Research to improve patient care

November 2018

www.rcoa.ac.uk @RCoANews

Working with you to improve patient care: the Health Services Research Centre

Travel to learn: return to inspire

Gross negligence manslaughter in medicine

UPDATeS IN ANAeSTHeSIA, CrITICAL CAre AND PAIN mANAGemeNT26–28 November 2018 | Hilton Liverpool City Centre

Held in the heart of Liverpool, this event will provide you with the opportunity to meet and network with anaesthetists in the North West and beyond, while learning about the latest ideas that will affect your practice.

Join us in November for discussion on the following hotly anticipated topics:

■ blood conservation: pre-operative anaemia and cell salvage ■ the future: drugs in the pipeline ■ obstetrics: risk, hypotension, critical care

■ trauma: initial management, surgery, rib fixation ■ pain management ■ paediatrics.

25–27 February 2019 | RCoA, London

Our first Updates in Anaesthesia, Critical Care and Pain Management event of 2019 will cover a broad range of topics to address the latest developments across the specialty.

Expert speakers will discuss essential clinical topics to keep your knowledge up-to-date, including:

■ physics of high flow nasal oxygenation ■ cardiopulmonary exercise testing ■ results of NAP6

■ the frail older patient ■ cognitive dysfunction and dementia ■ patients with diabetes.

CPD credits 15

#rCoAUpdates

Bulletin | Issue 112 | November 2018

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Discounts available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

book your place at www.rcoa.ac.uk/events | 1

Contents The President’s View 4

News in brief 8

Guest Editorial 12

Antibiotics: handle with care 12

Faculty of Pain Medicine (FPM) 14

Faculty of Intensive Care Medicine (FICM) 15

SAS and Specialty Doctors 16

Revalidation for anaesthetists 18

Patient Perspective 19

Clinical Directors’ National Executive Committee 20

Anaesthesia Clinical Services Accreditation (ACSA) 24

NIAA research grants 28

Perioperative Journal Watch 30

Working with you to improve patient care: the Health Services Research Centre 31

Meet the HSRC team 32

National Emergency Laparotomy Audit (NELA) 34

How PQIP hopes to improve care and outcomes from major surgery 36

National Audit Projects (NAPs) 37

Sprint National Anaesthesia Projects (SNAPs) 38

The COMPAC and StEP collaboratives 39

Patient, Carer and Public Involvement and Engagement (PCPIE) 40

What’s coming next for HSRC? 42

Hearing your views: perioperative medicine for all anaesthetists 44

International Standards for a Safe Practice of Anaesthesia 46

What should anaesthetists know about ‘genomics’? 50

The RCoA’s new style guides 54

TSP hits middle age 56

Dr J Edmund Riding CBE 58

Guest editorialAntibiotics: handle with careAntimicrobial resistance is now present in every country and represents one of the most pressing economic and health issues of our timePage 12

Your membership mattersAs a fellow or member of the College, you are an integral part of a growing specialtyPage 5

Supporting an anaesthetist in training with additional needsAdjustments for disabled workers to prevent discrimination against themPage 22

Travel to learn: return to inspireA Winston Churchill Fellowship experiencePage 26

Gross negligence manslaughter in medicineHow many of us conceive of criminal charges being brought against us for the errors that are, unfortunately, inevitable during a career in medicine?Page 48

Food for thoughtDo we as anaesthetists understand just how debilitating post-anaesthesia memory loss may be for previously fit and active patients?Page 52

From the editorDr David bogod

Welcome to the November Bulletin.We have devoted a substantial slice of this month’s Bulletin to the brainy bods at the Health Services research Centre (HSrC), the beating heart of patient care improvement initiatives at the royal College. Led by Professors ramani moonesinghe and Iain moppett, HSrC has taken on or pioneered an entire menagerie of acronymic projects. You will certainly be familiar by now with the common-or-garden NAP, and the lesser spotted NeLA will have come to your attention if you provide anaesthesia for the patient with an acute abdomen. SNAPs should be on your radar (think NAPs but snappier), and those of you seeking a gold star might be able to speak for a minute without hesitation, repetition or deviation on the life-cycle of the PQIP. but here, peeking out shyly from the foliage, are some new and exotic creatures, ComPAC, SteP and PCPIe. David Attenborough, eat your heart out!

elsewhere in this issue, I am delighted to carry an article by Professor Alan merry and his team, telling us how they succeeded in getting the World Health organization (WHo) to adopt and endorse the latest edition of the International Standards for a Safe Practice of Anaesthesia, on which Alan has led for the World Federation of Societies of Anaesthesiologists (WFSA). This protean work is pragmatic, recognising the dire shortage of even the most basic monitoring in the poorest parts of the developing world, but also manages to be aspirational. Standards are grouped into three categories, ‘highly recommended’ (in effect, mandatory), ‘recommended’ and ‘suggested’, with the anticipation that parameters such as capnography will move up the scale as technology delivers cheap and robust monitors. I suspect that WHo’s backing for this has the potential to save more lives than any other single advance in anaesthesia, and Alan and his co-workers deserve huge plaudits for seeing this project through to completion.

on a more sombre note, Kate mcCombe, anaesthetist and legal commentator, offers us her views on gross negligence manslaughter in the medical arena. Following recent events in the UK, this is a topic which must have been discussed in every theatre coffee room in the land, and the College is all too aware that many anaesthetists, junior and senior alike, have been distressed and angered by the bawa-Garba case. In this introductory article, Kate describes some of the history of medical manslaughter, and she will go on to consider the current state of play in subsequent editions of the Bulletin.

Finally, I would draw your attention to two articles which talk about those of our colleagues who we are sometimes guilty of overlooking. my Council colleague, Kirstin may, explains why she chose to become an SAS doctor and why it is becoming an increasingly attractive route for those of us seeking that modern Holy Grail, a good work-life balance. And, following on from venthan mailoo’s excellent piece in the last edition on the challenges facing anaesthetists in training with autism, Jen Warren, along with her College tutor, Andy Kelly, tells us about her life as a wheelchair-using anaesthetist in training. As a winner of nine medals at the 2016 Invictus Games and captain of the first disabled female team to compete in the ‘Arch to Arc’ running, swimming and cycling marathon, she leaves me – and, I am sure, you – in awe.

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The President’s View

YOUR MEMBERSHIP MATTERS4 |

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As a fellow or member of the Royal College of Anaesthetists, you are an integral part of a growing specialty. Your voice is important to the future development of anaesthesia, and as President, I am dedicated to making sure that the College does all that is possible to support you throughout your career. I am looking forward to my three-year term, working with Council members and you, our fellows and members, to succeed in making this College the best it can be for you and the specialty.Thank you to everyone who completed the 2018 membership survey – the majority of the findings were very positive. We will be sending an e-newsletter later this month highlighting some of the findings and what we are doing in response.

In this edition of Bulletin, I want to share with you an overview of the recent changes to our membership structures, your membership benefits, and how you can get involved with the College activities and work.

Your membership Improving our inclusivity Last year the College celebrated its 25th anniversary since gaining its Royal Charter. We also took this milestone as an opportunity to review our governance structure. A large part of this included reviewing the membership categories, where we took on board the comments and requests received from you. The resulting amendments to our Charter of Ordinances at the May 2018 AGM enabled us to make two important improvements in our membership.

Firstly, in response to your feedback, the College has introduced a less-than-full-time membership rate. This will help to better support

the wide variety of contracts and working patterns that fellows and members have. Anyone working fewer than eight programmed activities (including wider professional activities) per week, or less than 0.80 whole time equivalent, will be eligible for this. Please email membership@rcoa.ac.uk for more details.

Secondly, we are pleased to introduce a new category for medical students and foundation year doctors (bit.ly/RCoA-Career). Encouraging more students into a career in anaesthesia is one way that the College is working to address the current shortage of anaesthetists across the NHS.

Getting the most from your College membershipI am pleased to share that our recent 2018 membership survey showed that a large majority of you rated the College positively, with a quarter saying the College is ‘excellent’ as an organisation. The College however will never be complacent. Delivering good value for money is important to us. We have been able to maintain some of the lowest membership fees across the Medical Royal Colleges, and results from our 2018 membership survey showed a clear majority of members and fellows rated the College

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Professor ravi mahajan President

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‘good’ or ‘very good’ as a membership organisation and for ‘value for money’ – something we are proud of.

The 2018 membership survey showed a high level of satisfaction for the majority of our services, work and the membership benefits we offer. As well as receiving the College’s Bulletin (bit.ly/RCoABulletin) magazine, peer-reviewed journal the BJA (bit.ly/2xQXvHa) and BJA Education (bit.ly/2xM8gL5), you also have access to a number of additional services and benefits.

For example, we currently have over 120 educational webcasts available to you (bit.ly/RCoA-Webcasts), and the College is exploring ways in which we can improve our online learning content including e-Learning Anaesthesia. We are already running (bit.ly/RCoA-eLA) more regional events, such as the ‘Updates in anaesthesia, critical care and pain management’ in Liverpool later this month. Our aim is to hold 50 per cent of College events outside of London by 2023. However, if you are visiting Red Lion Square, I encourage you to make full use of the building. We have a Fellows’ and Members’ room on the 2nd floor with wifi and coffee on tap for when you need peace and quiet to study or just relax, and a prayer room on the 6th floor. In August this year, after two years of development, we launched our new Lifelong Learning Platform (bit.ly/RCoA-LLP), with the aim of improving support for training, assessment, reflection and lifelong learning.

The recently updated membership pages (www.rcoa.ac.uk/membership) on our website give further details on how you can get the most from your College membership.

Your membership countsAs well as the College’s responsibility to you, we also have a responsibility to the specialty itself.

Through your support, the College is also able to carry out important work in patient safety, clinical standards and research. This includes the Anaesthesia Clinical Services Accreditation (ACSA) scheme (www.rcoa.ac.uk/acsa), with benefits delivered to patients, clinicians and anaesthetic departments across the UK; and keeping our NICE accredited anaesthetic standards setting document, Guidelines for the Provision of Anaesthetic Services (GPAS) (www.rcoa.ac.uk/gpas), up-to-date. We welcome comments and advice from clinicians and managers to enable new information obtained from audit and research to be incorporated into GPAS, so that the College’s guidance reflects and supports best practice. For more information, please email gpas@rcoa.ac.uk

Your membership also enables the College to run a wide range of research projects. This includes the National Emergency Laparotomy Audit (NELA) (www.nela.org.uk) which has helped save hundreds of patients’ lives each year since its inception, and the National Audit Programmes (NAPs) (www.nationalauditprojects.org.uk) and the Sprint National Anaesthesia Projects (SNAPs) (www.niaa-hsrc.org.uk/SNAPs).

Your views also shape how we represent and champion our specialty and the needs of anaesthetists working in the NHS to influence policy makers and elected representatives in the UK and devolved nations’ governments.

Your membership, your say – get involved The College is committed to supporting you, and it is important for us to understand how we can keep doing it better every day, including listening to your views to shape future work and strategy.

Last year, the College’s Membership Engagement Panel was formed with over 1,700 fellows and members volunteering to be part of this virtual panel. This has now grown to over 2,200. Over the last 18 months, through surveys and focus groups, the Panel has contributed to the College’s Education and Events strategy, helped shape training, education and leadership development in QI, and helped us further develop our perioperative medicine strategy. If you have any questions or want to join the panel, please email engage@rcoa.ac.uk

If you would like to get more fully involved with the College, there are a number of different ways to do so. These range from being a College tutor or regional advisor, or joining the Membership Engagement Panel, to becoming an ACSA reviewer or an FRCA examiner, or assisting with College events. For more information, visit the website (bit.ly/RCoA-Involved). Whether you have ten minutes or ten hours to contribute, there is an opportunity for you.

I believe it is important for you to have your voice heard at the College, and would like to extend my gratitude

to all of you who have contributed to the work of the College. Every investment of time, energy and expertise has made a valuable contribution to making the College what it is today.

Furthermore, you have an important role in determining the work of the College by voting, or by applying and standing for important roles on College Council. Nominations for current Council vacancies have now closed, but there is still time to cast your vote. Turnout for Council elections is steadily improving but still College elections are often lost, rather than won, through low levels of engagement. The current election closes at 12.00pm on 3 December 2018, and I encourage you to use your vote.† When there will be future Council vacancies and calls for nominations for election to Council, do also consider standing to be a Council member.

Our future Moving the College outwards beyond its bricks and mortars in London is something that our immediate past President, Dr Liam Brennan, has spoken about. I will continue to champion geographical diversification of College activities across our regions and devolved nations, as well continuing our Global Partnership Strategy (bit.ly/GPstrategy) beyond UK borders.

We are committed to building a strong, supportive and inclusive membership and professional body that all anaesthetists can be proud of. I would like to thank you for your continued membership of the College, which plays a vital role not only in supporting your personal career, but in advancing the future of our specialty and, most importantly, enabling the delivery of excellent patient care.

I look forward to meeting and hearing from as many of you as possible over the course of my Presidency. If you have any comments or questions about your membership, I would be pleased to hear from you at presidentnews@rcoa.ac.uk

†Dependent on membership category.

Bulletinof the Royal College of Anaesthetists

Churchill House, 35 Red Lion Square, London WC1R 4SG 020 7092 1500

www.rcoa.ac.uk/bulletin | bulletin@rcoa.ac.uk

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Registered Charity No 1013887 Registered Charity in Scotland No SC037737

VAT Registration No GB 927 2364 18

President Ravi Mahajan

vice-Presidents Janice Fazackerley and Simon Fletcher

editorial board David Bogod, Editor

Monty Mythen Council Member

Jaideep Pandit Council Member

Krish Ramachandran Council Member

Joanna Budd Lead Regional Anaesthesia Advisor

Sudhansu Pattnaik Lead College Tutor

Emma Stiby SAS Member

Carol Pellowe Lay Committee

Gavin Dallas Head of Communications

Mandie Kelly Website & Publications Officer

Anamika Trivedi Website & Publications Officer

Articles for submission, together with any declaration of interest, should be sent to the 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.

The views and opinions expressed in the Bulletin are solely those of the individual authors. Adverts imply no form of endorsement and neither do they represent the view of the Royal College of Anaesthetists.

© 2018 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.

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

If you would like to get more fully involved with the College, there are a number of different ways to do so.

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News in briefNews and information from around the College

34% of the membership wants to

get involved with and contribute to the College

ACSA celebrates turning fiveAnaesthesia Clinical Services Accreditation (ACSA) (www.rcoa.ac.uk/acsa) is now in its fifth year and recognises anaesthetic departments at Aintree University Hospital NHS Foundation Trust, Wirral University Teaching Hospital NHS Foundation Trust and Bournemouth Hospital on being awarded full ACSA accreditation. All three hospitals and trusts have been recognised for providing the highest quality care to patients. Accreditation ceremonies for Aintree and the Wirral hospitals will take place in the coming weeks, while Bournemouth Hospital recently received their plaque (below).

These latest accreditations takes the number of trusts and boards in the UK that have achieved ACSA accreditation status to 24. Encouragingly, 55 per cent of trusts and boards with anaesthetic departments across the UK are now actively engaged with the ACSA programme.

ACSA information event 28 January 2019The College is holding an ACSA information event in London on Monday 28 January 2019. This is an opportunity to hear ACSA leads from a range of accredited departments discussing their hospital’s approach to engagement, how challenges were overcome and the difference engagement with ACSA has made to their departments.

If members are unable to attend the London event, the College will be holding similar events across the country in 2019 – if this is of interest please contact acsa@rcoa.ac.uk to arrange for a presentation to take place in your hospital.

The application window for new examiners has now closed but please remember you can apply again in July 2019. The College recently made

changes to the appointment process and will now consider flexible and less than fulltime training

working. We are also in the process of reviewing the essential requirements for examiner commitment so

please keep a look out for updated examiner regulations which can be found here: bit.ly/examinerregulations or get in touch with the exams department at exams@rcoa.ac.uk

Updated examiner regulations

Less-than-full-time rate is now available to fellows and membersIn response to fellow and member feedback, the College is pleased to have launched a less-than-full-time membership rate. This will help to better support the wide variety of contracts and working patterns that fellows and members have.

This means that members working fewer than eight programmed activities (including wider professional activities) per week or less than 0.80 whole time equivalent will be eligible for this.

Please email membership@rcoa.ac.uk for more details.

So many ways to get involved with your CollegeThe College is proud of its diverse membership and we are keen to involve you, our fellows and members, in the College’s work. Responding to feedback taken from the 2018 membership survey, 34 per cent of you told us that you would like to volunteer with us.

As a result, we have made it easier for you to find out what opportunities there are through our new ‘get involved’ pages on the College website (bit.ly/RCoA-Involved). Whether you have a few minutes or a few hours, or it is a one off or an ongoing commitment, there are a number of ways for you to engage with the College and work on behalf of its 22,000 fellows and members. From writing an article for the College Bulletin, speaking at an event, or becoming an examiner, there are a variety of ways to get involved.

Visit the College website to find out how you can join in – thank you for your support and participation.

bit.ly/RCoA-Involved

New and improved webcast platformThe College is pleased to announce that it has launched a modified version of its webcasting platform. The new platform allows members to access a range of videos and channels on various topics all aimed at helping members at every stage of their career. The newly improved platform now has the following functionality improvements:

■ videos are categorised into channels, making it easier to find what you are looking for

■ a new ‘how to register your CPD points’ video, has been produced and placed on the home page of the platform, making it easier for users to register their CPD points

■ an additional ‘spotlight’ section at the top of the page relays the latest uploaded videos

■ frequent population of the channels with the latest presentations from our events schedule.

