect to medical and dental staff in the Royal Free Group

  • local Terms and conditions of service
  • working arrangements
  • policies and procedures relevant to medical and dental staff
  • arrangements for the application of national TCS

Membership of the Joint LNC is composed on the staff side the accredited trade union representative of each of the following (one from each hospital)

  • Consultants
  • SAS
  • Junior Doctors
  • Staff Side Chair
  • Chairs of the following
    • Consultants/ Medical Staff Committee from each hospital
    • Junior Doctors Forum

+ the BMA Industrial Relations Officer (IRO)

Membership from the employer’s side include the following

  • The Group Chief Medical Officer
  • The Group Responsible Officer
  • The Group Director of Workforce
  • Medical Directors of each hospital
  • Deputy Director of Workforce (Medical)

No comments will be made on the speakers or the negotiating stances or conclusions as these are conveyed through the sLNC chair but the aim is to convey to members the function of staff and joint committee.  The items were discussed were the following :-

  • Minutes of the last meeting and matters arising not covered by the agenda (the LNC meets every quarter)
  • Clinical excellence awards local, national and involvement of clinical academics
  • A Trust guidance document (from 4 years ago) on covering absent colleagues
  • Another medical union’s request for trade union recognition by the Trust
  • Documentation relating to the Responsible Officers need for references for private work outside of the Trust and the cost associated with this.
  • The establishment of a SAS Committee at each Hospital in the group
  • An update given by the Guardian of safe working including Q2 documents from each Hospital of the Group including Exception Reporting at BCF, RFH and separately the GP trainees
  • The Trust Medical Leave policy regarding lieu days for study leave on days when not working.
  • New consultant job descriptions

Other useful information

BMA information on website

Consultants know your rights

 

BMA in the News 2019-01-03

03.12.2018 Sup[plied by BMA Comms

Mental health cuts in Oxfordshire

In an open letter to Oxfordshire County Council, the county’s NHS and charity leaders warned that plans to cut funding for the county’s mental health services by £1.6m would have ‘devastating consequences’. They warned that the proposed plans to cut the budget from £8m to £6.4m by 2022 would leave some of the most vulnerable patients without access to vital support.

Commenting in the Oxford Mail, BMA mental health policy lead, Dr Andrew Molodynski, said: “The fact that there has been little if any planning means that OCC is playing a dangerous game with the safety of many of our most vulnerable residents- neighbours, friends, family members.” He added: “It is nothing short of shameful in this day and age.”

Missed GP appointments costing NHS millions

There was further coverage of the BMA’s response to the announcement by NHS England warning that more than 15 million appointments at GP surgeries in England are being wasted each year because of patients failing to turn up without informing practices in advance with mentions on BBC News BBC News channel,  BBC Radio Suffolk, Three Counties, Coventry and Warwickshire and Essex.

Comments from the BMA GP committee chair, Dr Richard Vautrey, featured in Pulse. Dr Richard Vautrey, said: “Every appointment at a GP practice is precious, especially at a time when GP services are struggling to cope with rising patient demand, staff shortages and inadequate budgets.” He added: “Practices will try many ways to address this problem, but ultimately patients do need to play their part.”

Warning over child sugar consumption

The Newcastle Journal reports on warnings by Public Health England that children could die younger if we can’t cut the sugar in their diets with the average 10-year-old in the UK consuming more sugar than they should consume in their entire childhood.

Commenting, the BMA North East regional council chair, Dr George Rae, said: “There is massive social responsibility on food manufacturers to get it right and to make labelling clear. In the supermarkets, for example, people might see products labelled as ‘low fat’ and think that’s great for their health, but often the low fat products are high in sugar.”

 

Government rules out GDPR exemption for GPs

Responding to a question tabled by Nottingham North Labour MP, Alex Norris, asking what assessment had been made of potential merits of exempting general practices from the GDPR, Pulse reports that the culture, media and sports minister Margot James has said that GPs will not be given the right to charge for patient information requests as it would ‘weaken the rights of patients’. Under General Data Protection Regulation, GP practices can no longer change a nominal fee for providing patient information.

BMA GP committee chair, Dr Richard Vautrey, said: “This reply therefore is no help to practices struggling with increasing numbers of SARs requests which leads to major unfunded workload.”

Other news

NHS England has said that it is better equipped to deal with the winter crisis thanks to the £420m funding boost which has been able to help struggling A&E departments and add extra bed capacity at 80 hospitals across the country, the iNews reports. Health minister Stephen Hammond said that the health and care sector has “spent this money wisely”.

The Sun reports on an investigation by the HSJ, which reveals that fifteen NHS trust chief execs were paid annual salaries of more than £250,000 last year.

 

2018-12-01 UEMS Pathology Section

2018-12-01 The European Union of Medical Specialist (UEMS) Section of Pathology Meting.

This full day meeting to place in the elegant and medieval setting of the Palazzia del Bo in Padua organised by Professor Ambrogio Fassina.