Access the newly modified webcast platform here: bit.ly/WebcastsRCoA

Global Anaesthesia Surgery & obstetric Collaboration conferenceThe College was delighted to be invited to speak and exhibit at the Global Anaesthesia, Surgery & Obstetric Collaboration (GASOC) (www.gasocuk.co.uk) conference which took place in Oxford on Friday 14 September. Attendees comprised doctors in training from all three specialties – it was encouraging to see the passion and drive shown by those present. Dr Michelle White, who has extensive overseas experience through her work with Mercy Ships gave an overview of the College’s international work, and how overseas experience can count towards CCT training. Dr Karen Gilmore who attended on behalf of the Faculty of Pain Medicine gave an overview of the Essential Pain Management initiative (bit.ly/FPM-EPM). It is hoped that the day inspired attendees to get involved in global health work, and the Global Partnerships team look forward to hearing from UK anaesthetic trainees in the future.

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News in briefNews and information

from around the College

New to the NHS Meeting 2019The College recognises the important contribution that overseas doctors make to the specialty and to the NHS in general, and we will continue to support them in adapting to UK life and the NHS.

On Monday 9 July 2018, the College held its annual New to the NHS meeting. This was the fourth year this free event was organised. Aimed at anaesthetists and intensivists, new to NHS practice, the event received very positive feedback.

We are delighted to announce that the College is planning the 2019 meeting for all doctors new to the UK and as of 2019, we will be holding this event twice a year. The next meeting has been scheduled for Monday 11 March 2019 and we are planning to hold another meeting in September 2019 outside of London, so watch this space for more details.

research and quality improvementAs well as this News in Brief section, flick to pages 31–43 of this Bulletin for the NIAA Health Services Research Centre (HSRC)’s 2018 Annual Report, covering an array of the College’s research work in more detail.

Sprint National Anaesthesia Projects

SNAP-2 makes a national splashThe first peer-reviewed paper from the 2nd Sprint National Anaesthesia Project: Epidemiology of Critical Care Services (SNAP-2: EPICCS) was published in the British Journal of Anaesthesia in September (bit.ly/SNAP-2Paper) and received extensive national press coverage. The paper addresses the incidence and reasons for cancellation of inpatient surgery in the NHS. The Daily Telegraph, The Independent, The Guardian, ITV News Online, The Sun and Daily Mail and others covered the story.

A key finding was the cancellation of 1 in 7 of inpatient surgeries during the week of the study in March 2017. Lack of both critical care and general surgical beds as well as the lack of operating theatre capacity was concerning. In addition, of 14,936 patients undergoing elective, non-emergency inpatient surgery, 1,499 (10 per cent) had previously had the same operation cancelled at least once before.

Huge congratulations and thank you to the thousands of local collaborators who worked so hard on SNAP-2 and to the SNAP-2 fellow Dr Danny Wong, senior clinical leads Professor Ramani Moonesinghe and Dr Steve Harris, and the College Research team. Further outputs will be forthcoming.

Support the future of perioperative clinical trialsThere is still time for delegates to register for the UK Perioperative Medicine Clinical Trials Network’s (POMCTN) third autumn meeting, taking place at the College from 19–20 November 2018. The first two-day POMCTN meeting, will include trial presentations and discussion as well as trials skills training. Delegates can attend one day or both days at a discount. Please book via:

bit.ly/Autumnmeeting

rCoA welcomes new guidance on reflective practiceThe Reflective Practitioner guide (bit.ly/2NW3951) has been developed jointly by the Academy of Medical Royal Colleges, the UK Conference of Postgraduate Medical Deans (COPMeD), the General Medical Council (GMC), and the Medical Schools Council. This short guide has been published to help medical students, doctors in training and doctors engaging in revalidation on how to reflect as part of their practice.

There are 10 key points for being an effective reflective practitioner – these include the use of a variety of tools to support structured thinking, the benefits of group reflection and that reflective notes should capture learning outcomes and future plans.

The College welcomes the publication of this new guidance, aimed to help students and doctors at all stages of their career. It recognises the importance of reflecting on clinical practice, not only for individual wellbeing and professional development, but also as a tool to help improve the quality of care patients receive. Whether an undergraduate in training or in the later stage of a career, reflective learning is a cornerstone of good medical practice and everyone should engage with it.

Fitter Better SoonerEndorsed by

Preparing for surgery campaign launches As part of the ongoing work the College is undertaking regarding the development of perioperative medicine, the College’s Patient Information Group has launched the Fitter Better Sooner toolkit aimed at informing patients about how they can prepare for surgery and improve their postoperative outcomes.

Having an operation is a major event in a patient’s life and many will have had limited exposure to hospitals. But there is much patients can do ahead of surgery. The Fitter Better Sooner toolkit is aimed at providing the information patients need to make the most of this ‘teachable’ moment, with advice on lifestyle changes and practical preparation ahead of surgery.

Fitter Better Sooner is a College initiative and is endorsed by the Royal College of Surgeons of England and the Royal College of General Practitioners.

The toolkit consists of:

■ a generic leaflet about preparing for an operation

■ six leaflets about preparing for the most common surgical procedures including hernia repair, cataract and knee repair

■ an animation illustrating how patients can best prepare themselves for surgery.

For more information and access to the resources in the toolkit visit www.rcoa.ac.uk/fitterbettersooner

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Guest Editorial

ANTIBIOTICS: HANDLE WITH CARE

Dr Stephanie Jinks Anaesthetic Fellow, Great Ormond Street Hospital, London

12 November 2018 marks the beginning of the third World Antibiotics Awareness week. The World Health Organization (WHO) will reach out to the public, health professionals, governments, farmers, veterinarians, and the food industry to raise awareness of antimicrobial resistance.1 Antimicrobial resistance (AMR) is now present in every country, and represents one of the most pressing economic and health issues of our time.The term antimicrobial includes antibiotic, antiprotozoal, antiviral, and antifungal medicines. They are crucial in the management of significant infections in humans and animals. Resistance is a natural process that develops with repeated exposure to an antimicrobial. Inappropriate prescriptions by physicians and veterinarians and overuse by the public have accelerated this process.

AMR claims 50,000 lives in the UK and US alone every year. In 2014, 700,000 people globally died of drug-resistant strains of common bacterial infections, human immunodeficiency virus, malaria, and tuberculosis. In India, 60,000 neonates die every year from antibiotic-

resistant infections. A 2014 review led by Lord Jim O’Neill predicted that by 2050, 10 million people would die every year from infection, resulting in a 100 trillion dollars loss to global production.2

Challenges are emerging with the dramatic rise of multi-drug-resistant gram-negative bacteria. The extended-spectrum beta lactamase and carbapenemase enzyme-producing bacteria can now break down the active components of cephalosporins, penicillin and carbapenems. Treatment of such infections can be extremely challenging, often requiring multiple antimicrobial agents.

Antibiotics have not only been used to manage active infection but have also facilitated advancements in medicine and surgery. Antibiotics now provide both prophylaxis and treatment for the immune-compromised, those with chronic disease, and those receiving complex surgeries, all of which would be too high risk if antibiotics become ineffective.

There would also be a significant impact on society. We would lose the confident way in which we lead our lives. If you knew that a simple infection or one associated with an injury could kill you, would you go skiing? Ride a motorbike? Let your child play in the park? Would you continue to work in healthcare, surrounded by patients with infections?

Dame Professor Sally Davies first highlighted the issue in the Chief Medical Officer’s Annual Report in 2011. Prime Minister David Cameron then commissioned Lord O’Neill’s independent review in 2014. In 2013, the Department of Health; Department for the Environment, Food and Rural Affairs; Public Health England; and NHS England collaborated, and implemented the UK 5-Year Antimicrobial Resistance Strategy.3 They identified seven key areas for development:

1 improvement of infection prevention and control practices

2 optimisation of prescribing practice3 improvement of professional

education, training and public engagement

4 development of new drugs, treatment and diagnostics

5 improvement of access to and use of surveillance data

6 improvement of identification and prioritisation of AMR research

7 strengthening of international collaboration.

Critical care and anaesthetic staff will be familiar with the antibiotic stewardship programme launched in 2015. The treatment algorithm ‘Start Smart – Then Focus’, and the principle of administration of prophylactic antibiotics within 60 minutes of surgery are common knowledge.4 NHS England also launched a Commissioning for Quality and Innovation (CQUIN) national goal in 2016/2017, aimed at reducing antibiotic consumption and promoting stewardship.

In 2015, WHO launched a global action plan with similar aims to the UK strategy. The European Centre for Disease Control continues to provide surveillance reports on AMR, and the formation of the Global Antimicrobial Resistance Surveillance Systems has enhanced international surveillance. The UK government also created the Fleming Fund to improve disease surveillance in low and middle income countries.2

Political and public engagement has improved. AMR was acknowledged by leaders at the G20 summit and the United Nations Declaration on AMR in 2016. European Antibiotic Awareness Day (18 November in 2018) and World Antibiotics Week are established, and have improved public and healthcare-sector awareness alongside the Public Health England Antibiotic Guardian (#antibioticguardian) campaign.

Further investment is required in diagnostics and the development of new drugs. The UK and China have contributed to the Global Innovation Fund, and the UK Longitude Prize will be awarded to a competitor that can develop a point-of-care diagnostic test to conserve antibiotics.

Progress is being made. The UK Annual Progress Report for 2016 demonstrated that resistance was stable, that total consumption of antibiotics by humans fell by 2 per cent and that antibiotics

administration to food producing animals fell by 10 per cent. However, infection rates continue to rise.5 Infection prevention should be the priority along with judicious use of antibiotics.

To learn more and get involved visit www.who.int/campaigns/world-antibiotic-awareness-week

references1 World Antibiotic Awareness Week, 12–18

November 2018. WHO (bit.ly/2O5xpqm).

2 Tackling Drug Resistant Infections Globally. Final Report and Recommendations 2016. The Review on Antimicrobial Resistance Chaired by Jim O’Neill (bit.ly/2n3L59Z).

3 UK 5 Year Antimicrobial Resistance Strategy 2013–2018. DH 2013 (bit.ly/2LVlmPb).

4 Antimicrobial Stewardship: Systems and Processes for Effective Antimicrobial Medicine Use (NG15). NICE 2015 (bit.ly/2LUjCFO).

5 UK 5 Year Antimicrobial Resistance Strategy 2013–2018. Annual Progress Report 2016. HM Government (bit.ly/2M2e0tm).

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Reprinted from ‘Our time with antibiotics is running out’ © World Health Organization 2017 (bit.ly/2LWJmSF)

World Antibiotic

Awareness Week12–18 November

2018

Faculty of Pain Medicine (FPM)

New membership working party

Faculty of Intensive Care Medicine (FICM)

Update from the Professional Standards Committee

Dr John Hughes Vice-Dean, Faculty of Pain Medicine

Dr Peter macnaughton Chair, FICM Professional Standards Committee

With the College governance review and the GMC changes in curricula and training, there has been significant development by the FPM and its new membership working party regarding new routes of entry to the Faculty.

Affiliate fellowshipWhen fellowship by assessment (later by examination) came into being, it became very difficult for acute/inpatient pain medicine doctors to join the FPM family. Following work undertaken by the Faculty including acute pain representation it was clear the Faculty wanted to be an all-embracing home for doctors active in all types of pain medicine. We are therefore, opening the affiliate fellowship route for pain medicine doctors (with job-planned direct clinical care [DCC] sessions) who would not be eligible for other fellowship routes. We hope that interested clinicians will join and allow the FPM to evolve to have much stronger connections with acute/inpatient pain medicine. This route is also open to chronic pain consultants with DCC pain sessions who are not eligible for other fellowship routes.

In time it is hoped that this route will be available to anaesthetists in training. This links with ongoing curriculum and credentialing development work.

Details of the criteria for affiliate fellowship were published on the FPM website on 24 September 2018 (bit.ly/2xMHuC7).

Fellowship for non-anaesthetic physiciansThis is an opportunity to improve our liaison with colleagues working in the field who are currently not supported. Several hospital consultant groups may be interested, we have had productive discussions with the Palliative Care Training and Assessment Committee. There are two components to this, one is a ‘grandfathering’ process (2nd wave) for established non-anaesthetic consultants

delivering pain services – similar to when the FPM was originally developed. The second is for non-anaesthetist trainees to be able to undertake equivalent training to that currently offered by anaesthetic advanced pain training.

The College Council has ratified the new membership route, delegating the development of details to the FPM.

Running concurrently with this is curriculum and credentialing work related to recent GMC publications. The FPM is actively engaging in developing credentials in pain medicine. This broadens the opportunities for the training of non-anaesthetists in pain medicine.

This new fellowship route will be opened when it is clear how training and access will be delivered.

The main focus of the Professional Standards Committee (PSC) during recent months has been towards producing a comprehensive update to the joint Faculty and Intensive Care Society publication, Guidelines for the Provision of Intensive Care Services (GPICS). This is a significant piece of work that is progressing well. GPICS version 2 will focus on service delivery, quality and safety. As a result some of the current clinical chapters in GPICS (bit.ly/2Nwn9HU) will no longer appear, although relevant clinical guidelines will be signposted in the document. A number of new chapters relating to service delivery (including capacity management), point of care ultrasound, and serious infection outbreak have been commissioned. By the time you read this article, the final draft document should be out for open public consultation prior to final publication, which is expected to be early 2019.

The FICM/ICS ARDS (Acute Respiratory Distress Syndrome) guidelines have now been published, and are available on the Faculty’s website to download (bit.ly/2NBBgeY). This has been a significant piece of work that was undertaken using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, and I would like to thank all those involved, including the co-chairs Professor Mark Griffiths and Dr Simon Baudouin. The two recommendations

with the greatest weight that come with a strong advisory recommendation are the use of protective ventilation with low tidal volume in all patients, and prone ventilation in those with moderate and severe ARDS. These are interventions that all units can provide and which they should audit to assess their compliance. A survey of prone ventilation was commissioned by the committee

earlier this year, and the results are being analysed with a plan to produce guidance on management of the prone patient, which should support the greater use of the intervention.

Other ongoing activity of the PSC includes developing new guidelines for renal replacement therapy, management of delirium in the ICU, and prevention and management of air embolism.

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Bulletin | Issue 112 | November 2018

SAS and Specialty Doctors

A glass half-full, not half-empty

Dr Kirstin may RCoA SAS Member of Council, Banbury

SAS anaesthetists make up 22 per cent of our workforce (College Census 2015). The numbers in SAS and trust doctor posts are increasing. The College SAS survey in 2016 showed that 34 per cent enjoyed their job and 47 per cent believed it gives a better work-life balance. This contrasts with the previously held belief that SAS jobs are for ‘failed anaesthetists in training’, and are undesirable options of last resort.

My personal experience as an SAS doctorFollowing the birth of my first child in 2000, I went back into training on a part-time basis (then 48 hours/week) when the baby was three months old. Initially this went well as I returned to my previous place of work, but it became more difficult when rotating on, as I had to resit my Primary FRCA – thankfully with success – and commute a significant distance. Attitudes to part-time training varied considerably in those days, and I came across a certain amount of eye-rolling by trainers. I managed, but only just. Two years later my second child was born, and again I returned to

work four months later. The combination of family life, training, commuting, and the need to improve my CV in preparation for registrar-job applications eventually took its toll. I considered my options in depth: continue my training, go back to my previous specialty, move sideways into GP training, or even give up doctoring altogether. Luckily there was an opportunity to keep going as an anaesthetist, initially as part of a deanery-funded ‘retainer scheme’. After a few months I became a part-time staff grade anaesthetist in my previous place of training, and in 2008 I was regraded to associate specialist.

My working life has been brilliant since then: I have fabulous colleagues who have given me the chance to gain confidence and have encouraged me to develop wider interests. I have always been treated as a full member of the team, by colleagues and usually also by surgeons. My marriage and family life have benefitted from the stable employment situation, a short commute and predictable work patterns. After initially being on call on a junior rota, I have had different out-of-hours commitments and been on a senior rota for the last few years.

The only way to do great work is to love what you do. If you haven’t found it, keep looking. Don’t settle. Steve Jobs

I have represented SAS colleagues on my local negotiating committees, sat on various trust committees and have been an appraiser at my trust for the last three years. Joining College Council in 2015 has given me the chance to get involved in every area of College business, supported by my colleagues who put up with me making requests to change my working days to accommodate College duties. There are downsides to my SAS post, notably pay, but I have few regrets.

Lessons for recruitmentDuring engagement sessions we have been asked by clinical directors who find it difficult to recruit to such posts what SAS doctors are looking for and what they could offer to help them recruit and retain.

Doctors take up SAS and trust grade posts for a multitude of reasons, but increasingly to balance work and life outside of work. For some, fixed working patterns can be helpful to accommodate childcare requirements,

other interests, or even a parallel career. For others the desire, or even need, for flexibility can be what drove them to this type of employment, and with a bit of imagination even electronic self-rostering has been successfully trialled.

Career grade doctors should have a chance and a desire to develop, and their duties, responsibilities and job plans should reflect that and may change significantly over time.

SAS anaesthetists are permanent employees, and deserve to be treated as long-term colleagues with equal rights to other doctors in permanent posts. They should be invited to, and actively participate in, staff and clinical governance meetings, and not always be the ones left to ‘hold the bleep’. They should have equitable access to study and annual leave slots. As requirements on them for appraisal and revalidation are identical to those on consultants, they should have the same support in terms of assistance, SPA time and study-leave funding.

Many trusts are currently reluctant to recruit to permanent specialty-doctor posts, and instead offer fixed-term, trust grade contracts. Clinical directors should not, however, underestimate the advantages of offering job security in a permanent post.

In emergency medicine, consultant Dan Boden from Derby Teaching Hospitals NHS Foundation Trust has led the introduction of a retention programme which values and respects all clinical staff and has had remarkable results. It has proven to be financially viable and to provide a higher standard of healthcare.

Further reading ■ SAS anaesthetists – securing our workforce.

RCoA, 2017 (bit.ly/RCoA-SAS).

■ A charter for SAS doctors England. AoMRC, 2014 (bit.ly/2MJnOcV).

■ SAS doctor development guide. AoMRC, 2017 (bit.ly/2MDKLhi).

■ SAS development and retention programme. HEE, 2018 (bit.ly/2wwRBLr).

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Revalidation for anaesthetists

‘Mythbusters’ about appraisal for revalidation

Chris Kennedy rCoA CPD and revalidation

Coordinator

Patient Perspective

How close to the bone is Allelujah?Recently, I had the opportunity to see Alan Bennett’s new play Allelujah at the Bridge Theatre in London. As a long-term admirer of the scribe I was interested to see how he would deal with the NHS in modern times.Although not of the same genre as The History Boys or The Lady in the Van, I nevertheless found it thought provoking and reflected on its content. It is set in the fictional Bethlehem hospital, fondly known as 'the Beth', in Yorkshire, on the Care of the Elderly ward (though they call it Geriatric). For years the hospital has provided care from birth to the grave, but all this is now in doubt. The hospital, though financially successful, is earmarked for closure, and the chairman, who is more concerned with his own survival than that of the Beth, invites in a film crew to document its work. Although it is meeting targets, the Department of Health wants to close it. As Colin, the bright young management consultant,

argues, ‘The State should not be seen to work. If the State is seen to work, we shall never be rid of it.’

The residents/patients represent a wide range of people – a teacher, a librarian, a miner. All have done important and significant work in the past, but now are on the undervalued scrap heap. There is a feeling of decay, bed-blocking, and of patients just waiting for death when others perhaps could use their beds more effectively for a younger (more important?) cohort. The staff seem worn out, and they portray all the current issues of burnout, working on student visas, and working with limited resources and trying to make the best of those they have.

One inspired nurse establishes a choir, even though one notes that the old folk won’t be there long enough to really get it off the ground! However, despite their frailty, once the music pipes up they can remember the lyrics and the old dance moves. Meanwhile the sister, played superbly by Deborah Findlay, turns out to be a Beverly Allitt character with her own methods of creating turnover.

I did wonder if this might be Bennett’s own swan song. It’s his first play for six years and in it, despite the comedy, there is a plea to respect the elderly and acknowledge their vulnerability, and to protect what we treasure – that is the NHS and all it represents.

Carol Pellowe Chair, RCoA Lay Committee

The revalidation article in the May 2018 edition of the Bulletin focused on the ‘Mythbusters’ document, which has been produced to clarify recommendations and requirements. With a number of enquiries about appraisal recently received at the College Revalidation Helpdesk, we would like to reference the following examples from ‘Mythbusters’.

MythI need to undertake five appraisals to revalidate successfullyYou are expected to engage fully in the annual appraisal process to revalidate successfully (see bit.ly/2oInpZx). However, there is no requirement to have five annual appraisals before a revalidation recommendation can be made. It is important that any appraisals missed in the revalidation cycle are agreed by your responsible officer (RO) as necessary and appropriate. Before the RO can make a positive recommendation to revalidate, you must have collected all the GMC supporting information required to provide assurance that you are up-to-date and fit to practise, and have reflected on it during your appraisal. This is likely to take at least two appraisals – one to define what you need and to design a personal development plan (PDP) that supports you in achieving it all, and a second where you can reflect, with your appraiser, on all your supporting information, in particular your feedback from colleagues and patients.

MythIt is my responsible officer’s responsibility to ensure that I have an appraisal GMC statutory guidance states that to maintain your licence to practise you must ensure that you have an annual medical appraisal and demonstrate your continued competence across your whole scope of practice. Your RO has a statutory responsibility for ensuring that the appraisal process is fit for purpose, but you must play your part in engaging fully with the process.

For further information please contact ckennedy@rcoa.ac.uk

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Bulletin | Issue 112 | November 2018

Clinical Directors’ National Executive Committee

The Clinical Directors’ Network

Dr richard Davidson RCoA Clinical Directors’ National Executive Committee

I am one of the new members appointed to the College Clinical Directors’ National Executive Committee in August 2017.Following a year in industry, I completed undergraduate training in London and postgraduate training during a short commission with the Royal Navy, and in London, Cambridge and Yorkshire, supplemented by a year as a ‘visiting instructor’ at the University of Michigan in Ann Arbor. During all of this it rapidly dawned on me that there are many effective ways of achieving the same thing. Appointed to a consultant post in Bradford in 2000, I’ve held many educational roles, latterly moving into management and leadership when I was appointed Clinical Director in Anaesthetics and Critical Care in 2009. Fast-forward through nine years, several management structure reconfigurations, and a short spell when a colleague took over the role, and I remain in a very similar capacity (albeit now called ‘clinical lead’), having been asked to reapply for the vacant position during a difficult time for the department when no one else was interested…the ‘poisoned chalice’.

I first became involved in leadership roles as it all looked pretty easy really! I could frequently see much more effective ways of doing things, and wanted the opportunity to influence

the changes required. How naïve was I! I would forge ahead with schemes that were ‘so beneficial’ and were ‘so obviously’ the right things to do, only to find disengaged colleagues looking down at their feet. The expectation of senior management was more modest, and the constraints both they and I were working under rapidly became apparent. It also became abundantly clear to me, probably sometime after it was already clear to colleagues, that my enthusiasm was not necessarily matched by my leadership abilities. I benefited enormously from the investment the trust made in providing me with some skills and knowledge, as well as from the influence of informal coaching and that of the Faculty of Medical Leadership and Management. As a result I’ve learned to become much more pragmatic and ‘hands-off’. I encourage much greater colleague engagement in terms of ownership of problems, and no longer take the inevitable setbacks quite so personally. Hopefully I’ve made things better, but I guess that’s for others to say – such as the colleague who recently announced ‘well you couldn’t have made it any worse than it was!’

In terms of my involvement with the Executive Committee, after my appointment I committed the ‘schoolboy error’ of missing the first Committee meeting, at which there was unanimous support for awarding me the role of coordinating the clinical directors’ meeting in May this year, and having passed that one I now find myself in a similar position for the November meeting. I’m also representing the Executive Committee on the College Anaesthetic Curriculum Review Group.

Clinical leadership can be daunting, lonely and thankless. What makes it easier is the recognition that very few problems are new ones, and that even those that appear intractable invariably have already been resolved elsewhere, which is why the Clinical Directors’ forum is such a useful resource. I hope to contribute to even greater collaboration between colleagues in similar roles across the country, and particularly at a local and regional level. The following is an example from the forum of what other organisations have done to address a common problem.

How do directorates deal with necessary governance ‘half-days’ and still maintain activity?There are a variety of approaches. Some trusts align half-days so that all activity is lost at the same time, thus minimising lost activity. This is probably the most efficient way of managing the GMC requirement for departmental governance meetings, but it requires a coordinated approach authorised by the medical director/board. Additional benefits include the opportunity to convene joint meetings (eg obstetric/anaesthetic).

One of the central tenets of the 2003 contract was that consultants should not be paid twice for the same work. As clinical governance half-days constitute SPA activity, if they occur in direct clinical care (DCC) time it may be possible for the trust to ‘claim back’ DCC activity if SPA is worked flexibly. This further reduces the overall impact of lost DCC.

Our trust requires ‘payback’ of any lost DCC, but this has proved difficult to implement for surgical directorates in the division who, unlike the anaesthetic department, don’t use an electronic rota system. Our directorate has an overall target number of sessions to be

delivered as part of the contract agreed by individuals through the job-planning process, which would include any clinical sessions displaced by clinical governance half-days.

Further information on the Clinical

Directors’ Network is avilable on the website:

bit.ly/RCoA-CDN

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Society for Education in Anaesthesia (UK)

Supporting an anaesthetist in training with additional needs

Dr Jen Warren ST5 in Anaesthesia and Intensive Care Medicine, University Hospitals of Coventry and Warwick

Dr Andrew Kelly Consultant Anaesthetist and College Tutor, University Hospitals of Coventry and Warwick

Jen is an ST5 in Anaesthetics and Intensive Care Medicine currently working in Warwickshire. Following an accident in 2008, Jen is a wheelchair user. Andy is her College tutor.

The Equality Act 2010 requires employers to make reasonable adjustments for disabled workers and to prevent discrimination against them. NHS training programmes are not exempt. Disability or long-term health conditions are commonly encountered in medical practice, yet are rare amongst doctors. Nearly 20 per cent of working-age adults report a disability, in stark contrast to under 2 per cent of doctors in the 2017 GMC survey. The World Health Organization describes disability as a broad term, covering impairments, activity limitations, and participation restrictions. Disability is thus not just a health problem; it is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives. Overcoming the difficulties faced by people with disabilities requires interventions to remove environmental and social barriers.

Anaesthetist in training perspectiveHaving to work hard to rebuild my career has only enhanced my desire to be a good anaesthetist. I have been supported by some incredible colleagues, but I have experienced a wide variety of reactions when starting a new post – most commonly surprise or fear of what to expect.

I am proactive and always visit a new workplace before starting, enabling me to anticipate areas of difficulty. Generally, hospitals are very accessible, as everywhere a patient needs to reach I can reach. It is sometimes challenging to get to offices for meetings, to changing areas or to coffee rooms, and this can be a bit isolating. In my experience, clinicians are not confident with risk assessments, however these are essential to ensure patient safety and to reduce

the risk of unfairly discriminating against an anaesthetist in training. I have found senior ODPs and nurses very helpful with risk assessments.

At times I wish my disability was not so visible – healthcare professionals are used to viewing disability in medical terms, so can make unhelpful assumptions about my capabilities. Disabled people live with their impairments all of the time, not just at work, and even simple household tasks require problem solving and adaptation. I think my disability actually enhances my abilities as an anaesthetist.

Feedback is a fundamental aspect of progression through training, and occasionally this is used as a means of expressing a discriminatory opinion. A single opinion may not affect an ARCP outcome, but this does not mean it should go unchallenged. If workplace

culture is to be changed, discrimination needs to be challenged head-on. Isolated environmental changes, such as a ramp or ‘disabled’ toilet, do not make a workplace accessible. In my opinion the NHS already has most useful environmental changes, but the cultural ones need some work.

College tutor’s perspectiveAccurately identifying individual training needs is fundamental for satisfactory progression during the placement, as well as being vital for morale. With regards to an anaesthetist in training with additional needs, this was relatively uncharted water for our trust.

The first barrier was the perception of staff on seeing a doctor in a wheelchair, with an immediate response that focused negatively on what the doctor would not

be able to do. Many of these concerns were allayed during the process of risk assessment that we carried out in all clinical areas. The risk assessments were broadly split into the work that was required of an anaesthetist in training, the dangers that may exist for Jen, and any dangers that might affect patients resulting from being cared for by a doctor who mobilises in a wheelchair.

There is nothing that is expected of an anaesthetist in training that Jen cannot do. Of course there are adaptations to be made – for example Jen doesn’t push a bed on transfers, but is present to monitor and react to any problems just as one would expect. The main area of danger for Jen was in the theatre complex with its heavy doors and high windows, which required a different technique to be employed in order to avoid injury. There were no areas where patients were at any increased risk.

Once Jen started work at University Hospitals Coventry and Warwickshire, it became clear that our risk assessment was appropriate. While there was some adaptation needed to working practices, the main barrier was the negative attitudes regarding her capabilities.

It is here that the other facets of Jen’s life helped greatly. Her performance in the Invictus Games, completion of the Arch to Arc challenge and other elite sporting activities propelled her to the status of celebrity within the trust. This, coupled with being an extremely caring and competent clinician, made it clear to those who had doubted her that she in fact performs at a far higher level than they had expected, and that she is a well-respected and valued member of the team.

Jen has taken part in numerous sporting events; most notably winning nine medals at the 2016 Invictus Games, becoming the first person to take part in the Lewa Marathon in a wheelchair and captaining the first female disabled team to complete the Arch to Arc (running, swimming and cycling from Marble Arch in London to the Arc de Triomphe in Paris).

© Help for Heroes

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Dr Jonathan Chambers ACSA lead, Dorset County

Hospital and co-opted member of the ACSA

Committee

The expectations of life depend upon diligence ; the mechanic that would perfect his work must first sharpen his tools . Confucius

From reading previous articles in the Bulletin by other departments who chose to engage in ACSA, it is clear that many started the process despite a questioning and sceptical department. Our path towards accreditation started in a similar vein back in 2014, with a raised eyebrow or two and the standard questions of ‘why?’, ‘what?’, and ‘how much?’ Further investigation by our clinical director and myself led us to start assessing the gap between ACSA standards and the current practice within the department. We felt that, historically, we were a good department – anaesthetists in training and patients rated us well, but the challenge was to confirm that this was an accurate view and, if it was, that we had the evidence to prove it.

ACSA provided both the platform and the tools to reassure our department that we had many of the required policies, guidance, personnel and procedures in place. It also highlighted the gaps in our service provision and quality, which had not kept up with recent clinical developments and changes in practice. Or, as Confucius said, which tools needed sharpening.

Once the consultant body had agreed to engage with ACSA, work on the gap analysis started in earnest late in 2016. The clinical director and I divided up the ACSA standards into specialty groups and areas of departmental SPA responsibility (be careful what you claim to do in your SPA time). Once allocated to relevant individuals, we requested feedback on where we stood between the requirements of each standard and our current practice. This included beginning to collate evidence and battling our hospital intranet to confirm that the policies and departmental guidelines listed were accessible, relevant, and up-to-date.

Over the ensuing months, colleagues tolerated my incessant requests, nagging,

chasing, and reminding. This was the time-consuming aspect. I have great colleagues who supported and engaged with the ACSA process, but we are all busy, and collating evidence takes time. By early 2017 we decided that we had made enough progress to request a visit, and this was booked for November.

Having this deadline helped move the process forward. It was also an opportunity for the wider theatre teams to get involved with reviewing the theatre facility, drug cupboards, training logs, theatre security, and patient information, and for the collation of audit data on activity. The joy of any department is that we all bring a mix of different approaches to meeting any objective. Some love to get the work done early, some will spread it out over time, and some love to see me sweat only to pull it out of the bag at the last minute (you know who you are...).

With two months to go, and with the help of our IT department (yes, I did say ‘help’ and ‘IT’ in the same sentence!), we started uploading relevant policies and guidance to a web-based portal (http://datanywhere.com) which enabled the review team to have sight of documents prior to the review. While it would add to the work, we felt that this would give the review team a clearer idea of who we were and how we worked, and help them get a better idea of the challenges and the successes of our department.

Finally, after a huge departmental effort, the two days of on-site review took

place. The team themselves were polite, approachable and thorough. While it is not possible to assess all ACSA standards in a two-day visit, it felt as if they left no stone unturned. The visit was an opportunity for the department to show how we work and to demonstrate how we have overcome a number of challenges. The theatre staff also rose to the occasion both as a source of information to help the team triangulate compliance with the standards, and, when given the opportunity, to showcase their department.

Every department has a culture at its heart, and this approach to clinical care was not something that could be developed overnight. Our accreditation has enabled us to reflect on and demonstrate the hard work and dedication of many colleagues, both past and present, who have set the standards we now benefit from. As a team we have taken pride in our accreditation, and in so doing successfully withstood the rigours of external scrutiny, and benchmarked ourselves against nationally agreed standards and against other anaesthetic departments. Working towards accreditation gave the department a common purpose and an opportunity to involve the whole theatre community in reviewing how we work, and why we do what we do. As John Ruskin said, ‘Quality is never an accident. It is the result of intelligent effort’. ACSA has proved this to be true: the effort involved should not be underestimated, but as a process which improves quality of patient care, it is worth it.

Anaesthesia Clinical Services Accreditation (ACSA)

Our journey towards ACSA accreditation at Dorset County Hospital

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TRAVEL TO LEARN: RETURN TO INSPIREA Winston Churchill Fellowship experienceThe Winston Churchill Memorial Fellowship Trust was founded when Winston Churchill died in 1965. Thousands of people, out of respect for the man and in gratitude for his inspired leadership, gave generously so that a living memorial to him could benefit future generations of British people.As Sir Winston’s national memorial, the trust carries forward his legacy by funding UK citizens from all backgrounds to travel overseas in pursuit of new and better ways of tackling a wide range of the current challenges facing the UK. Successful applicants are known as ‘Churchill Fellows’ for life.

The fellowships support professionals from a wide range of professions and disciplines, including those from a dedicated Healthcare Award Category focused on supporting ‘innovations for the twenty-first century’. It was to this category that I applied for funding

to travel to the US to experience and understand US approaches to digital care and innovation.