Attendees

Representatives from the Pathological Societies or Colleges of European nations were in attendance including from the following nations (up to two representatives per nation)

  • Austria        Sigurd Lax
  • Belgium      Claude Cuvelier
  • Croatia        Sven Seiwerth
  • Denmark    Carsten Rygaard and Karsten Nielsen
  • France         Phillipe Camparo
  • Hungary      Laszlo Vas & Janina Kulka
  • Germany     Gisela Kempny
  • Greece        Anna Batistatou
  • Italy,            Ambrogio Fassina (President)
  • Poland        Andrzej Marszalek
  • Spain          Aurelio Ariza
  • Portugal    Herminia Pereira
  • UK              John Firth

 Apologies were given by Holland ,Switzerland, Slovenia and Turkey

 Key issues of interest discussed:

This full day meeting to place in the elegant and medieval setting of the Palazzia del Bo in Padua organised by Professor Ambrogio Fassina. There were no facilities for videoconferencing.

A report was given on the state of Formalin restriction by the EU by Aurelio Ariza . The UEMS Pathology section has been instrumental in lobbying to avoid the total ban of formalin as there is no alternative for its use in the healthcare sector. It was noted the most important level of scrutiny of the amendment to the relevant EU directive was the EMPL committee which last met on 20th November 2018. There have been a number of compromises (1-14) of which compromise 8 9 and 10 have been approved by an overwhelming majority. Compromise 9 in particular is relevant which gives good visibility to pathology . There is no text from the European Commission. Aurelio Amize MEP has lead on this. Following this hurdle the compromises will pass through the European Parliament in December/January and European Council (Minister of Governments) after this. Then European Parliament and Commission. It was noted that the new levels of 0.3 ppm over 8 hours and 0.6 ppm short term exposure is significantly lower than currently. The likelihood will be a need for constant monitoring with evidence of this in pathology laboratories, embalmers and anatomy dissection rooms.

The President of the Pathology section is to send a letter of thanks to Laura Agea. It was noted a large numbers of MEPS are involved. It was suggested to contact national representatives. The UK representation Tim Aker MP and Jean Lambert MEP are UK MEPs with an interest.

The President of the Pathology section gave a report which include the following

  • recent UEMS Council meeting in Europe. where European Training Requirement in Radiology, Transplant Surgery and Wound Healing were passed. I mentioned that as part of my scrutiny of ETRs both the Transplant and Wound Healing ETRs mention the need to know pathogenesis and immunology but Pathology should be included in the updated versions of ETRs this was noted and accepted.
  • a number of Honorary UEMS awards were given out in Brussels
  • the new working Groups 1-3 were shown with Pathology in working Group 3 with Paulo Ricci as Chair.
  • The working Groups on Post Graduate Training, CME-CPD, ehealth digitisation were discussed.
  • UEMS EACCME which took place in Brussels 23-24 November
  • The Network of Accredited skills Centres in Europe (NASCE)  meeting took place in 4-6th October. The program is of interest to those in medical education consisting of a 1 1/2 day scientific meeting followed by 1 day train the trainer course for 12 participants
  • UEMS Council of European Specialists Medical Assessments (CESMA)is an advisory body of the UEMS created in 2007 with an aim to provide recommendation and advice on the organisation of European examinations for medical specialists at the European level.It was called in the beginning the “Glasgow group” referring to the first meeting held in Glasgow. It was then decided to adopt the name CESME (Council of European Specialist Medical Examinations). This name was finally changed to CESMA (Council of European Specialist Medical Assessment) Its main role is to:
    • To promote harmonisation of European Board assessments
    • To provide guidelines to the Boards on the conduct of assessments
    • To encourage take up of Board assessments as a quality mark
    • To offer an alternative to National assessments, where appropriate

https://www.uems.eu/areas-of-expertise/postgraduate-training/cesma

  • There was a discussion of income from EACCME accredited live and on line events. It was encouraged to discuss with national organisations. As UK representative of the RCPath and Deputy to the UK Delegation I said they maybe opportunities to explore accredited webcast. As an example there are free webcast available to BMA members. There might be a way of accessing these such that both BMA and UEMS Pathology Sections benefit financially from non BMA members accessing.

A report was given by Claude Cuvelier Treasurer of the UEMS Section . There was a general discussion regarding the finances of the UEMS which has assets of 8 million Euros (mainly in the Domus Medica) and now has a single bank account. There is a centralised National Contributions which are made by the National Medical organisations and National Societies to the Sections. I pointed out that the BMA has paid it bill 12 month in advance. There was a discussion about the contribution nationally to the sections contributions to central costs.

There was a request from one of the members to send a letter to request restitution of the loan given centrally by the section. This amounted to 25000 Euros in 2015 and is related historically to the finances of the Domus. This will be paid back to the section in 3 instalments

It is recognised that the income of the Pathology section is significantly than other sections such as Obs & Gynae who have a large number of transactions. An the Board does not have money coming in from an exam.  The sections balance in the bank as of November 2018 was 33,991 Euro  up from 29,343 Euros in January 2018. It was noted that a number of contributions from the National Societies have yet to be paid in the UKs case it is about 470 Euros. The invoice may have gone to an old address of the one of the UKs representative. It was noted by the group that sometimes the absence of payment does not get back to the representative to follow up.