The programme was coordinated by Professor Jaideep J Pandit of Oxford University, and supported by the Chief Medical Officer of my host trust (University Hospitals Coventry and Warwickshire NHS Trust [UHCW]). I spent a month in the US, visiting Washington DC, Phoenix, Kansas City and Boston, where I visited organisations including the Cerner Corporation, the American Diabetes Association, and the Patient Centered Outcomes

Research Institute. A key focus of the trip was two weeks spent in Boston at The Beth Israel Deaconess Medical Center, hosted by Professor Satya Krishna Ramachandran, anaesthetist and the Center’s Vice-Chair of Quality and Safety.

During my time at the Beth Israel, I was able to witness a department-wide Safety Grand Round, where all operating theatre activity was paused for an early morning and multidisciplinary discussion

of root-cause analysis findings and core safety messages arising over the previous months. This was alongside meetings with clinicians and academics from Harvard Medical School’s informatics department, learning how to better use data to support safe and innovative patient care.

Churchill Fellows are encouraged to document their experiences in a reflective journal, through a process of thematic observation and reflection. Their learning is then condensed into a Fellowship Report published on the Churchill website (www.wcmt.org.uk). The key findings from my own report explore how the UK can learn from US approaches to digital healthcare implementation as we look to improve patient safety and care quality through digital innovation across the NHS. The key elements that I now feel are necessary for achieving this include:

1 patient engagement in development of digital healthcare environments

2 clinician engagement in the development of digital health environments

3 support of entrepreneurship and innovation

4 improved use and analysis of routinely collected data in digital health environments, including patient-safety data

5 training for clinicians in clinical informatics (the capture, communication and use of data and clinical knowledge to support health professionals).

There is significant potential to achieve this in NHS settings, with UHCW in the West Midlands an excellent example. UHCW itself has a collaborative relationship with the Institute of Digital Healthcare at the University of Warwick, with a number of staff working across both organisations. Since returning to the UK I have been involved in a number of initiatives there, including development of a postcard-based approach to recruiting patients to digital and diabetes research engagement, creation of a collaborative relationship with commercial organisations looking to revolutionise digital diabetes education, and initiation of a project looking to use existing routinely collected data to risk-stratify patients with diabetes. All of these further integrate and align with a range of innovative safety-led digital interventions at UHCW, which encourage staff from all groups to engage in leadership and safety initiatives that will take the trust closer to its aim of being the safest hospital in the UK and a frontrunner in research, education and innovation.

Churchill Fellowships represent an incredible opportunity for UK doctors to travel internationally, to broaden their experiences, and to directly apply that learning back in the United Kingdom. If you are passionate about a healthcare challenge faced by the NHS, this could be the ideal opportunity for you to travel, learn and inspire!

Dr Robbins’ full report, and information about how to apply for your own Churchill Fellowship are available at: www.wcmt.org.uk. His fellowship was facilitated by a research collaboration between Professors Pandit and Satya Krishna Ramachandran, and supported by Professor Meghana Pandit, Chief Medical Officer and Deputy CEO, University Hospitals Coventry and Warwickshire NHS Trust.

Dr Tim robbins Clinical Research Fellow,

University Hospitals Coventry and Warwickshire NHS Trust, Coventry

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YEARS

10 NIAANational Institute of Academic

Anaesthesia 2008–2018

NIAA RESEARCH GRANTSResults of 2018 Round 1On Wednesday 27 June 2018 the NIAA Grants Committee met to consider the first round of applications for 2018 on behalf of the Association of Anaesthetists, Anaesthesia, the Association for Cardiothoracic Anaesthesia and Critical Care (ACTACC), the British Journal of Anaesthesia (BJA), the Royal College of Anaesthetists (RCoA), the British Society of Orthopaedic Anaesthetists (BSOA), the Difficult Airway Society (DAS), the Neuro Anaesthesia and Critical Care Society of Great Britain and Ireland (NACCSGBI), the Obstetric Anaesthetists’ Association (OAA), and Regional Anaesthesia UK (RA-UK).

The committee considered 38 applications over ten categories for a requested sum of £1,123,182, and made a total of 14 awards over seven categories to a value of £486,235. The success rate for applicants was 37 per cent.

A list of the successful applicants can be found in the following table, and abstracts can be viewed here: bit.ly/2N9DjKq

Association of Anaesthetists/Anaesthesia research Grants

Dr Ronelle Mouton General, local, and regional anaesthesia in emergency surgery (GALORE)

£28,092

Dr Anna Ratcliffe Accelerometers for assessing recovery (AFAR) £5,142

Dr Pawandeep Sarai Novel monitoring tools in vascular surgery: can transcranial magnetic stimulation be used to monitor spinal-cord function during open and endovascular repair of thoraco-abdominal aortic aneurysms?

£22,236

Dr Ben Shelley PROFILES : bnP for pRediction of Outcome FollowIng Lung rEsection Surgery

£25,239

Association of Anaesthetists/ACTACC research Grant

Dr Gudrun Kunst Comparison between propofol and isoflurane anaesthesia (COPIA) on cardiovascular outcomes following cardiac surgery: a randomised, controlled feasibility trial

£43,758

BJA/rCoA Project Grants

Dr Joseph E Alderman Could characterising different phenomes associated with hyperlactaemia allow better targeted therapy for patients in shocked states?

£14,938

Professor Iain Moppett Cerebrovascular accident and acute coronary syndrome and perioperative outcomes study (CAPO)

£69,999

Dr Jonathan Rhodes Traumatic brain-injury associated radiological deep venous thrombosis incidence and significance (TARDIS)

£69,454**Joint funded with NACCSGBI

Dr Hailin Zhao Novel preservative strategy in protecting lung graft £69,173

bSoA Project Grant

Dr Rachel Baumber Understanding which perioperative factors increase complexity and influence quality-of-life outcomes in revision lower-limb arthroplasty

£10,000

oAA Large Project Grants

Dr Rachel Kearns Effect of maternal anaesthesia on short- and long-term offspring outcomes: a population-based study

£59,942

Dr Nazir Lone Maternal critical care: identifying at-risk women and understanding the short- and long-term consequences of critical illness in pregnant or recently pregnant women

£48,262

oAA medium Project Grant

Dr Rachel Collis Characterising the coagulopathy of postpartum haemorrhage (PPH) £15,000

rA-UK Project Grant

Professor Graeme McLeod Objective measurement of regional-block performance using new eye-tracking technology

£5,000

Did you know? minutes from all NIAA Grant

Committee meetings are freely available to view on the NIAA

website (bit.ly/2ChKQ5L).

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Most of you will have heard of the National Audit Projects (NAPs), Sprint National Anaesthesia Projects (SNAPs), National Emergency Laparotomy Audit (NELA) and the Perioperative Quality Improvement Programme (PQIP). All of these projects – and many more – are delivered by the Health Services Research Centre (HSRC), based at the Royal College of Anaesthetists. As the Director and Deputy Director, it is our privilege and pleasure to introduce this annual report, which provides an overview of our people, our activities and our future plans.

The HSRC is a unique collaboration between a clinically-led research centre based at a Medical Royal College, and grass-roots clinicians working throughout the NHS. The scope and ambition of research activity that the HSRC leads is unparalleled within UK healthcare. There are two key ingredients which make this possible. The first is the ‘citizen-science’ approach – this means the participation of thousands of frontline clinicians who do not usually have research skills or experience, or research time within their clinical contracts. This is critically important to ensure that our scientific findings are tied to the ‘real world’ and reflect the challenges and complexity of delivering high-quality perioperative healthcare in the NHS. The second is our commitment to supporting the

development of the next generation of clinical academic leaders through our research fellowship programme, which recruits up to five fellows every year.

Over the following pages we will cover all our current activity, including our less visible work – in particular, projects involving patients and the public such as the Core Outcomes (COMPAC) programme and the Patient Carer and Public Involvement and Engagement group. We also have several exciting new ventures to tell you about. We are grateful to the College for our core funding, and to numerous external funders, including the Healthcare Quality Improvement Partnership, the Health Foundation, the Association of Anaesthetists, the Association of Paediatric Anaesthetists,

the National Institute for Health Research, and the University College London Surgical Outcomes Research Centre, for providing project-specific support. Above all, we want to thank you, our collaborators, without whom this work would be impossible. If you want to find out more, just get in touch.

hsrc@rcoa.ac.uk www.niaa-hsrc.org.uk

PERIOPERATIVE JOURNAL WATCHDr Katie Samuel, bristol School of Anaesthesia; Dr Nicole Greenshields and Dr bence Hajdu, Perioperative medicine Fellows, University College London Hospitals

The relationship between preoperative hypertension and intraoperative haemodynamic changes known to be associated with postoperative morbidityThis South African five-day, multicentre, prospective observational cohort study looked at adult patients undergoing elective non-cardiac and non-obstetric surgery. It questioned whether preoperative hypertension (HTN) predisposed patients to intraoperative haemodynamic instability (hypotension and tachycardia), and whether it may therefore be associated with perioperative outcomes.

A total of 324 patients were included, of whom 164 had HTN. Intraoperative tachycardia (>100) occurred in 126 patients (45 per cent with HTN), and intraoperative hypotension (MAP <55 for > 1 min) occurred in 59 patients (42 per cent with HTN).

No association was found between preoperative HTN and intraoperative haemodynamic changes. The authors therefore support the continuing of practice as per current guidelines, proceeding with elective surgery if blood pressure is <180/110mmHg.

Crowther M et al. Anaesth 2018;73:812–818.

Efficacy of perioperative dexmedetomidine on postoperative delirium: systematic review and meta-analysis with trial sequential analysis of randomised controlled trialsThis meta-analysis sought to determine the influence of dexmedetomidine (DMT) on incidence of postoperative delirium (POD) in adults. It included randomised control trials conducted before July 2017 that analysed POD incidence in adults after its administration.

Eighteen studies involving 3,309 patients were included. POD risk was decreased overall with DMT (OR 0.35; 95 per cent CI 0.24–0.51), with subgroup analysis showing similar benefit in both cardiac and non-cardiac patients. Postoperative use of DMT was also found to reduce POD in patients of all ages (<65 yr (OR 0.19; 95 per cent CI 0.10–0.36) or ≥65 yr (OR 0.44; 95 per cent CI 0.30–0.65)). Further work on the optimal dose and timing of DMT, as well as its impact on secondary outcomes, side effects, and more specific patient cohorts, is still needed.

Duan X et al. Br J Anaes 2018;12(2):384–397.

Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfortPatient comfort during and after surgery is a key concern for perioperative care providers, but objective measures of this have been poorly defined. The authors of this paper undertook a systematic review of multispecialty literature, with the aim of identifying a set of factors to use in defining patient-comfort outcomes.

122 studies were identified with 24 outcome measures, which were refined by a multi-round Delphi consensus process. The final six endpoints were pain intensity at 24 hours postoperatively, nausea and vomiting, quality-of-recovery score (QoR-score or QoR 15), time to gastrointestinal recovery, time to mobilisation, and sleep quality. The authors suggest use of these standardised outcome measures in future studies focusing on patients’ postoperative comfort or pain to facilitate benchmarking and meta-analysis of trials.

Myles PS et al. Br J Anaes 2018;120(4):705–711.

American Society for Enhanced Recovery and Perioperative Quality Initiative joint consensus statement on postoperative gastrointestinal dysfunction within an enhanced recovery pathway for elective colorectal surgeryThis consensus statement standardises the definition, assessment and treatment of impaired postoperative gastrointestinal function in elective colorectal surgery.

A number of recommendations for prevention are made – minimising opioid use, maintenance of euvolaemia and electrolyte balance, avoidance of nasogastric tubes, application of minimally invasive surgical techniques, anti-emetic prophylaxis, and immediate resumption of oral intake (including coffee and chewing gum).

Treatment options recommended are nasogastric tube placement for intractable nausea, review of analgesia, patient mobilisation, fluid and electrolyte replacement, and consideration of imaging if dysfunction persists more than seven days postoperatively.

Hendrick TL et al. Anesth & Analg 2018;126(6):1896–1907.

Perioperative Journal Watch is written by TrIPom (trainees with an interest in perioperative medicine – www.tripom.org), and is a brief distillation of recent important papers and articles on perioperative medicine from across the spectrum of medical publications.

WORKING WITH YOU TO IMPROVE PATIENT CARE: the Health Services Research CentreProfessor ramani moonesinghe, Director, Health Services research CentreProfessor Iain moppett, Deputy Director, Health Services research Centre

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MEET THE HSRC TEAMBefore and after you do your bit for the HSRC’s research by submitting data to a NAP, SNAP, P-COMMAS, NELA, PQIP or any of our other projects, a huge amount of work goes into developing the research or audit design, getting regulatory approvals, cleaning and analysing the data and ultimately, writing it up for publication. The HSRC team beaver away at all this, and while you might recognise the names or faces of some, many remain hidden. Now is your chance to find out a little bit about them. We asked each of them to sum themselves up in three or four words – see if you can match the descriptions to the individuals...

1 Cheerful by northern standards.2 Optimistic, collegiate and curious.3 Keeps plugging away.4 Pragmatic, idealist, sports-lover.5 Data wrangler, perioperativist, explorer.6 Passionate, striving, work-life balance.7 Food, coffee, get to work.8 Budding academic mum.9 Tallest Indian girl in town.10 Middle-aged runner and musician.11 Committed to the cause.12 Polite, thoughtful, procrastinator.13 Run, work, sleep, repeat.14 Fearless, fitness, foodie.

15 Tall amateur statistician.16 Dedicated, passionate, innovative.17 Caffeine dependent, cyclist, cynic.18 Loves innovation and digital health.19 Enthusiastic, all about inclusive

leadership and empowering others.20 Likes numbers and models.21 Tall, experienced, eyebrow-raiser.22 Irreverent Irish improver.23 Fitness freak, caring, artistic.24 Not from here but getting there. 25 Enthusiast, communicator, educator;

sometimes irreverent. 26 Always on boats.

27 Iberian beery quizzer.28 Geeky immigrant dad.29 Doesn’t wear ties.30 Stokie born and bred.31 Doing it differently.32 Trouble saying no.33 Difficult, cussed, occasionally funny,

innumerate.34 Aspiring bike mechanic.35 Mostly harmless, sometimes funny,

baby factory.36 Glued to the screen.37 Greying wavy = ‘gravy’ hair.

Matt Oliver [MO], NELA Fellow 2014–2017, now NELA Research Lead; ST6 Central London School

Mike Bassett [MBa], NELA fellow 2015–2016, previously Manchester anaesthetist in training, now Consultant Anaesthetist, Manchester

Tom Poulton [TP], NELA Fellow 2016–2018, previously Northern School anaesthetist in training, now post-CCT Fellow in Perth, Australia

LJ Spurling [LJS], NELA Fellow 2017–2020; ST6 Imperial School

Sara Catrin-Cook [SCC], NELA Fellow 2017–2019; Consultant Anaesthetist, Bath

Michael Berry [MBe], NELA Fellow 2018–2019; ST7 Imperial School

Perioperative Quality Improvement ProgrammeClinical lead: Ramani Moonesinghe

Duncan Wagstaff [DWa], PQIP Fellow 2015–2019; ST5 Central Thames

James Bedford [JB], PQIP Fellow 2016–2019; ST6 Anaesthetics and Intensive Care Medicine, South East Thames

David Gilhooly [DG], PQIP Fellow 2015–2018 (previously trust-grade doctor, UCLH), now Consultant Anaesthetist, UCLH

Arun Sahni [ASa], PQIP Fellow 2016–2018; ST6 Barts and London School

Maria Chazapis [MC], Darzi Fellow 2016–2017; Consultant Anaesthetist, UCLH

Aleksandra Ignacka [AI], PQIP Fellow 2018–2019; ST6 Barts and London School

Sprint National Anaesthesia ProjectsClinical lead: Ramani Moonesinghe

Ellie Walker [EW], Anaesthetist in training Lead, SNAP-1. Previously Central Thames anaesthetist in training, now Locum Consultant, Great Ormond Street Hospital

Danny Wong [DWo], Anaesthetist in training Lead, SNAP-2; ST6 South Thames

COMPAC/P-COMMASClinical lead: Mike Grocott [MG], Professor of Anaesthesia and Critical Care, Southampton; HSRC founding Director 2011–2016

Olly Boney [OB], COMPAC StEP Fellow 2014–2017; ST6 Barts and London School

Data scienceClinical lead: Iain Moppett

William Lindsay [WL], Data Science Fellow 2018–2019; ST6 Nottingham

Martin Murphy [MM], Data Science Fellow 2018–2019; ST6 Nottingham

Paediatric and obstetric researchClinical lead – Ramani Moonesinghe

Amaki Sogbodjor [ASo], Anaesthetist in training Lead for Children’s Acute Surgical Abdomen Programme; ST6, Imperial school

Cyrus Razavi [CR], Anaesthetist in training Lead, Paediatric Outcomes; ST6 Central School

Reshma Patel [RP], ST5 Imperial School; Anaesthetist in Training Lead for Obstetric Research

Clinical academic leadershipRamani Moonesinghe [SRM], HSRC Director (2016–present); Professor and Honorary Consultant in Perioperative Medicine, UCL/UCLH

Iain Moppett [IM], HSRC Deputy Director (2016–present); Professor and Honorary Consultant in Anaesthesia and Perioperative Medicine, Nottingham

College leadership, project management and administrationSharon Drake [SD], RCoA Director of Clinical Quality and Research and Deputy Chief Executive Officer

James Goodwin [JG], RCoA Head of Research

Jose Lourtie [JL], Clinical Audit Manager

Alexandra Brent [AB], Project Co-ordinator, PQIP

Laura Farmer [LF], HSRC Administrator; NAPs and SNAPs Administrator

Dorian Martinez [DMa], Project Co-ordinator, PQIP

Karen Williams [KW], Audit and Research Administrator

Lay representativeBob Evans [BE], PCPIE Group and lay representative on HSRC

Academic staffCecilia Vindrola [CV]), Social scientist: evaluating PQIP and setting up the new Perioperative Improvement Research Lab

Peter Martin [PM], Statistician for PQIP and NELA

National Audit ProjectsTim Cook [TC], RCoA Audit Lead; Consultant Anaesthetist, Bath; Professor of Anaesthesia, University of Bristol

National Emergency Laparotomy AuditDave Murray [DMu], NELA Chair 2017–present (previously National Clinical Lead); Consultant Anaesthetist, James Cook Hospital, Middlesbrough

Sarah Hare [SH], National Clinical Lead; 2017–present; Consultant Anaesthetist, Medway Maritime Hospital, Kent

Carolyn Johnston [CJ], National QI Lead 2016–present; Consultant Anaesthetist, St George’s Hospital, London

Members of the HSRC team From left to right, top row: Dr LJ Spurling, Dr Arun Sahni, Dr Cecilia Vindrola, Dr Michael Berry, Dr Carolyn Johnston, Dr Peter Martin, Ms Karen Williams, Dr Aleksandra Ignacka, Dr Dave Murray, Ms Laura Farmer and Mr Jose Lourtie.