A large amount of time was spent discussing the European Training Requirements in Pathology. Professor Fassina introduced the discussion by discussing the ETR in Radiology in depth which was passed by Council in October in Brussels. This included the process, timing, purposes content, structure, history, involved societies, revisions. The ETR in Radiology I pointed was not supported by the UK UEMS Council delegation on a number of counts. First it is very much a European Society of Radiology Document and does not conform to the UEMS ETR template. Secondly the document did not include the Royal College of Radiologists as co-authors as they had not (sic) been involved with its development and had sent a letter showing areas of concern about the document though this was only a month before the UEMS Council meeting. As UK Representative i suggested that if any document was to have a UEMS badge on it it should be produced by the UEMS section though gathering a wide group of stakeholders and views. I also said that there is also an expectation that a draft document would be circulated to a wide number of societies for feedback before submission. The draft ETR was set down at Berlin Poznan

A number of comments have been made by Arthur Felice (Malta) in writing

  • The ETR is concise practical and to the point.
  • More detail would constitute an improvement.
  • In the e-portfolio and logbook units of training should be competence based
  • Consider the concept of Entrustable Professional Activity (EPA) which he sees is a critical part of professional work that can be identified as a unit to be entrusted to a trainee once sufficient competence has been reached
  • One should not aim at the maximum number of competencies held in common in the various national curricula since this approach would inevitably lead to unacceptably low standards.
  • Theoretical knowledge content should be specified in detail
  • Competencies should be quantified and not qualified
  • In the schedule of training more detailed quantification is suggested The common trunk needs to be qualified in more detail to be of practical use.
  • The curriculum is just a bare outline. More specifics are suggested.
  • A good exposition of proposed assessments and their QA is missing.
  • The suggestion that trainees should spend a significant period in their training in foreign institutions of excellence is appreciated and suggested should become a rule

On this last comment I wondered whether UEMS had a role in the future in accrediting these foreign institutions.

There was a long discussion about subspecialty training and national variations in Cytology Neuropathology and Dermatopathology.

Questions asked about ETR in pathology included what numbers should be proposed in

  • Autopsies
  • Surgical Pathology Cases
  • Cytology Cases
  • How will Molecular, Informatics and Administrative and organisational issues be addressed

There was long discussion about content and how the European Board of Pathology Exam should evolve. Points discussed included

  • The value of a European Board of Pathology Exam
  • Who is it aimed at, what is the likely take up
  • The history of the exam (10 years CC has been involved he noted a high proportion of Middle Eastern nationals taking it)
  • Whether it would just parallel national exams or would it become a substitute
  • How the proposed exam compares with other national exams
  • The likelihood of national governments wantingto replace thir exam
  • The inclusion or not of OSCE type examination
  • Does setting the exam in English only penalise non English speaking nationals.
  • A Memorandum of Understanding with the European Society of Pathology
  • Letters to go to Cytology and Haematology
  • National view of Cytology Training in Greece
  • I asked whether ETRs should take into account trainees that are less than full time by stipulating pro-rata. It is noted in Belgium LTFT training is not allowed.
  • There were differences of opinion as how to count Cases, Number of Specimens, Number of slides.
  • National differences were noted in the length of time for each sub speciality
  • There was agreement to ensure inclusion of pathogenesis.
  • There is a need to collaborate with Radiology as both Radiology and Pathology have similar featurs of future developments
  • I suggested the RCPath 2015 Curriculum utilising assessment methods of DOPS CbDs and ECEs for Skills and Knowledge , and MSF for behaviours were very useful . The section recognised the advantages of the UK system though noted it nationally specific. I suggested there was a lot to potentially absorb from the RCPath the curriculum and I would be happy to explore if this was acceptable to the College. ACTION JF to discuss with RCPath stakeholders
  • There will be a need to have the amended ETR ready in advance of Athens meeting in May 2019
  • Expectation is that the Working group would have draft finished by the end of February
  • There is a need to have new bank of MCQ questions. I pointed out there will have to be note shared copyright on images. I pointed out that one has to avoid copyright infringement.
  • There was a discussion of standardised reports
  • It was noted that Breast Colorectal, skin and prostate have standardised reports in many countries. I pointed out that the RCPath had an extensive documentation and datasets which could be circulated.

Invitro diagnosis of medical devices 2017/746

See https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32017R0746&from=EN

A review is given in

https://ec.europa.eu/growth/sectors/medical-devices/regulatory-framework_en

This applies to diagnostic not processing except for immunochemistry

The Pathology Progress test was discussed. See

http://pathology.hu/en/news/1375/pathology-progress-test-2018

Other matters with insufficient time to discuss in depth included

  • The German representative submitted a slide which pointed out the requirement of DIN EN ISO/IEC 17020-2012 and technical criteria for their application for accreditation in pathology and neuropathology. The scope of the application is that  the rule has been drawn up by the Sector Committee Pathology/Neuropathology and serves as an interpretation for its application. A number of representatives where not aware of it,  Consequences are
    • Interpretation and recommendation
    • Subject specific criteria are stated
    • Their fulfilment must be proven by an inspection body for accreditation
  • Big Data
  • Artificial (Augmented) Intelligence

Future board meetings were agreed in Athens and Ghent

BMA in the News 29th October

All information supplied by BMA Comms

We need cleaner air

Over the weekend and this morning, there was coverage of the BMA’s membership of the UK’s Health Alliance on Climate Change and the demand for the government to implement the biggest shake-up of air quality legislation for 60 years in an effort to tackle the country’s growing air pollution crisis. The Times coverage focussed on the ask for the ban on new petrol and diesel cars to be brought forward by 10 years to 2030 and The Guardian took a broader view.