From left to right, bottom row: Dr Amaki Sogbodjor, Dr Reema Nandi, Professor Iain Moppett, Professor Ramani Moonesinghe, Mr Bob Evans and Mr James Goodwin.

Solution to descriptions of individuals1–WL; 2–DWa; 3–MM; 4–JB; 5–MO; 6–OB; 7–LJS; 8–ASo; 9–RP; 10–IM; 11–AB; 12–EW; 13–TP; 14–KW; 15–MBa; 16–CV; 17–ASa; 18–CR; 19–SH; 20–PM. 21–JG; 22–CJ; 23–DG; 24–MBe; 25–BE; 26–LF; 27–JL; 28–DWo; 29–DMu; 30–SD; 31–SCC; 32–SRM; 33–TC; 34–DMa; 35–MC; 36–AI; 37–MG.

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Encompassing all the recommendations is the importance of reviewing and using local data and sharing it with all stakeholders, including the executive team and the clinical staff. Data can inform Morbidity and Mortality meetings, mortality reviews, can identify gaps in care processes and help teams collaborate with other improvement initiatives such as GIRFT, surviving sepsis, and deteriorating patient programmes. This effective use of data can then support developing clearly defined pathways of care during the perioperative period.

Consistent challengesThe management of patients who have signs of sepsis has remained poor throughout all years of reporting – only 24% of patients received antibiotics within the recommended 60 minutes. This figure is markedly different to NHS England data assessing all-specialty administration

of antibiotics within one hour (80%) and this now needs to be a key area of improvement work by local teams.

In addition to antibiotic administration, source control is crucial in the management of septic patients, and it is therefore concerning that the proportion of patients arriving in theatres within appropriate timeframes has remained unchanged over four years of reporting. In particular, the proportion of the most urgent patients arriving in theatre within two hours has fallen from 76% to 73%.

Bringing about change will always be challenging, and addressing these remaining areas is likely to be no different. However, given the considerable improvements in care that have already been achieved in the last five years, we are optimistic that hospitals and clinicians can meet these challenges for the benefit of patients undergoing emergency laparotomy.

National Emergency Laparotomy Audit (NELA)

THE FOURTH PATIENT REPORTDr Sarah Hare, National Clinical Lead, National emergency Laparotomy AuditDr Dave murray, Chair, National emergency Laparotomy Audit

Multidisciplinary teams have continued to work together nationally, improving outcomes and standards of care for their patients who undergo emergency laparotomy surgery.

†These results include all causes of death.

The fourth NELA report presents data about 23,929 patients who had their operation between December 2016 and November 2017, and who were looked after by multidisciplinary teams at 179 hospitals in England and Wales. Alongside the familiar key outcome measures, for the first time NELA has also reported on the longer-term outcomes for patients from the last three years. This knowledge can help inform shared decision-making with patients. The preoperative assessment of risk continues to be a key driver in ensuring patients receive the expected standards of care.

Key resultsMore patients are now benefiting from preoperative input from consultant surgeons (92% of patients) and anaesthetists (89%). Data also showed that consultant intensivists reviewed high risk patients (either in person or via discussion) before surgery in over 60% of cases. Consultant involvement increases further if a patient has a higher individual predicted preoperative risk documented. This is important because, as more patients are having their risk considered before surgery, more patients are potentially benefiting from having

a consultant involved in their care than would have done previously. Consultant presence during surgery is at its highest level since NELA started collecting data, with anaesthetists present 88% of the time and consultant surgeons 92%.

In addition to 30- and 90-day mortality, NELA, as the world’s largest prospective dataset of patients who have had emergency laparotomy, has reported mortality rates for up to three years after surgery. 23.2% of patients died within a year of surgery, 29.4% within two years, and 33.8% within three years.† Mortality increases within higher risk groups, such as the elderly – a third of over-70-year-olds die within a year of surgery and half within three years.

Morbidity is also an important consideration for patients and clinicians when making decisions about their care. Alongside considering their chances of surviving surgery, understanding the impact of major emergency surgery on their lifestyles and their abilities to carry out their normal daily activities is vital. NELA presents the data on discharge destination after surgery. The cohort that are likely to suffer the biggest change

in lifestyle are those who are admitted from their own home but are discharged to residential/nursing homes. This may imply a significant impact on their ability to manage their own activities of daily life and their quality of life. Unfortunately, data quality was poor for this question, and we would like to highlight the importance of entering accurate data (for all questions) so that it can be used to successfully inform discussions and decision-making with patients in the future.

Key recommendationsThere are six overarching key recommendations, each of which has supporting recommendations to guide implementation.

1 Improving outcomes and reducing complications.

2 Ensuring all patients receive an assessment of their risk of death.

3 Delivering care within agreed timeframes for all patients.

4 Enabling consultant input in the perioperative period for all high risk patients.

5 Effective multidisciplinary working.

6 Supporting quality improvement.

Since 2013, national 30-day mortality rate has fallen from

11.8% to 9.5%

The number of days a patient spends in hospital has fallen further, to

15.6 days in 2017Down from 16.6 days in 2016 and 19.2 days in 2013, when NELA began

75% of patients now receive an assessment of risk (up from 71% last year, and 56% in Year 1)

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NO NAMING AND SHAMING – ONLY CELEBRATING SUCCESSHow PQIP hopes to improve care and outcomes from major surgeryDr James bedford, PQIP Fellow on behalf of the PQIP Project team

The Perioperative Quality Improvement Programme (PQIP) has been running for almost two years. It has now enrolled more than 13,000 patients in more than 85 NHS hospitals. It is a perfect springboard for meaningful quality improvement delivered collaboratively by the perioperative team, with near-realtime dashboards and quarterly hospital-level reports that highlight opportunities for improvement.

Our first annual report was published in April 2018 (bit.ly/2oM5UaO), and highlighted these national improvement priorities:

■ management of preoperative anaemia (>40 per cent of patients anaemic) – follow this link to the perioperative medicine programme’s guidance on developing a local anaemia pathway (bit.ly/2oONvub)

■ perioperative management of diabetes (over 30 per cent of diabetic patients did not have an HbA1c recorded)

■ individualised risk assessment

■ enhanced recovery implementation

■ individualised pain management

■ DrEaMing – getting patients drinking, eating and mobilising within 24 hours of the end of surgery.

We have also been able to highlight the huge difference in length of stay between patients who do and don’t sustain a major postoperative complication. By looking at local processes recorded through PQIP, we hope that local teams will be able to identify how to bring complication rates down and improve patient satisfaction.

It has been a privilege to celebrate the hard work of local teams at our two hugely popular collaborative events – more than 250 clinicians from 60 hospitals attended for free group learning and discussion in London and Manchester. Over the next few years we hope to build collaboration between hospitals so that they can share best practice and, together, raise standards

everywhere. All local contributors are named in the report, and will be listed as collaborators on future research publications using PQIP data.

PQIP also has a library of resources, including research papers and QI tools (bit.ly/2tZTxw0). You can now access all of these resources with the PQIP mobile app (available free on Android and iOS). Our hope is that all NHS hospitals will be taking part in PQIP within the next two years.

NATIONAL AUDIT PROJECTS (NAPs)Professor Iain moppett, Deputy Director, Health Services research Centre

The College National Audit Projects (NAPs) are year-long, service evaluations of anaesthesia-related topics. They evaluate rare, potentially catastrophic events that are not amenable to other types of study. The depth and breadth of the NAPs is unparalleled internationally.

Six NAPs have been conducted. NAPs 3 to 6 have had distinctly different methodology and leadership from NAPs 1 and 2, and have yielded substantially greater outputs. Associated spin-off projects from the main NAP programme of work usually include an activity survey which enables some ‘census’ type information to be gathered.

The College has committed to supporting NAP7, recognising the importance of these projects to patients and the anaesthesia community.

■ NAP3 (2006–2009) described the complications of neuraxial blockade in perioperative practice. It provided novel estimates of the various associated risks in different settings as

well as qualitative analysis of the risk factors associated with them.

■ NAP4 (2008–2011) covered major complications of airway management – including those occurring in ICUs and emergency departments. The qualitative analysis and associated recommendations are widely recognised as contributing to a marked shift in individual, team, and systems approaches to airway management.

■ NAP5 (2012–2014) investigated accidental awareness during general anaesthesia (AAGA). Alongside the quantitative analysis, and the investigation of why AAGA occurs, the patient voice was prominent – highlighting the fundamental need

to listen and respond to patients experiencing AAGA.

■ NAP6 (2015–2018) recently reported on anaesthesia, surgery and life-threatening Allergic Reactions. Antibiotics were identified as the commonest trigger, ahead of muscle relaxants and chlorhexidine.

There is strong support from members and the College to continue the NAP programme. Following an open call and a selection panel, including lay, anaesthetists in training, consultant, and academic members, cardiac arrest in the perioperative period was chosen as the topic for NAP7. The process of recruiting a clinical lead for NAP7 is underway (please see the advert on page 41 for further information).

Get in touch to find out more:www.pqip.org.uk pqip@rcoa.ac.uk

@PQIPNews

Download the new PQIP app!Available on iOS and Android

Perioperative QualityImprovement Programme

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SPRINT NATIONAL ANAESTHESIA PROJECTS (SNAPs)Dr Danny Wong & Professor ramani moonesinghe on behalf of the SNAP-1 and SNAP-2 project teams

SNAPs are short, sharp prospective observational studies, which aim to recruit large cohorts of patients from as many NHS hospitals as possible. So far there have been two SNAPs.

■ SNAP-1 studied patient-reported outcomes after surgery, collecting data from 15,040 patients over two days in May 2014. More than 1,700 collaborators from 257 hospitals took part, and the findings were published in the British Journal of Anaesthesia (BJA) (bit.ly/SNAP-2Paper). We found that anxiety was cited most frequently as the worst aspect of the perioperative experience, and that thirst and pain were common causes of severe discomfort. These findings have been used to inform new patient information leaflets which will soon be published by the College.

■ SNAP-2 took place over a week in March 2017, and investigated postoperative critical care provision.

It collected data from more than 22,000 patients, and also from 10,000 clinicians who gave their views on perioperative risk stratification and critical care admission criteria. Massive enthusiasm for this study was again shown by clinical colleagues, with more than 2,800 collaborators from 245 hospitals. The BJA has now published our first research paper, with substantial media coverage (bit.ly/2OCc88l), showing that 1 in 7 inpatient operations were cancelled on the day of surgery. We found that 1 in 10 patients who underwent planned inpatient surgery during the week of the study had previously been cancelled; inpatients postponed for non-medical reasons (around 50 per cent of the

cancellations) were at increased risk of cancellation if they required critical care postoperatively or had surgery in hospitals with emergency departments. Further SNAP-2 outputs will be published in the next few months.

The two key principles of the SNAPs have been their ‘citizen science’ approach, with enormous support from anaesthetists, surgeons, intensivists and nurses working at the NHS coalface, and anaesthetist in training leadership, both locally and nationally. The HSRC is hugely grateful to the thousands of clinicians who have made these projects possible, and we look forward to future publications, with all our collaborators named, so that you can continue to be rewarded for your efforts.

Which clinical outcomes matter to patients and clinicians?THE COMPAC AND StEP COLLABORATIVESDr olly boney, ComPAC-SteP research Fellow

COMPAC (Core Outcome Measures for Perioperative and Anaesthetic Care), is a collaborative venture bringing patients and clinicians together to agree a set of ‘core outcome measures’ for anaesthesia and perioperative medicine research trials. ‘Core outcomes’ means outcomes which are widely agreed to be fundamentally important to all stakeholders – ie both to patients undergoing major surgery, and to clinicians working in all areas of perioperative care – and which therefore warrant reporting in all research, regardless of the underlying research question being investigated.

The aim of COMPAC is to improve standards of outcome reporting across the perioperative literature – by reducing ‘selective’ outcome reporting, the under-reporting of non-significant outcomes, and the heterogeneity and inconsistency in the way outcomes are measured and defined. Such variation in outcome reporting severely hampers meta-analyses and systematic reviews, which are designed to distil all the relevant primary research on a particular topic into a succinct summary.

However, systematic reviews are often inconclusive because trial outcomes are inadequately reported.

Meanwhile the StEP initiative (Standardised Endpoints for Perioperative Medicine) is a parallel venture seeking to recommend unified definitions for perioperative outcomes. Currently, trial authors might report the incidence of postoperative pneumonia, or lower respiratory tract infections, or pulmonary or respiratory complications without reference to a recognised global standard – because none exists. This makes it impossible to compare rates of postoperative pneumonia between different trials, because they’ve all defined ‘postoperative pneumonia’ slightly differently, and used different criteria to decide which patients have developed postoperative pneumonia. The ‘standardised endpoints’ developed

by StEP will define precise criteria for all perioperative outcomes in order to reduce this inconsistency and variation.

The aspiration is that journal editors will eventually require authors to adhere to these standards of outcome reporting, much as many journals require adherence to guidelines such as CONSORT (Consolidated Standards of Reporting Trials) for randomised controlled trials. The overall benefits of COMPAC and StEP will be:

■ greater transparency and standardisation of research outcomes reporting

■ greater relevance of research outcomes to patients and clinicians

■ facilitating comparison of results between different trials

■ allowing trial results to be combined in meta-analyses more easily.

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Sprint National Anaesthesia Projects

National Audit Project of the royal College of Anaesthetists

Clinical Lead for NAP7: Perioperative Cardiac ArrestThis post is a fixed term College appointment to lead NAP7.

NAP7 will examine Perioperative Cardiac Arrest in NHS and Independent hospitals in England, Scotland, Wales and Northern Ireland. The successful candidate will work closely with the clinical leadership of the NIAA Health Services Research Centre (HSRC).

The HSRC manages the National Audit Projects on behalf of the College, and will provide administrative and organisational support for NAP7.

The role will span the duration of the project, expected to start in February 2019 and run for three to four years. The post is supported by one period of professional activity (1 PA) per week in order to enable the successful candidate to dedicate a minimum of four hours per week to the project.

Applicants should submit a one page CV and one page letter of support from their Head of Department/line manager to hsrc@rcoa.ac.uk. This must include contact details (daytime telephone and email address).

Further information including the job description, person specification and information on former NAPs is available from the NAP (www.nationalauditprojects.org.uk) and College (www.rcoa.ac.uk) websites.

Prospective candidates are advised to discuss the role with HSRC leadership before applying – contact hsrc@rcoa.ac.uk with any queries.

Closing date for applications: midday 10 December 2018 Interview date: 7 January 2019

PCPIE – IS IT A JOLLY POLICE OFFICER…?Or a politically correct pastry dish…?mr bob evans, Lay Committee member on behalf of the PCPIe group

No, it’s the Patient, Carer and Public Involvement and Engagement (PCPIE) Group of the HSRC. Professor Dame Sally Davies, Chief Medical Officer has said ‘No matter how complicated the research, or how brilliant the researcher, patients and the public always offer unique, invaluable insights...’.1

One of the themes of the HSRC Strategy 2017–2022 is to ‘…continue to offer a lay perspective on planned research, and advice on future public involvement to the entire perioperative research community through the PCPIE Group..’.2 To that end, PCPIE is a partnership between patients, carers and the public, and researchers, to try to make the research process more effective.

The PCPIE Group was set up in 2013 and has since reviewed more than 30 proposals for research in anaesthesia. The Group comprises eminent clinician scientists as Chairman and Vice-Chairman (Dr Mark Edwards and Dr Joyce Yeung respectively), together with at least six lay people drawn from the College Lay Committee. The Group is expertly administered by Pamela Hines at the National Institute for Academic Anaesthesia. We meet quarterly to discuss and plan our work, including our own draft Strategy. We hold an annual Education Day to widen our knowledge on relevant subjects. Most of our efforts go into commenting electronically on research proposals submitted to us for appraisal.

We consider would-be projects under the following criteria:

■ the importance of the subject to perioperative medicine

■ the value of such research to patients

■ the clarity of the lay version of the proposal

■ the nature of the consent process and its reasonableness and confidentiality

■ the sample size ■ the arrangements for dissemination

of results ■ the extent of early public/patient

involvement in the proposal’s design.

We have received positive feedback from a number of researchers who say that our advice has helped them to deal with ethical aspects and to obtain funding. We seek to promote our work

through our flyer, given out at events. If you have a subject for a research project, or work with someone who has a good idea to take forward, the sooner you get in touch with Pam (phines@rcoa.ac.uk), the more we can help.

references1 Staley K. Exploring impact: public

involvement in NHS, public health and social care research (Foreword). INVOLVE. NIHR, 2009 (bit.ly/2oNuF6w).

2 The Next Five Years – Strategy 2017–2022. HSRC, 2017 (bit.ly/2QdXx4v).

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The forgotten tribe: improving the care of the emergency paediatric surgical patientDr Amaki SogbodjorHSRC-led research has so far focused entirely on adults – but we know that there are problems which could be addressed in the perioperative care of children. For example, recently published UK data† indicate that emergency abdominal surgery rates in children (such as appendicectomies) are declining but complications are rising – so is this due to sicker patients or falling standards?

So, in 2019 we will launch the Children’s Acute Surgical Abdomen Programme (CASAP). CASAP will be an observational study which will collect data on all children aged 1–18 years undergoing emergency abdominal surgical procedures in the UK during a six-month study period. The quality of care being delivered will be measured using evidence-based quality indicators. Perioperative clinicians will be asked to complete a questionnaire for each patient at the time of surgery

which documents information such as the patient demographics, type of surgery, perioperative

physiology, and postoperative destination. Postoperative morbidity and mortality will be

measured, and our prospective data will be linked with NHS databases for a 10-year follow-up. We hope that in addressing such an important issue CASAP will help cultivate a culture of improvement in paediatric perioperative medicine. Watch out for more information in the new year.

Data scienceProfessor Iain moppett

There is a lot of hype and many overblown claims about data science in healthcare. The old adage of ‘rubbish in, rubbish out’ applies just as much now as it ever did. But understanding and interpreting large datasets can help us, and more importantly help our patients. Good data science is not just about crunching the numbers, it also requires clinical insight into what might be important. The importance of presenting the

† Giuliani S et al. Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012. Ann Surg 2016;263:184–190.

data and interpretation in a meaningful, engaging and honest way is increasingly recognised. Those of you who have read the NELA and PQIP reports will have seen how the teams have used novel graphics and charts to explain the underlying data. The HSRC is currently working on two data-science projects:

■ variation in perioperative care – by collating data from publicly available perioperative registries (hip fracture, emergency laparotomy, vascular disease and gastrointestinal cancers), we will describe the extent of variation in perioperative outcomes and processes of care

■ the Cerebrovascular accident and Acute coronary syndrome and Perioperative Outcomes (CAPO) study – this will look at several million episodes of care to explore the associations between previous myocardial and cerebrovascular events and outcomes after surgery.

Perioperative Improvement Research Laboratory (PIRL)Dr Cecilia vindrola and Professor ramani moonesingheHave you ever seen a great service innovation and wondered whether or not it really made a difference to patient outcomes? Or costs? Or how to spread the word about the service to other hospitals in order to share best practice? Innovation can arise anywhere in the NHS, but ability to evaluate and report on it, can vary according to whether a hospital is linked to an academic centre, has access to research active clinicians, or simply has the resource (people, time) to do such an evaluation alongside a busy clinical workload.

The PIRL will try to address this need. It will comprise a team of researchers who will work collaboratively with local healthcare professionals to evaluate the effectiveness of novel services or practice. In so doing, we hope to develop research-curious and research-aware staff members, generate research and evaluation capacity in provider organisations, and promote the use of research evidence to inform decision-making in healthcare planning, organisation and delivery. We’re still working on the details, but envisage that the PIRL would be flexible in its level of engagement – ranging from fully delivering the evaluation, to playing a purely advisory role. In this latter approach, local staff will be responsible for doing the evaluation, and will thereby build local capacity for research activity.

International collaborationsProfessor ramani moonesinghe

Over the next few years, we will try to branch out internationally. We have made a start through COMPAC-StEP and also SNAP-2 which also took place in Australia and New Zealand. We plan to develop two ambitions – firstly to collaborate more widely with international partners in general, and secondly to explore opportunities to engage in research activity with colleagues working in low- and middle-income (LMIC) settings.

We will be reaching out to potential collaborators, both to those who are UK-based but with LMIC research experience and to clinicians and researchers who work overseas. Current ideas include mentorship schemes for overseas researchers, exchange fellowships, sharing our existing resources with LMICs (eg data collection infrastructure of projects such as PQIP and NELA) and developing new research proposals in collaboration with international colleagues.

As you can see, there is a lot of exciting new activity for you to get

involved with on the horizon – so if you would like more

information – just get in touch!

www.niaa-hsrc.org.uk hsrc@rcoa.ac.uk

@HSrCNews

WHAT’S COMING NEXT?Four exciting new initiatives on the horizon

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H S R CHealth Services Research Centre

NIAANational Institute of Academic

Anaesthesia H S R CHealth Services Research Centre

NIAANational Institute of Academic

Anaesthesia

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HSRC Annual Report | 2018

Identified risk factors for surgery in order of importance

Frailty Levels of physical activity obesity Cognitive

impairment Smoking

Dr Anne-marie bougeard RCoA Fellow in Perioperative Medicine

We recently surveyed the College’s Membership Engagement Panel asking about perioperative medicine. In this article I will present some of the main findings of the survey, together with our proposals to address points raised and signposting to what is happening in perioperative medicine at the College.The survey was conducted between February and March 2018, and we had 259 responses, the majority of which were from were practising consultants, with approximately 16 per cent from anaesthetists in training, and 10 per cent from SAS grades, students and academics. The responses showed a broad geographic spread, as well as a broad spread of major subspecialty interests. More than 75 per cent were quite supportive or very supportive of the perioperative medicine programme, and the free-text part of the responses indicated that respondents welcome

its addition to the curriculum and are pleased that the College is taking a lead.

CommunicationsMost respondents indicated that their first port of call for information on perioperative medicine is the College website, followed by their perioperative medicine lead, colleagues and journals. In response to this feedback, we have updated the perioperative medicine section of the website to make it easier to access information on current best practice, case-studies, talks from events we have run, and information on

perioperative medicine leads around the country, as well as links to other sources of information. To see all this, please visit: www.rcoa.ac.uk/perioperativemedicine

Barriers to delivering perioperative medicineThe biggest barriers to delivering perioperative medicine were felt to be:

■ the practicalities of redesigning the pathway

■ financial pressures

■ lack of ‘buy-in’ from colleagues and other stakeholders

■ manpower or skill mix

■ capacity.

On thematic analysis, the free-text comments included reference to lack of time to run effective preoperative assessment as a result of service pressure, problems with rigid referral pathways, and funding of new services to address anaemia and frailty.

We asked about awareness of Sustainability and Transformation Plans (in England) and their relevance to perioperative medicine, and 93 per cent of respondents said they had no awareness of any work being done to align STP priorities with those of perioperative medicine.

To address this, and in recognition of the difficulties faced when approaching commissioners and management for funding and increased capacity in the current financial climate, we have commissioned a piece of work specifically looking at how the priorities of the new models of care align with perioperative medicine. We are interviewing Integrated Care System leads to ascertain their level of awareness of perioperative medicine, and demonstrating how these new pathways and integration across the perioperative pathway align with their priorities. We are already seeing overlap with public-health initiatives such as self-care of diabetes and COPD, weight management, and physical activity, and there are examples of funding being granted for exercise interventions for the surgical population. We hope that

by doing this we will see a demand from commissioners for integrated perioperative medicine pathways, thereby making introduction of new services more straightforward for clinical directors and perioperative medicine leads.

Education and trainingTwenty-one per cent of respondents indicated that they had been involved in delivering teaching and training in perioperative medicine. Themed responses in the free-text boxes highlighted uncertainty about curriculum requirements, lack of awareness of existing resources, and lack of clarity on the structure of a perioperative medicine module. In response to these points, we would point out that:

■ an e-learning module for perioperative medicine is under development – please look out for more information on release date and access

■ there is a free Massive Open Online Course (MOOC) in perioperative medicine run by University College London which is endorsed by the College www.futurelearn.com/courses/perioperative-medicine

■ examples of module structures for all levels of training have been added to the College website.

Best practiceThe survey identified risk factors for surgery from the respondents’ perspective in order of importance as:

■ frailty

■ levels of physical activity

■ obesity

■ cognitive impairment

■ smoking.

Free-text comments also asked for guidance on best practice for the management of these conditions. This will be added to the perioperative medicine section of the website in due course, and will be updated with case-studies and signposting to sections of the ACSA process and GPAS where relevant. We are also building good relationships with the Royal Colleges of Physicians, General Practitioners, and Surgeons, who are supportive of this work and keen to collaborate where needed.

In summary, while there is insufficient space here to detail the full results of the survey, we have used the results of the survey to influence the work we are doing, and would value feedback on how it is received. Please read the Bulletin (bit.ly/RCoA-Bulletin), follow us on Twitter (@RCoANews), read the President’s eNewsletter (bit.ly/PresidentsNews), and look at the College perioperative medicine microsite (www.rcoa.ac.uk/perioperativemedicine) to keep up-to-date on the programme. Further reading and links are listed below.

■ Trainees with an interest in Perioperative Medicine (TriPOM) – www.tripom.org

■ Massive Open Online Course in perioperative medicine: www.futurelearn.com/courses/perioperative-medicine

HEARING YOUR VIEWSPerioperative medicine for all anaesthetists

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Bulletin | Issue 112 | November 2018

International Standards for a Safe Practice of AnaesthesiaTHIRD EDITION GAINS WORLD HEALTH ORGANIZATION (WHO) APPROVALThe adoption of standards has contributed to impressive improvements in anaesthetic mortality in high-income countries during the last 50 years – improvements that have not typically been matched in less resourced areas of the world.

In 1986, following the addition of pulse oximetry and capnography to the monitoring technologies available for anaesthesia, Eichhorn, Cooper and others developed the Harvard Monitoring Standards to establish appropriate monitoring as a standard of care in the United States. Anaesthesia organisations in other countries, notably the UK, Australia and New Zealand, soon followed suit. A few years later, Eichhorn and Gravenstein brought together an independent group of anaesthetists to form the International Task Force of Anaesthesia Safety, whose mission was to ‘enhance the safety of anaesthesia by promotion of international standards for anaesthesia practice’. This group worked over several years to develop the International Standards for a Safe Practice of Anaesthesia. These Standards were endorsed and adopted as global standards by the World Federation of Societies of Anaesthesiologists (WFSA) at its World Congress of Anaesthesiologists (WCA) at The Hague in 1992. They were not intended to replace standards already in place in different countries; instead, the Task Force aimed to provide a resource that was universally applicable but would be of particular value in countries that had not yet developed their own standards.

In 2004 WHO established the World Alliance for Patient Safety. ‘Safe Surgery Saves Lives’, the second Global Challenge for Patient Safety, led by Atul Gawande, was launched by the Alliance in 2007. Its best-known output was the WHO Surgical Safety Checklist, but another important output was a revision of the International Standards. This revision was undertaken by an Anaesthesia Working Group through an extensive process of literature review and wide consultation, which included presentation of the revised Standards at a plenary session of the WCA in Cape Town in March 2008 and then at three General Assemblies of the WFSA, at

which they were finally endorsed on 7 March 2008. These Standards were subsequently published in the Canadian Journal of Anesthesia.

Regular revision was planned and another revision has just been completed, again following an extensive process of literature review and wide consultation, and endorsement of the process by the General Assembly of the WFSA in 2016. The WFSA has worked hard over the past six years to build a closer and stronger relationship with WHO, especially through the Emergency and Essential Surgical Care programme (led by Dr Walt Johnson) and also the Essential Medicines, Emergency Trauma Care, and Patient Safety programmes. The near-final document was also reviewed by the Guidelines Review Committee which requested some changes, after which this iteration of the Standards was published as a WHO–WFSA Standards document, approved by both WHO and WFSA.

The Standards are written in the language of WHO, using the terms ‘Highly Recommended’, ‘Recommended’ and ‘Suggested’. In effect the Highly Recommended standards are mandatory. Importantly, there is an explicit acknowledgement that the provision of anaesthesia without meeting these standards may sometimes be necessary for ‘procedures that are absolutely essential for the immediate (emergency) saving of life or limb’.

The Standards range from professional aspects of anaesthesia practice to the conduct of anaesthesia itself. The primary importance of ‘clinical observation by an appropriately trained anaesthesia provider’ is emphasised. In the 2008 revision, the use of pulse oximetry was elevated to the level of Highly Recommended, in line with the inclusion of pulse oximetry as an item on the Checklist. In the latest revision, the use of a carbon dioxide detector for patients

undergoing intubation is included as Highly Recommended, with a note that ‘continuous waveform capnography will be Highly Recommended when appropriately robust and suitably priced devices are available’.

To some extent the Standards are aspirational. They provide a clear statement of acceptable and unacceptable standards of care, but they are designed for progressive implementation of Highly Recommended, Recommended and Suggested standards as resources permit. They recognise different levels of healthcare facility, but also recognise that terminology in relation to such facilities varies from country to country. Our intention is that these Standards will prove valuable for those who are struggling to improve the standard of anaesthesia care for patients in many poorly resourced parts of the world.

Further reading ■ Merry AF et al. An iterative process of global

quality improvement: the International Standards for a Safe Practice of Anaesthesia 2010. Can J Anaesth 2010;57:1021–1026.

■ Gelb AW et al. World Health Organization–World Federation of Societies of Anaesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anaesthesia. Can J Anaesth 2018 (special article) (bit.ly/2oAY2J5).

■ Gelb AW et al. World Health Organization–World Federation of Societies of Anaesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anaesthesia. Anesth & Analg 2018;126:2047–2055.

Dr Alan merry, Dr Walter Johnson, Dr Wayne morriss and Dr Adrian Gelb on behalf of the International Standards for a Safe Practice of Anaesthesia Workgroup

WHO headquarters in Geneva, Switzerland© World Health Organization (WHO)

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THERE BUT FOR THE GRACE OF GOD?Gross negligence manslaughter in medicine

Dr Kate McCombe Consultant Anaesthetist, mediclinic City Hospital, Dubai and Assistant Professor at mohammed bin rashid University, Dubai

All doctors are aware, however abstractly, of the ever-present spectre of civil litigation for medical negligence. How many of us, though, conceive of criminal charges being brought against us for the errors that are, unfortunately, inevitable during a career in medicine?most of us have followed the case of Dr bawa-Garba with a mixture of disbelief, outrage and horror. Her shocking conviction for gross negligence manslaughter has cast a long shadow and left many of us with the impression that we are all ‘only one error away from potential criminal

prosecution.’1 This article will look a little more closely at the crime of gross negligence manslaughter (GNm).

manslaughter is the legal term used to describe unlawful killing when the perpetrator did not plan to kill the victim. The law recognises different types of manslaughter:

1 voluntary manslaughter: this crime occurs following provocation and is, therefore, often called a ‘crime of passion’. The defendant’s culpability is reduced because of his/her state of emotional turmoil

2 involuntary manslaughter: this refers to unintentional killing resulting from criminally negligent or reckless conduct. GNM and corporate manslaughter fall into this category and are considered below.

Medial negligence is a civil tort (wrong) that occurs when harm comes to a patient because of their doctor’s actions or inactions. For a claim in negligence to succeed, the claimant must prove that:

■ the doctor owed them a duty of care

■ the doctor’s practice fell below an acceptable standard

■ they suffered harm as a direct result of this substandard care.

If the patient dies as a direct consequence of the doctor’s negligence, that doctor may find himself accused of GNM. If ‘the way in which its activities are managed or organised by senior management is a substantial element in the breach’2 (of duty of care to the patient), then the trust can be prosecuted for corporate manslaughter which, if successful, carries an unlimited fine.

There are three sources from which criminal investigation into medical deaths arise: if the relatives of the deceased complain to the police; if the hospital contacts the police; or, most commonly, if the coroner refers a death to the local police force’s Criminal Investigations Department as suspicious or unnatural.

Following referral, the police will investigate to determine whether there is a case to answer and to gather relevant evidence for potential prosecution. They will then refer the case to the Crown Prosecution Service (CPS) who will weigh the strength of the evidence and decide whether a prosecution is in the public interest.

The test for GNM was defined by the case of R v Adomako.3 Dr Adomako was acting as a locum anaesthetist, despite the fact that he had no postgraduate training

in the specialty. His failure to recognise breathing-circuit disconnection resulted in his patient’s death on the operating table.4 Following appeal, the House of Lords ruled that, for them to be found guilty of criminal negligence, the doctor’s conduct must be ‘so bad in all the circumstances as to amount to a criminal act’. The lack of clear boundaries around this threshold was challenged in Misra5 and, while the Court of Appeal acknowledged its inherent vagueness, it maintained that it is for the jury to decide in each individual case whether the defendant’s behaviour was grossly negligent and consequently criminal.