According to The Independent, there’s no doubt that the will of the people is to have a final say on Brexit.  The editorial talks about the BMA’s motion to back another vote and it even manages to weave in a mention of a song from Les Miserables, “Do you hear the people sing? Singing the song of angry men? It is the music of the people who will not be slaves again”

Closing the gender pay gap

Practice Business covers the recent Women in Academic Medicine conference in South West England. Dr Helen Fidler talked about the value of supporting local efforts to encourage female doctors to apply for CEAs. As the chair of the local negotiating committee in Lewisham, she is seeking to draw up a plan with her hospital trust to do just that.

Hospitals falling apart

A number of local papers, including, Dunmow Broadcast have written articles about local trusts requiring millions of pounds worth of repairs. The Cambridge University Hospitals NHS Foundation Trust, which runs Addenbrooke’s Hospital, is currently sitting on a backlog of £101.5 million worth of repairs or replacements which should have been carried out on its buildings and equipment. We provided a comment from Dr Chaand Nagpaul, who said there was an “urgent” need for an injection of capital funding to address the NHS’ “impoverished infrastructure”.  This has been widely used at a local and regional level

Brexit is bad for our health

The ‘spectre’ of Brexit is already damaging our health service, according to an article in The House this morning and writer, Jeanne Freeman cites the BMA survey on EU doctors, working in the UK and making plans to leave since the referendum.

Mental health more prevalent than asthma  

Dr Richard Vautrey was interviewed on LBC radio on Saturday talking about the fact that GPs now wee more patients with mental health problems than they do with the traditionally more prevalent conditions such as asthma, high blood pressure and obesity.  One in ten patients has had depression diagnosed, as the condition overtakes obesity on GP records for the first time. The Times carried the story on Saturday, quoting Dr Vautrey. Depression is noted by doctors almost twice as often as it was five years ago as more attention is paid to mental health, according to official data from NHS Digital

In other news

£2bn for mental health

A large number of media outlets carry the news that the Chancellor is expected to announce an extra £2bn for mental health care in today’s Budget speech. Sky News says specially developed ambulances to treat people with conditions like depression, anxiety and PTSD are part of the new measures to ensure mental illnesses are treated as seriously as physical ones.

The Guardian says the commitment should lead to comprehensive mental health support being available in every large A&E department and the Mail Online claims that every school in Britain will get a mental health support worker to help pupils suffering from depression, self-harm and eating disorders.

#MeToo….not in the NHS?

Victims of harassment and abuse in the NHS are officially encouraged to speak out. In practice, this rarely happens, according to an article in the New Statesman. Written by a Cardiologist from South Wales, it says that the #MeToo phenomenon has not impacted the NHS as it has in other industries.

Medical Examiner in Cause of Death

INTRODUCTION OF THE MEDICAL EXAMINER POSITION IN ENGLISH TRUSTS

A report on the meeting held on 20th September 2018

Declaration

These are not official minutes of the meeting and are the personal view of the meeting by the writer. They therefore do not represent either BMA or Royal College policy or approval. See official sites for this.

Introduction

The Royal College of Pathologists hosted a meeting over the introduction of the Medical Examiner in Cause of Death (MEs) at the Royal College of Physicians on 20th September. This the second of its type this year and more are planned. The all-day meeting was introduced by President of the Royal College of Pathologists and immediate past president. The Royal College has been central in developing the training requirements, on line learning, job description and person description for the posts. After many years of frustration and delay these positions will be introduced in England from April 2019.

 

Topics covered in the all-day conference included:

  •  The role of the Medical Examiner
  • Working with Stakeholders
  • How will it work in practice?
  • Timetable for the implementation of MEs
  • Role of the National Medical Examiner
  • Appointment and role of Regional Medical Examiners
  • Accountability and independence – who will employ MEs and how will independence be assured?
  • Working with the Coroner
  • Changes to completion of cremation forms
  • The role of the ME Officer
  • Forms and data collection – update on digital support
  • Training of local MEs – e-learning and face-to-face sessions

The ME system will be phased within the NHS and now not by Local Authorities. It will be a non- statutory ME service and will include MEs and MEOs (Medical Examiner Officers) in salaried posts. ME systems will be phased into NHS secondary care from April 2019.  Implementation in primary care will require new statutory changes.

The Government are committed to moving to a statutory medical examiner process to include all deaths, but as yet it is unclear when this will be implemented. The decision to not take “a big bang approach” and implement the system statutorily from the 1st April enables Trusts and the government to introduce the system in a considered way which will allow for learning and the continued dialogue needed with all stakeholders to bring about positive changes.

No Trust is being forced to implement from the 1st April but from the oversubscribed conference it is clear many are keen to bring in the new system for the clear benefits it will bring to the families, professionals and services who feed into the process.

The NHS now have the learning from deaths programme and the safety programme which also need to be fed into the ME system.

There was also the decision to change the appointment of MEs from local authorities back into the Trusts. This still causes some concerns over their independence and accountability, but it is important to state that this is a process government will be learning from and there have been further levels of independence introduced into the roles to ensure this continues. MEs will be reporting to a separate line of accountability for malpractice. The success of this is to do with working with the pilot sites and early adopters.