The threshold was revisited in the recent case of R v Rose,6 where an optometrist failed to diagnose papilloedema in a child who died of hydrocephalus some months later. The Appeal Court restated that for her to be guilty of GNM, her breach of duty must be, ‘truly exceptionally bad and so reprehensible as to justify the conclusion that it amounted to gross negligence and required criminal sanction.’

Prosecution of doctors is highly emotive and inevitably accompanied by a media feeding-frenzy. Extensive coverage promotes fear and distrust in both the public and the profession, and contributes to the impression that prosecution of doctors is on the rise. But how true is this. Data on GNM are not collected routinely, and so it is hard to know for certain. The CPS receives an estimated 200 referrals for GNM per year, but not all of these involve medical staff. The CPS teased out data concerning prosecution of doctors since 2013 for consideration by Sir Norman Williams in his recent review of GNM in Healthcare7 (see Annex A – Gross Negligence Manslaughter Data: bit.ly/2N3nUYU).

Since Adomako in 1994, 47 healthcare professionals (37 doctors, nine nurses, one optometrist) have been prosecuted

for GNM following the deaths of 38 patients. Twenty-three were convicted, with four convictions subsequently overturned on appeal. More recently, there has actually been a decline in conviction rates – since 2013, nine deaths have led to the prosecution of 15 healthcare professionals. Only six of these were convicted, and two decisions were subsequently overturned on appeal.

Is it any small consolation then, that prosecution of doctors for GNM is infrequent, and conviction even rarer. Not, I’m sure, for Mr David Sellu, found guilty of GNM and imprisoned for two years before having the verdict quashed on appeal. Nor for Mr Kenneth Woodburn, a vascular surgeon who was acquitted, but who recounts the personal agony suffered during his lengthy investigation and subsequent trial.1 And certainly not for Dr Bawa-Garba, whose case we will consider in the next article.

references1 Woodburn K. Surviving a criminal prosecution

for manslaughter. Trends Urol Men’s Health 2015;6:13–18.

2 Corporate Manslaughter and Corporate Homicide Act 2007 (bit.ly/2O1eU6u).

3 R v Adomako [1995] 1 AC 171, HL (bit.ly/2MMmSjU).

4 Brahams D. Death under anaesthetic: the case of Dr Adomako. Anaesth 1990;45:981–982.

5 R v Misra & Srivastava [2005] 1 Cr App R 328 Court of Appeal (bit.ly/2MNmDEX).

6 R v Rose [2017] EWCA Crim 1168 (bit.ly/2KRfhP9).

7 Williams review into gross negligence manslaughter in healthcare. A report from Professor Sir Norman Williams looking at gross negligence manslaughter in healthcare. HM Government (bit.ly/2KiGt93).

The College submission to the Hamilton review (previously known as the marx review) of gross negligence manslaughter and culpable homicide can be found on the website: bit.ly/2zvFkZA

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Bulletin | Issue 112 | November 2018

What should anaesthetists know about ‘genomics’?

Professor Jaideep J Pandit RCoA Genomics Champion and RCoA Council Member, Oxford

One of my roles on Council is to represent the College at the Academy of Medical Royal Colleges (AoMRC) as ‘Genomics Champion’. The question in the title of this article is one that I have been asked by the AoMRC to answer on behalf of the College, and I am, in turn, posing it to you, the readers of our Bulletin.

Aims of the AoMRC Genomics GroupThe AoMRC Genomics Group is a large cross-specialty group designed to implement ‘new’ genomic approaches to diagnosis and treatments in everyday practice. I have attended meetings and engaged in surveys and email exchanges designed to ascertain for each specialty:

■ the current state of genomics in that specialty

■ the specialty’s aspirations in respect of genomics

■ the specialty’s current capability to deliver on the genomics initiative.

The ambitious set of proposals are described in several policy documents.1,2 The aim is to facilitate tailored interventions by combining whole-genome sequencing with ‘big data’ and technology to create a platform for the delivery of personalised medicine as a set of transformed pathways based on careful characterisation of patients. In the long term, this will improve outcomes, reduce costs, and also reduce harms

from treatment, as patients will only receive the treatments they are predicted to respond to (as side effects can also be confidently excluded). Developments in technology as well as sequencing make this achievable – for example, whole human genome sequencing now takes a few days and costs around £1,000.

The Medical Royal Colleges have correctly been identified as key drivers. The AoMRC working group has much discussion around the technicalities of laboratory support, staff recruitment,

funding, and facilities. The ethical dimensions are fascinating, involving issues around data sharing across organisations, but also around the fact that whole-genomic data can never really be truly non-identifiable (since a whole genome identifies an individual).

Future genomic research themes in anaesthesiaThere is particular interest in potential research themes that each specialty might consider as priorities. This is relatively simple for medical specialties (for example, key questions in cancer-genetics, haematology, reproductive medicine and prenatal diagnosis can only be answered by genomic approaches), but what might anaesthesia suggest as its important research questions that are amenable to a genomic approach?

At this point it is important to spell out that the Genomic Group is not simply about identifying well-established genetic diseases already of known relevance to the specialty (for example, malignant hyperthermia or plasmacholinesterase deficiency) and suggesting more research in these. Relevant as this approach is, what is more in tune with the aims of the Group is to demonstrate how novel questions might be addressed using new approaches. To this end, I have already made three specific initial suggestions. The first of these is the very first research recommendation of NAP5, that there should be a national register for cases of accidental awareness during general anaesthesia, which should be interrogated for possible genetic factors in resistance to anaesthesia.3 The second suggestion is the question of whether perioperative outcomes might be strongly influenced by genetic factors. The third is the possibility that cancer outcomes might be influenced by type of anaesthesia, and that these outcomes in turn are influenced by genetic factors.4 Questions like these are essential to our

development because identifying the relevant polymorphisms immediately creates collaborations with other specialties or groups studying the same polymorphism from a different angle. An example is the hypoxia-inducible factor (HIF) system – initially characterised in the von Hippel–Lindau syndrome, in fact it is central to cellular-oxygen sensing and body iron metabolism.5

However, it is not my role to set this agenda on my own. What we really need is input from interested UK anaesthetists who can help identify a portfolio of potentially relevant research questions that can exploit the emerging framework. The barrier is that there is no central database of anaesthetic researchers (a deficiency I alluded to in a recent editorial, as an example of ‘research waste’ in our specialty).6 This article therefore is an appeal for readers to make contact to make relevant suggestions.

Future genomics in core curriculum for anaesthetic trainingA second question the College has been asked by the AoMRC is to what extent genomics should feature in our curriculum. Again this is something that goes beyond simply having knowledge of specific diseases like sickle cell disease or malignant hyperthermia. Rather, the question asks us to identify the core knowledge an anaesthetist of the future will need to thrive in a post-genomic environment. Even common diseases such as hypertension will be reclassified by our medical colleagues according to a genomic taxonomy, and we will need familiarity with certain concepts to communicate properly. This certainly touches upon the notion of ‘pharmacogenomics’.

Influenced by my personal interests,7,8 I have suggested areas of core knowledge, framed as FRCA examination questions

(see box below). But again, I am not qualified to set, alone, an entire genomic curriculum for the specialty. This article serves as an appeal to those readers with an educational interest to contribute.

What is the Hardy–Weinberg principle? Give an example of its relevance to clinical practice or research.

What is the Lyon hypothesis? Give an example to how it can influence disease or diagnosis.

The College would be most grateful for assistance from colleagues with an interest in genomics, both from a research and an educational/training perspective.

references1 Castle-Clarke S. What will new technology

mean for the NHS and its patients? Four big technological trends. The Health Foundation, The Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust, 2018 (bit.ly/2nGYTHQ).

2 Topol E. Preparing the healthcare workforce to deliver the digital future. The Topol Review Interim Report June 2018 – a call for evidence. HEE 2018 (bit.ly/2nGZ5a2).

3 Pandit JJ et al. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesth 2014;69(10):1089–1101.

4 Connolly C et al. Expression of anaesthetic and analgesic drug target genes in excised breast tumour tissue: Association with clinical disease recurrence or metastasis. PLoS One 2017;12(5):e0177105.

5 Pandit JJ, Maxwell PH. New insights into the regulation of erythropoietin production. Br J Anaesth 2000;85(2):329–330.

6 Pandit JJ, Merry AF. Minimising ‘research waste’ in academic anaesthesia funding and outputs. Anaesth 2018;73(6):663–668.

7 Pandit JJ. ‘Hardy’s law’ and genomics in anaesthesia. Anaesth 2008;63(12):1284–1287.

8 Pandit JJ, Gopa S, Arora J. A hypothesis to explain the high prevalence of pseudo-cholinesterase deficiency in specific population groups. Eur J Anaesthesiol 2011;28(8):550–552.

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FOOD FOR THOUGHTDo we as anaesthetists understand just how debilitating post-anaesthesia memory loss may be for previously fit and active patients?

Dr marie Nixon RCoA Clinical Quality Advisor

The College received a thought-provoking letter from a patient’s husband. This rather disturbing read highlights the longer-term difficulties faced by older patients and their families associated with cognitive problems revealing themselves following surgery and anaesthesia. The writer is happy for me to share some extracts from his letter to emphasize the personal tragedy that can unfold for patients at home months and years after discharge. To set the scene – his wife, aged 72, had a total hip replacement more than two years ago; the patient had previously been fit, active and high-functioning, still teaching her specialist subject regularly, and a company director.

‘It’s been a great success BUT:

Ever since her op her short-term memory has been distressingly to her, and of course to me, considerably reduced.

She has suffered loss of her identity, feeling herself as a failure and generally feeling inadequate, with depression and continuing mild despair at her perceived loss of self-worth.

It’s a heavy burden for her to bear, and a completely unanticipated result of an operation intended to relieve hip pain.’

Though some of the writer’s assumptions regarding causation are perhaps incorrect, or at least rather more complex than suggested, this highlights an important issue of postoperative cognitive decline (POCD) – an issue that continues to be poorly understood and, I believe, one that we as anaesthetists generally are not good at discussing with older patients.

We still don’t know terribly much about memory loss and cognitive problems following surgery and anaesthesia, even as far as whether it really exists as an entity. I started my first sentence initially by writing ‘the difficulties associated with POCD’ but of course this is one of the main issues in our lack of understanding – is cognitive decline seen in an individual post-surgery a separate entity (POCD) or part of a cognitive trajectory in a patient previously apparently asymptomatic? That is, is it really dementia that existed at a masked level before the surgery, but was unmasked after the operation?

Part of the reason for paucity of knowledge here is undoubtedly associated with lack of reporting and subjectivity of symptoms both pre- and postoperatively. There is also a lack of routine testing, never mind our lack of access to long-term follow-up of patients and therefore a lack of understanding of what happens when they go home. All these result in difficulty in making the diagnosis, about which there is little consensus.

Owing to this lack of clarity in diagnosis, there is little consensus on the spectrum of the problem, though overall its seems that while 10 per cent of over-60-year-olds have POCD at three months after surgery, only 1 per cent still have it after one year.

How good are we at talking to patients about postoperative cognitive decline preoperatively, as something that no doubt ‘a reasonable person in the patient’s position would be likely to attach significance to’? Surely this should

be a key discussion point when seeking consent post-Montgomery. We talk about a 1 in 13,000 risk of nerve damage after an epidural, and a 1 in 10 incidence of cognitive dysfunction certainly trumps that. The College’s Risks associated with your anaesthetic series patient information leaflet Becoming confused after an operation would be a useful preoperative read for older patients.

However, there is a view that we should not be scaring older patients with the potential for cognitive decline, and this has had some traction. This paternalistic view is not one that I believe would be shared by our more aware and probing patients, and this approach can’t be seen as compatible with informed consent.

The writer also raises the interesting point: ‘What about the patient’s family and carers? Are relatives involved in the discussion and counselled?’ There are clearly ethical issues related to such

involvement, but this does not mean that, with the patient’s agreement, the family should not be involved in the discussion.

My feeling is that our reluctance to discuss this openly with patients, and to gain their consent in the light of this risk, results from the fact that we find it difficult to talk about things where there is such uncertainty. I suggest some illuminating further reading below, but these articles don’t dispel the uncertainties – indeed they raise more.

This returns me to another of the questions posed by the writer: ‘How is better understanding of the anaesthetic risks to patients aged over 60 being actively investigated?’

There are the beginnings of good news here. The James Lind Alliance Anaesthesia and Perioperative Care Priority Setting Partnership (a collaborative effort involving patients, the public and clinical professionals),

when identifying the most important directions for new research in perioperative care, has included in setting its top ten priorities the questions: ‘What long-term harm may result from anaesthesia, particularly following repeated anaesthetics?’ and ‘How can we improve recovery from surgery for elderly patients?’

But more needs to be done…

Suggested further readingNadelson MR, Sanders RD, Avidan MS.. Perioperative cognitive trajectory in adults. Br J Anaesth 2014;112(3):440–451 (bit.ly/2PwvzPY).

Foo I. Postoperative Cognitive Dysfunction: Fact or Fiction. AAGBI Core Topics in Anaesthesia 2015 (Chapter 9) (bit.ly/2PCiRQ7).

Becoming confused after an operation. Risks associated with your anaesthetic. RCoA 2017 (bit.ly/RCoA-PI-Confused).

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Communication, style, grammar, split infinitives, and the Oxford commaTHE RCoA’S NEW STYLE GUIDES

Dr Will Harrop-Griffiths RCoA Member of Council, London

I have an unpleasant affliction. It is one that impacts not only on me and my family, but on many if not most of those with whom I come into contact. I am obsessed with the English language. I am a grammar tyrant, a word nerd and a prose pedant. Although this may sound like a trivial complaint, I assure you that it is not. The grammatical errors that surround us cause many well-educated people annoyance. However, they cause me not just deep distress but actual physical pain. An aberrant apostrophe that might simply raise the eyebrow of a run-of-the-mill nitpicker can cause me such agony that I have been known to fall to the ground. A simple phrase from a teenager such as ‘Me and Katie went down the shops’ can render me paralysed and breathless for minutes. It is something I have learned to live with. I avoid environments that are likely to cause problems, such as greengrocers, Twitter or any outlet that sells the Daily Mail. I even try to steer clear of supermarket checkout queues for fear that one may be limited to ‘five items or less’.

I know that I am not alone in this eternal, linguistic anguish, and I have spent many enjoyable hours debating with fellow sufferers the merits of the Oxford comma or the undesirability of the split infinitive. I spent 10 years editing the journal Anaesthesia, during which I and my fellow editor–pedants David Bogod and Steve Yentis dedicated more time than was healthy to heated grammatical debate. How well I remember our protracted arguments about whether the first table in any academic paper that sets out the age, gender and weight of the study’s subjects should be entitled ‘Demographic data’, ‘Patient data’, ‘Patient characteristics’, ‘Patients’ characteristics’ or ‘Characteristics of patients’. Oh, happy days!

Given what you now know of me, you can imagine my excitement when I was told that the RCoA was developing not one but two style guides, and that I was allowed to be involved in their creation. ‘Two? Why two?’, I hear you ask. Let me explain.

The College has communication built into the very fabric of its being. It is obliged by its Charter and Ordinances (www.rcoa.ac.uk/charter-and-ordinances) to disseminate the results of research into anaesthesia, to educate medical practitioners and the general public in matters relating to anaesthesia, and to set and promulgate the highest clinical standards. The College therefore must communicate very different material to very different audiences. The language

necessary to describe the detailed results of a comprehensive literature review underpinning a Guidelines for the Provision of Anaesthetic Services (GPAS) chapter is not the same as that required to explain the need for starvation before anaesthesia to a member of the public or indeed to explain anything to a journalist. The College therefore needs two style guides: one for its ‘public-facing’ material and one for professional communications such as the Bulletin and GPAS or Anaesthesia Clinical Services Accreditation (ACSA) documents. The College’s Communications Directorate developed a style guide (bit.ly/RCoA-StyleGuide) for public-facing material. It is an excellent document, in spite of being largely based on the Guardian’s style guide. However, as a stroll through its introduction will rapidly reveal, it does not always suit professional output well:

‘Avoid jargon. Explain technical terms in the first instance’. It is difficult to produce a professional document without using jargon in the form of technical terms, many of which do not need explaining to an audience of anaesthetists. We therefore need a guide for those writing professional documents for consumption by our fellows and members.

Developing a style guide for technical output has been a labour of love for Jeremy Langton (GPAS Editor), David Bogod (Bulletin Editor) and myself (hopeless pedant), ably assisted by ever-patient staff members Nicola Hancock and Carly Melbourne. It will be available on the College’s website in due course and we welcome comments from Bulletin readers on its content. It is loosely based on the British Journal of Anaesthesia’s revised style guide (bit.ly/2NLcEk1) that, I am delighted to report, brings back words ending

in ‘–ise’ in place of the arguably correct but rather American ‘–ize’. The word count offered to me for this article by the Bulletin Editor does not allow me to explore every nook and cranny of the College’s two style guides or to illuminate the subtle but important (and to me endlessly fascinating) differences between them. However, if you are one of those who salivates when contemplating the differences between abbreviations, contractions, acronyms and unpronounceable initialisms, the guides will be available to you on the College’s website.

Happy grammatical nitpicking!

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Technology Strategy Programme (TSP)

TSP HITS MIDDLE AGE

mr Aaron Woods RCoA TSP Director

The TSP is a three-and-a-half-year change programme that will impact on every aspect of College technology. Now, 27 months or 64.3 per cent into the programme, the TSP Director reflects on progress to date.