Strategic overview

The conference was given a strategic overview by Jeremy Mean, Programme Director for Implementation who reports directly to Mark Davies

The DHSC has a strong commitment to the implementation and in October meeting of NHS England & NHS Improvement regarding finance will take place. There is recognition of the frustrations but there is a fresh commitment with a new vision of an ME service based in the NHS. In this initial stage it is a non-statutory service. Both the MEs and Medical Examiners Officers (MEOs) will be salaried in secondary care. There will be a process of reform and a move to a statutory system as specified in the 2009 Coroners Act. The interim period is unclear and the parliamentary process, complex. There is also a new impact assessment – which shows differences from the 2016 impact assessment.

This also links in with other patient safety developments such as learning from deaths encompassing all deaths.

The Medical Examiner lead will be appointed locally but there will be a separate line of accountability held centrally to ensure the need for an independent voice separately accountable to the Trust the ME is working within.

The DHSC is working with many to deliver on the following key objectives;

  • The bereaved, next of kin or informants are engaged and can raise concerns
  • There is joined up thinking with other departments
  • They are working with the pilot Trusts (some of which have been running for 10 years) and earlier adopters sites.
  • Working with coroners – MEs or Coroner with only two routes
  • Working with Registers of Death to avoid delay and ensure the cause of death is acceptable
  • Initial non-statutory approach with a move to statutory MEs over time
  • Improvement of recording of the MCCD
  • Improvement of the five-day timetable
  • For the future there will be a focus on urban and rural areas working with Funeral Directors and the BMA regarding deaths in the community.

Regarding IT support the government is committed to developing a system to provide a digital solution for the ME service. There are procurement arrangements in hand with DH Digital and a number of high quality bids for a digital solution we received. A decision has been made but not yet announced.  Input for implementation important as no one size fits all. The aim is for improve scrutiny and outcomes for the bereaved together with high quality data

Dr Aidan Fowler, is the newly appointed NHS Improvement National Director of Patient Safety and will working closely with the DHSC on this He is a surgeon by background and has already visited some of the pilot sites. Dr Fowler announced that the National Medical Examiner position will be advertised in October and will report to him regarding

  • Patient safety strategy
  • Insights
  • Infrastructure
  • Interventions
  • Ensuring bureaucracy remains relevant and manageable

Dr Fowler stated the need to improve the process for the bereaved when discussing the cause of death be a better experience of cause of death by relatives. Relatives want to know what the deceased died of and if it was an unexpected death. There needs to be an accurate recording of death recognising the importance of the current Coronial system and maternal and child death reviews. The aim is to assist in preventing excess deaths and spotting concerns earlier. There is also a need to know how data flow works.

Dr Fowler went on to discuss how the MEs are to be employed. They will be employed in the Trust they will be working within as this is practical however their reporting lines will be separate and independent. . There remains practical issues such as HR and pensions to discuss, but it is important that the jobs are desirable and those appointed have the desirable skills required for this role.

Role of the Medical Examiner and Medical Examiner Officer

Dr Alan Fletcher, Lead Medical Examiner in the Sheffield pilot gave an overview gave an overview of his role. Alan has been an ME in Sheffield since 2008 as one of the earliest pilots. Other pilots included Gloucester Mid Essex, Basildon, Brighton Hove and Powys, He gave a map of the current position of Medical Examiners that have been established in England. South Tees, Buckinghamshire, Lincolnshire, Barnsley, Norwich, Royal Devon and Exeter have all established MEs. He gave a background to the changes in the system that date back to the Harold Shipman case.

The purpose of MEs was defined as answering the following questions

  • What did the deceased die from?
  • Is the MCCD accurate?
  • Is there a need for a Coronial referral?
  • Is there a governance concern?

The steps of the ME procedure were highlighted as:

  1. An appropriate review of the medical records
  2. Interaction with attending doctor and enquiring of any concerns
  3. Interaction with bereaved.
  4. Confirmation of the MCCD

All this will be undertaken within 24 hrs. though it was stated Steps 2 and 3 maybe delegated to Medical Examiner Officers (MEOs)

Dr Fletcher gave a number of examples of poorly completed MCCDs highlighting specific areas that would either be queried or rejected by the Registrar of Death including “malnourished”.

He said there is often a need for clarification and to ensure relatives are engaged. Whilst there is a list of what to report to the coroner this may vary a little locally. It was noted that in the Learning from Deaths review the ME is not a replacement for national mortality case record reviewers, but the ME is seen as an initial filter, though independence and transparency is required.

In the pilot areas regarding Coroners referrals there appears to be no difference in the rate of referral but they (the Coroners) are said to be better informed. In most pilot areas the Form 5 forms are completed by the ME.

Part of the ME scrutiny is signposting which is currently undertaken by skilled people e.g. bereavement officers and therefore Trust are very much being encouraged to build on existing systems and good practice. The ME Dataset will include the usual demographics.

The ME training needs will be discussed and appraised. There are core sessions of e-learning (26) which have been refreshed recently by the Royal College of Pathologists.  Updating of all documents is taking place by the Royal College of Pathologists and will be available on their website shortly. There is a need to avoid inconsistencies in the system. The list of acceptable causes of death is also being refreshed and revised to emphasise the collaboration that is taking place. As well as e-learning there will be a face to face component 1-day event later this year and early next year which will include input from the faith community.

There were several questions from the floor and answers from the panel:

  • There was a discussion of what is a reasonable workload
  • In Sheffield there is 1 whole time equivalent ME for 3000 deaths and 4 wte Medical Examiners Officers. In addition to the bereavement officers already in place
  • Conversations with the bereaved will include hospital consent autopsy. But consented autopsy is not a replacement for coroner referral.
  • There is noted an increased level of complexity of referrals to the coroner
  • If there is a coronial referral this ends the MEs involvement.
  • MEs cannot instruct what the Qualified Attending Physician (QAP) writes but they are there to help advise them and agree wording that would acceptable to all. Ultimately it is the QAPs certificate, with the consultant in agreement.

There were discussions from the floor on:

  • the notion of independence of ME in Trust
  • training of junior doctors and medical students on completing MCCDs.
  • whether it was the fee from just Form 5 to be used for funding the MEs
  • The DHSC representative stated that when the statutory system comes in it there will likely be a fee introduced for all deaths (around £100 each)
  • The need or bereavement booklets for families
  • Out of hours scrutiny
  • The need for business continuity planning in the mortuary

Medical Examiner Officers

Medical Examiner Officers have a role to assist the ME in the three steps of scrutiny though this differs by location. They obtain the medical record which are looked at by the medical examiner. They also complete data entry.

MEOs do not replace bereavement officers but there is no reason why Trusts cannot combine the role. They don’t advise what to write on the certificate as this is still done by bereavement services. There was a discussion of what sort of MEOs, administrative, data entry, more clinical or combined role and who are we going to recruit. This can be a mix or work with what you already have. In one case this is a team of MEOs, nurse registration and bereavement specialties (7 part-time)

How does the ME scrutinise?

  • Medical Records reviewed, clinical letters, surgery, nursing note, safeguarding issues considered. This maybe electronic or paper or the combination of the two.
  • Conversation with the qualified attending practitioner (QAP)
  • Discussion with the bereaved
  • Conclude whether the death natural or unnatural

There will be a need for local solutions. The task of discussing with the QAP and bereaved maybe delegated to the MEOs as in Sheffield depending on whether the MEO is clinical or non-clinical.

Role of the Qualified Attending Practitioner (QAP)

At Gloucester the ME asks open questions about the deceased and is given an overview including, medication, procedure and terminal episode. Questions include are there any concerns? Has a coronial referral been considered? Has there been any conversation with coronial officers?

The MCCD is formulated by the QAP. Any fundamental disagreements (which are rare) lead to conversations with other members of the tea. The MEOs bleep the relevant QAPs in the morning for availability but there is a recognised need for flexibility.

There is a 24 hour ME service including out of hours. Though calls out of hours are uncommon. There is a need to cover paediatrics and organ donation.

Practical considerations discussed include:

  • who needs to see the body
  • who signs the cremation forms (Form4 – QAP  Form 5-ME)
  • Payment for Form 5 goes towards funding the ME service
  • The current Cremation forms remain in place
  • New forms

Administrative Information Form ME-1 (Part A)

    • Medical Examiner’s Advice and Scrutiny Form ME-1 (Part B)
    • ME-2 form
  • The QAP must complete death certification summary
  • Sheffield has an access database developed by Peter Furness (ME) which includes a summary of the record and medical examiners notes. This is linked to other reviews
  • Based on the Sheffield experience the ME time is on average 25 minutes but more complicated cases take longer.
  • As an example, review of records can vary between 12 – 15 minutes.
  • The ME interacts with both the QAP and with the family
  • Bereavement appointments are within 2 working days of death
  • Relatives need to have time to reflect often day after
  • Faith concerns, paediatric cases and organ donations are prioritised
  • The cremation waiting time is around 2 weeks
  • There are problems around availability of the QAP.
  • It is recognised that the ME system must be responsive as any delay might be directed at the ME system
  • The ME system avoids unqualified referrals to the coroner and the coroner receives more information
  • The Junior Doctor writing the MCCD gets support more easily.
  • It will take a while to embed the system
  • There may be an issue of long distances in some rural areas
  • Concerns – occasionally there is no agreement on the cause of death
  • Current pilots show no increase or decrease in complaints
  • Burial within 24 hrs – out of hrs service to facilitate release

Accountability of Medical Examiners

MEs will be regarded as Independent with different levels of accountability than within the Trusts and when introduced into Primary Care. Doctors will behave independently and professionally. There should be a minimal acceptable distance. There will be a need for peer review by a ME colleague. The MEs will be working with but not for the coroner. There will be collaborative working with MEOs. As with other specialties there will be professional accountability and annual appraisal. There will be a “channel of communication” of reporting to the National Medical Examiner.

There will be a need once established for a survey on how to make it a better system

Affects on the Coroner system

Increase or decrease number of inquests?

Sheffield – increase in inquests

Gloucester- no increase in inquests

 

Coroners PMs

There is a general reduction in coroners post mortem

Relationship between ME and Coroner

If there is a disagreement the ME has further discussions and a second opinion from another ME is sought.  In Sheffield this often arises out of a misunderstanding of the reasons of the report. If the law says so the case must be referred. It may therefore be a matter of improved explanation and polite reporting.

Cases of discrepancy where discussed in one area that had too few Coroners Officers and the fact that Doctors are moving areas with increased locum doctors.

In Sheffield there was a case where the ME was referred to the Coroner and then the case came back, but this is infrequent. There is therefore a need to ensure that the coroner is furnished with the right information.

The Coroner cannot tell a doctor what to put on the MCCD. There was a discussion of how you get the feedback. The MCCD does have a tick box to say that the QAP has discussed the cause of death with the coroner.

There was a general discussion on:

  • Examples of undue pressure in the event of a disagreement on a workable MCCD where there has to be an open investigation with a coroner’s autopsy or inquest
  • Communication – coercion.  “My consultant told me”
  • Pressure by hospital on healthcare acquired infections

 

 Interaction with the bereaved

 A leading MEO discussed their interaction with the bereaved. When a patient dies there is a booklet given out on the ward which explains the ME system and what steps will take place.

It is crucial the ME has a high level of empathy, be approachable and has good judgment. They are also there to inform the bereaved if there is a concern or if the bereaved raise a concern, understand what the issue is. In the Sheffield pilot care prior to admission is the most common concern raised. There is also a need to adhere to the local escalation policy.

There is a need to establish who needs to be involved in the conversations. Abiding by the openness of Learning from Death if a problem is identified, there needs to be discussions as to whether it will require independent review. If there is a duty of candour issue, sometimes not before death, the team would be there to address this and provide an open discussion without the fear of appearing to cover anything up.

The bereaved should also be asked if there are any problems they are aware of or what worries them and then reassure them there will be an investigation, but not undertaken by the ME.

The interaction with the bereaved has been very well received and all very much positive. But talking to relatives needs appropriate training as there is often a need to explain the terminology.  Skilled writing and plain language is also needed particularly when interacting with the bereaved. Bereavement staff have also welcomed an ME being there to talk to difficult relatives. Flexibility and empathy is needed with the bereaved and allowing them the space to process the death before approaching them with information.

Some of the following questions were discussed:

What happens if the relative doesn’t want to talk to the ME?

This is rare but may affect different members of the family. Sometimes this is because there are no concerns.

What do you do if relatives have concerns over their own mental health?

This too is uncommon and is a judgement call. There is a duty of care.  Are you the right person to speak to? Similar problems are seen in capacity issues.  Coroners also have much experience of facilitating challenging discussion and can offer support to MEs on this.

What will be the impact on the Registrars of England and Wales?

There is a need for collaboration at the outset. Registrars need to accommodate the changes. But engagement has been positive. Under non-statutory changes the registrar still has the statutory function with the 5-day target remaining. The Royal College of Pathologists is working with the registrars on the list of Acceptable and Unacceptable Deaths. These should be in place by April 2019 and there are now good channels of communication.

This is a new welcome level of scrutiny, but it is not a triage system. In Leicester there can be an MCCD release before the ME scrutiny takes (for deaths within faith communities). In a non-statutory system there is also flexibility for any urgent repatriation release.

A Panel discussion took place around the following

  • Current pilot schemes have varied some will differ to how it will work from April 19
  • Additional resources will be needed for a comprehensive system
  • MEs are likely to be part-time
  • A Job description will be place
  • As this is a non-statutory system the current system will prevail
  • There is a need for 7-day service – close to 24 hr consultant consultation
  • MEs are not bereavement counsellors but they have the ability to refer
  • There are workforce issues. For 2000 deaths which require up to 40 minutes a case Trust will need approximately 10 PAs.
  • A knock-on effect maybe an increase in hospital autopsy rate.

 

LATE AFTERNOON PANEL DISCUSSION

Panel included National SRO for wales, ME Bucks, Project Manager Lead ,

Senior SMEO.

Other topics discussed included;

  • Integration
  • ME in Learning from Death strategy
  • Mortality review ME involvement is critical as seen in Wales
  • Guidance in LfD for those for investigation.
  • ME is a flight path to a structured judgement review
  • Functions and oversight of ME
  • MEs are not working in sealed box if they send a case for a SjR
  • It is all about patient safety
  • MEs Involvement SjR
  • Involvement of ME in Trust Mortality group
  • ME recruited on the premise – multispecialty
  • Datix can be used for positive excellence
  • Evidence of recent ME experience
  • Talking for some time
  • Started planning mid May, November start
  • Planning training raising profile
  • Robust mortality review process is needed with positive input.
  • Set up a program of gradual role out (e.g start with 3-4 wards and progress to cover the whole hospital over a matter of weeks)
  • Link into mortality review
    • Scrutiny in the ME office
    • Spoken to family and qp
    • Document in electronic system that links to the mortality review. Promotes early review.

How to set up a Medical Examiner Service in a Trust

  • Consult with all stakeholders.
  • There is no need to begin with all deaths – no big bang is needed.
  • Identify how many medical examiners will be required in the trust?
  • How long should be taken on a case to do based on statutory roll out?
  • As this is not a statutory roll out the best we can do is “don’t do too many badly”
  • Initially review 50% – 75% deaths. Look at the number of cremations
  • DHSC is discussing additional funding for those deaths that result in burial and child deaths which will come to trusts centrally.
  • Need to look at Infrastructure, phones, territories, partnerships in the planning phase. Prioritising administrative support. There will need to be a full time administrative person and bring bereavement staff on board with review of job plans.
  • How this will work in primary care is under discussion. The Sheffield 23 GP practices are involved. IT solutions are important. The ME has access to GP records for 30 – 40 cases per month. The ME is based in the hospital as remote access to system 1 is easer.

What do Trusts have to do by April 19?

  • Don’t have to do anything
  • Trusts will want to work towards this
  • Roll out as quickly as able to do
  • Look at what your requirements would be
  • Work needs to be done by NHSE & NHSI
  • The enthusiasm and willingness of wanting to reform the system is the biggest incentive to deliver it and will show the benefits
  • Advert for National Medical Examiner set for this year

 

FOR THE FUTURE

Once embedded the next phase will be statutory implementation but this will need future legislation changes.

The official minutes of the meeting can be found at  Royal College of Pathologist’s Conference on the Medical Examiner System

 

 

BMA in the News 1st October

As supplied by BMA Comms

Evening and weekend GP appointments going unfilled

Today marks the deadline, set by David Cameron in 2014, for all areas to offer extended access GP appointments, yet according to an investigation by Pulse magazine, demand for the service remains low. Figures obtained under the Freedom of Information Act show that around 25 per cent of evening and weekend slots are going unfilled, while in one area only 3 per cent of its Sunday slots are being used.

Commenting on the statistics, Dr Richard Vautrey, BMA GP committee chair, said: “Because it has become a political must-do, everybody is jumping. We understand there is huge pressure from the centre on CCGs to demonstrate they are providing a full seven-day service.

“Sensible CCGs that want to use their resources in a better way are under pressure to maintain a service that really isn’t good value for money.

“That is ridiculous so I think we really do need to see much more common sense and pragmatic flexibility… if we had the luxury of resource and workforce then we could look at extending the service but until then we’ve got to focus on what is most important.”

Pulse’s investigation, and Dr Vautrey’s comments were also features in the Daily Mail, the Guardian, The Times, the Daily Telegraph and more.

Hundreds underpaid at hospital

More than 600 workers at East Suffolk and North Essex NHS Foundation Trust were underpaid – some by thousands of pounds – after overtime, expenses and unsocial hours were not taken into account this month. The Daily Gazette quotes a tweet from the BMA East of England regional junior doctors committee, which stated: “Hearing of significant problems at @ESNEFT with many members of staff of all professions being paid the wrong wages, many hundreds some more than a thousand pounds short.”

Dr Jeeves Wijesuriya, BMA junior doctors committee chair, said: “We know that junior doctors being paid incorrectly, or at times not at all, has become all too common for a workforce with lives, families, and financial commitments to meet. We hope the trust will work with us to swiftly resolve these issues.”

According to the paper, more than 500 staff have now been paid in full, with the rest expected in the coming days.

Pension rules now hitting middle earners

A news feature in the Daily Telegraph covered the growing protests against public sector pension tax relief cuts that have left middle earners worse off. The piece references BMA guidance which warns that NHS staff “with long service and or significant promotional pay rises” are most likely to be affected.

Missed appointments cost NHS millions

There was more regional coverage of statistics compiled by the Press Association on the prevalence of missed outpatient appointments and the subsequent cost to the NHS. Approximately 8.6 per cent of outpatient appointments in England were missed, rising to 18 per cent at some trusts. Breaking down the figures regionally, the story was covered by the Bridgnorth Journal, Hartlepool Mail, Kent Messenger, Medway Messenger, Oxford Mail, South Shropshire Journal, Sunderland Echo and the Hunts Post.

Responding to the figures, Dr Robert Harwood, BMA consultants committee chair, said:

“It is important that no appointments are wasted at a time when the NHS is under incredible stress. We should not stigmatise patients who may for legitimate reasons be unable to attend. However, we do need the NHS to emphasise through clear publicity to the public that given the current unprecedented pressure, patients should make every possible effort to rearrange their appointment so that another person is able to receive treatment in their place.”

Other news

Research released by the Labour Party has revealed that the NHS will suffer cuts worth £2.7bn after the government miscalculated the pension costs of public sector workers, the Mirror reports. The Labour party has said that the money lost could have paid for the salaries of over 61,900 nurses.

The Telegraph reports that an unpublished inquiry by the cabinet office reveals that police are illegally detaining more than 4,000 mentally ill people in custody a year because of a lack of NHS beds. Delays in finding a bed means that thousands of those being arrested and in need of mental health care, some as young as 15, are being held for up six days without charge.

An opinion piece by Wellcome’s director, Jeremy Farrar, in the science section of the Guardian warns that a no-deal Brexit would stall the NHS medical revolution. He argues that the NHS has thus far benefitted from being at the forefront of genomic medicine, largely because the UK has been an attractive place to “collaborate and invest in science”. A no-deal Brexit, he fears, would be hugely damaging for future research collaborations.

The Observer reports that the health secretary is expected to announce that the government is to produce the first official guidelines on the maximum amount of time young people should spend on social media in order to address mental health problems among children.