What’s been happening? ■ August saw the College go live with

the biggest TSP project so far, the new Lifelong Learning Platform, which combines both e-Portfolio and Logbook functions. The system is entirely bespoke and newly built for our membership, and reaching this milestone has required a herculean effort by both staff and members alike – a huge thank you to all those who have played a role in bringing this to life.

■ At the end of 2017, the new Unified Communications system went live; this replaced both the old College telephone system and previous online conferencing applications.

■ We introduced a new service management system called TOPDesk in January this year. This is used by the College IT and Facilities teams, and latterly the Training team, to manage all issues and requests made by staff and members.

■ January also saw the completion of the new website(s) design specification, ready for building work to begin soon. To say this is just an update of the College website is a

serious understatement – it covers a new member portal, single sign-on to various member applications, a dedicated ACSA/GPAS management system, and of course reworkings of the main website and subsites such as those of the Faculty of Pain Medicine (FPM) and the Safe Anaesthesia Liaison Group (SALG).

■ The new College Finance system project is in full swing and we are also on the cusp of introducing the new Document Collaboration platform, which will allow committee members and other clinicians with College roles to safely share and co-edit documents online.

■ Numerous improvements have been made to the College’s underlying IT infrastructure, including the network, back-ups, email systems, servers and more. Although unlikely to set your soul alight with a crescendo of multicoloured passion and enthusiasm running out of control, this traditionally boring underbelly of IT provision is nonetheless vital to your College being able to function securely, and these improvements mark an important milestone for the TSP.

Successes ■ The top spot here has to go to the new

Lifelong Learning Platform. Unless you are switching on completely standard applications like Word or Excel, the chances are that any new system is going to have a bumpy landing when going live. And so it was for Lifelong Learning, which suffered serious performance issues in its first week. However, once a fix was applied the system started to rocket along as it should do. It is worth reminding people that the platform is unique, newly built and has 11,000 users – this is complex, unpredictable stuff. However bumpy that first week was, given these factors I am really proud of the team who delivered the project and encouraged by all the positive feedback we have had since going live.

■ Procurement. A large part of the TSP is about choosing the right systems and suppliers for staff and members. The last year has really seen the TSP team hone their skills in getting this right, negotiating good deals, and developing a generic selection process that the College can continue to use beyond the programme. Basically, we’ve got really good at shopping!

■ Technology responsibility within College roles. Over the last year I have been very pleased to see the College senior management understand and adopt a modern approach to how technology is supported. We have seen a blossoming of formally recognised ‘product owner’ roles amongst the College staff, which ensures the systems the TSP is putting in will be properly looked after and further developed over time.

Challenges ■ Spinning lots of plates. As the TSP

has matured in its second year it has also widened the number of projects running in parallel. For those with nautical knowledge, the analogy is ‘sailing close to the wind’ – you go fast but increase the danger of the boat tipping over. Analysing, quantifying and managing risk is at

the heart of the TSP process, and so it is a continual challenge to balance moving at speed with safety.

■ Hitting a target when you are standing on a moving platform. Its hard enough running a programme containing 32 separate projects, but the last year has also seen the College go through a radical change to its governance structure: new Council members, a separate trustee function, new committees and new people. These are really good, progressive changes for the College, but such positive disruption can’t not make it harder to manage risks, resources and plans.

What comes next? ■ The remainder of 2018 will see us go

live with Document Collaboration and introduce offline working for the Lifelong Learning Logbook.

■ The new Finance system is scheduled to go live at the very start of next year.

■ By the first quarter of 2019 the bulk of new websites and online applications planned for both members and the public will go live.

■ Work on extending the Lifelong Learning Platform to offer a CPD Diary commences in the autumn. Diary entries will integrate with existing functions such as Reflections and Logbook.

■ Work begins this autumn on the new College membership database, the last of the ‘big three’ within the programme (Lifelong Learning, new websites, new member database).

If you have any questions or would like more information please get in touch at tsp@rcoa.ac.uk

The Lifelong Learning Platform team (top left to right):

Paul mincher, Shamim Ullah, esma Doganguzel and

Claudia moran

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Professor John Norman Southampton

In 1976 Dr Edmund Riding became the tenth Dean of the Faculty of Anaesthetists. He died at the age of 94 this year. He was universally respected and loved as being one of the best. He was known universally as Dinge, acquiring the name at school where he appeared in the register as ‘Riding, E’ – the initial syllable was dropped.

Many of us knew him first when we were in training. He had become the assistant editor of the British Journal of Anaesthesia in 1959 while a consultant in Liverpool. In 1961, Cecil Gray, the editor, disappeared to Australia for several months as a visiting professor, leaving Dinge in charge. On his return, he commented that Dinge was doing so well that he might as well become the editor – a post he held until 1972. During that time the BJA doubled in size, in the numbers of subscribers and the number of papers published – and in price. All this done from a small office in the university department with one secretary – and little money.

The letters he wrote to contributors were always helpful. One paper I had accepted elicited his comment ‘this was one of the papers he had most enjoyed reading’. One especial thing I recall was that he maintained a high standard for the use of English. Patients were never allowed to be ‘intubated’; tracheas were. Much later I joined the Board, and had the pleasure of taking over as treasurer from him when he retired in 1983. He had cared for the BJA well in the times when the publishers were changing, and the journal, although a charity, started to make a surplus. Dinge remained on its Board and rightly advised caution in the use of its resources; he had been through some hard times as editor and treasurer. One paper

DR J EDMUND RIDING CBEoffered to it was withdrawn and published elsewhere. Fortunately the ensuing lengthy libel action did not succeed.

In 1974, after two years on the Board of the Faculty of Anaesthetists, he became chairman of the Examinations Committee. Here he led the way in the reforming of the exam. The coming of multiple choice questions led to controversies over whether they could be used as a screen, and over the need to maintain links with the faculty examinations of the College of Anaesthetists of Ireland. There was also the need to assess hospitals where anaesthetists in training were working. That came under the aegis of exams. Did the hospitals provide adequate experience for the candidates for the examinations? Mostly the hospitals assessed were the non-teaching hospitals; teaching hospitals only came in later. A new Hospital Recognition Committee was needed. Dr Riding’s common sense was needed to maintain standards.

Once Dean, amongst many problems he faced there were widespread discussions as to the future of the faculty. The powers of the Board were subject to the need for formal approval by the Council of the Royal College of Surgeons (RCS), and many fellows were in favour of full independence. Others, taking a more conservative view, were aware that the RCS in Lincoln’s Inn Fields had good resources of space, staff and finance, and that these would be expensive to replicate for an independent College. The compromise reached was to amend the Charter of the RCS to increase the participation of its faculties in its council, and to delegate matters such as fellowship and honours directly to the boards of the faculties. It took another decade for full independence to arrive.

Of more importance was the recognition of schemes for part-time training in the specialty. Dr Riding’s support for married women was exceptional, possibly in part due to the problems his wife had had in coping with work and the raising of children.

Throughout his time in Liverpool, he ran a pain clinic. At his last clinic before retirement he met one of his regular patients. He said how sorry he was he had not been able to do any more for her. Her reply was that just coming to see him was a major boost.

He retired, with his wife, Joyce. Both were expert gardeners; sadly, they eventually had to sell their house and garden. I met the purchasers at his funeral, and they introduced themselves as the people who ‘bought his garden’ – the house was not mentioned. They were novices, and Dinge came back regularly to help them maintain the displays. Sadly, Joyce died a few months before he did. His eyesight was failing but, with the help of his iPad, the audiotapes of the Royal National Institute of Blind People and music from Radio 3, he carried on. One regular visitor in his latter days has commented that after an hour or so and tea with Dinge he always went home feeling much better. I am sure we all feel the same from knowing him.

Dr J E Riding CBE MD FRCA FRCS(Hon) FRARCSI(Hon) FANZCA(Hon)

One regular visitor in his latter days has commented that after an hour or so and tea with Dinge he always went home feeling much better. I am sure we all feel the same from knowing him

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Bulletin | Issue 112 | November 2018

Dr Ian barker RCoA Heritage Committee Member and Retired Consultant Anaesthetist, Sheffield

AS WE WERE...The General Purposes Committee of the Faculty of Anaesthetists

The committee’s recommendations were that:

■ undergraduates should receive instruction from the department of anaesthetics

■ posts with anaesthetic duties in the pre-registration year should be established

■ teaching hospitals could appoint registrars in conjunction with a regional hospital ‘so that interchange can be facilitated’

■ there should be a review of the number of senior registrar posts (the bottleneck persisted into the 1980s)

■ there should be a moratorium on SHMO appointments with a concomitant increase in the number of consultant posts.

Hospital recognitionThere was no GMC quality assurance of training back then. Recognition for training was the responsibility of the Colleges and Faculties. There’s no detail of how recognition visits took place, and lots of hospitals were recognised for training, including Palmerston North and the University of Toronto.

Several were not recognised, for instance in the 1950s:

■ D— Hospital for not keeping a record of anaesthetic mortality

■ O— Hospital because it had inadequate anaesthetic rooms

■ W— Hospital because ‘most of the anaesthetics are given by General Practitioners with one consultant visit a week’

■ in 1953, the committee decided that N— Hospital would be recognised for training if their ‘Sister (presumably nurse) Anaesthetist could be offered alternative work’.

A new CollegeIn 1974, the Association of Anaesthetists invited the Faculty to join a working party ‘to determine the functions of a hypothetical College of Anaesthetists’.

Finally, the minutes are written reflecting the attitudes of a bygone era. Here are a couple of examples:

■ in 1962 the Institute of Chiropodists wrote asking for the views of the Faculty on the use of local anaesthetics by their practitioners. The committee minutes read that ‘It would be a dangerous precedent for the Faculty to associate itself with the teaching of anaesthetics to non-medically qualified people’

■ in the present climate of leaving the EU, we can look back at 1950 whence it is noted: ‘It was pointed out that Medical Practitioners from the continent were coming

to this country and obtaining responsible anaesthetists’ posts…it was considered that this practice was detrimental to the specialty.’ The GPC were concerned that some of the newcomers had insufficient experience, and suggested that they should be ‘vouched for by a recognised teacher in anaesthetics’

■ by 1962 attitudes had changed, and the Faculty was represented on the Common Market Specialist Committee on Anaesthesia. Their remit was to consider the ‘implications of the Treaty of Rome in respect of anaesthesia.’

There’s much more that I’ve not told you about, for instance: the establishment of the fellowship examination, the establishment of the research department of the Faculty, junior doctors’ hours, dental anaesthesia, the relationship of the Faculty with other organisations such as the Department of Health and the GMC, and in 1967 ‘part-time posts for married women anaesthetists.’

Plus ça change...? Well there’s quite a bit of la même chose!

Picture the scene – September 2017; two retired anaesthetists (let’s call them Anne and Ian) are rummaging around in the bowels of the College building looking for documents from the College’s history. In a gloomy corner Anne chances upon a dusty old file box. ‘I wonder what this is?’ Anne says, blowing the muck over the already dusty old Ian. Between bouts of coughing they open the box – and almost hear a distant fanfare as they realise that they’ve chanced upon the complete minutes of the General Purposes Committee (GPC) of the Faculty of Anaesthetists from 1948 to 1975.The GPC, it transpires, was the Faculty committee to which all other committees reported. It comprised the Dean of the Faculty, the Vice Dean and the chairmen of the standing committees. Over the years, these standing committees consisted of some of the Research, Finance, Examinations, Education, Fellowship Election Committees, a sub-committee for the ‘New Fellowship Examination’ in 1951, and the Nominations Committee. The GPC gave itself the remit to be ‘the Executive and Financial Committee of the (Faculty) Board’, and in essence this was where the decisions of Faculty were made – this was the inner cabinet. The names of those attending echo those portraits decorating today’s Council chamber and other rooms: Mackintosh, Bernard Johnson, Mushin, Organe, to name but a few.

These GPC minutes are a window into a different world. It’s not possible to give you more than a taste of their contents; some of them are very brief, but some are much longer – especially after the electric typewriter came into service in 1967.

Issues of training and staffing run throughout the minutes, and the following gives a taste of these and of other major themes.

TrainingAs an example, in 1950 there is a list of criteria for a hospital to be accepted as suitable for training to become a consultant anaesthetist, including the requirements for: 100 beds, 120 operations per month, facilities for anaesthetists in training to anaesthetise for major surgical operations under the supervision of a consultant anaesthetist, up-to-date anaesthetic apparatus, and anaesthetic rooms separate from but

near to the operating theatre.

StaffingIn 1953 a letter was received from Dr J Alfred Lee expressing concern about ‘the great difficulty that is being experienced by some provincial hospitals in obtaining junior anaesthetic staff’. Consequently, the Committee convened an extraordinary meeting which concluded that the causes of this were:

■ the financial attractions of general practice

■ the Senior Hospital Medical Officer (SHMO) grade, which many potential recruits to anaesthesia feared would be a dead end

■ little or no exposure to the specialty at undergraduate level.

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LETTERS TO THE EDITORIf you would like to submit a letter to the editor please email bulletin@rcoa.ac.uk

Dear Editor,

Professor michael rosen Cbe

Your tribute (RCoA Bulletin;110:14–15) to Michael Rosen illustrated perfectly the breadth and the depth of his achievements. When combined with his connections to Dundee (where he was born, schooled and received his basic medical education) those achievements made for a cogent argument for an honorary degree in 1996. Possibly the post-nominal abbreviation for that degree (Hon LLD) has lead to some confusion, but the degree was a Doctor of Laws, not Law, a small difference in spelling, but a huge difference in meaning. Thus the statement in the tribute that the degree was awarded ‘for his medicolegal work’ does not match the degree nor the content of the citation presented at the relevant degree ceremony.

Tony Wildsmith, Professor Emeritus, University of Dundee

NEW TO THE COLLEGEThe following appointments/re-appointments were approved (re-appointments marked with an asterisk).

Deputy Regional Advisors AnaesthesiaNorth Central LondonDr S Brocklesby (Barnet Hospital) in succession to Dr C Shaw

barts & the LondonDr R Cordery (University College Hospital)

College TutorsWalesDr S Mitra (Ysbyty Gwynedd, Bangor) in succession to Dr S Burnell*Dr H Jewitt (Royal Gwent Hospital)*Dr S Gill (Glangwili Hospital)

england Kent, Surrey and SussexDr R Kapoor (Kent and Canterbury Hospital) in succession to Dr N Somerville*Dr A C R De Silva (Medway Hospital)Dr S Nene (Worthing Hospital) covering for Dr T D A Standley

London North Central LondonDr C Ng (Barnet Hospital) in succession to Dr M Sodhi

Thames valley oxfordDr R B Ramasundaram (Wexham Park) in succession to Dr S Dinesh Selvan

WessexDr H Edgar (Salisbury District Hospital) in succession to Dr B Siggers

West midlands birminghamDr Z Hush (Birmingham City Hospital) in succession to Dr A Brake

WarwickshireDr A C Mayell (University Hospital of Coventry and Warwickshire) in succession to Dr A N KellyDr Y Chickermane (Heartlands Hospital) in succession to Dr H Ebrahim

Certificate of Completion of TrainingTo note 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, or Anaesthesia with Intensive Care Medicine or Pre-Hospital Emergency Medicine where highlighted.

May 2018DefenceDr Ravi Chauhan Joint ICM

east of englandDr Helen Boys Dr Hannah Kiziltug

Kent, Surrey & SussexDr Roisin Monteiro Dr Sarah Nour

London ImperialDr Michelle Quinney

barts & The LondonDr Thomas Bishop

South eastDr Roopa Chatterjee

North West merseyDr Simon Morton

North WestDr Sujata Anipindi Dr Richard McGuire

Scotland West of ScotlandDr Anne Davidson Dr Peter Paisley Dr Kate Slade Joint ICM

South West PeninsulaDr Johannes Retief

SevernDr Helen Howes

WalesDr Matthew Carwardine

WessexDr Nigel Beauchamp Dual ICM

West midlands birminghamDr Phillip Lo

StokeDr Sarah-Jane Basterfield Dr Victoria Yates

Yorkshire & The Humber South YorkshireDr Martyna Berwertz Dr Helen Thornley

July 2018DefenceDr Jonathan Pearson

east midlandsDr Umair AnsariDr Richard JonesDr Mahesh KodivalasaDr Madhur MehtaDr Pradeep IngleDr Adeel MajeedDr Bhavesh Raithatha

east of englandDr Eloise McMasterDr Joanna Lynch

Kent, Surrey & SussexDr Boris SajinDr Venkatesan DuraiswamyDr Rasha AbouelmagdDr Sanjay AgrawalDr Robert ConwayDr Andrew HartoppDr Veera Machavarapu

London ImperialDr Savita MaratheDr Nadia MasoodDr Sabeen KhanDr Kiranjit Khazan Singh

North Central LondonDr Baljit PhullDr Lisa NichollsDr Neel DesaiDr Martin GrayDr Alexa StrachanDr Michelle Le CheminantDr Lauren OswaldDr Philip Sherrard

South eastDr Zhi OonDr James WightDr Priyakam Chowdhury

St George’sDr Nicholas Dennison

North West merseyDr Simon AliDr Anita BidwaiDr Joseph HobsonDr Yi TanDr Alin SimionicaDr Sam Michlig

North WestDr Shikha SardaDr Adam SlackDr Matthew Bowler

NorthernDr Anthony RostronJoint ICM

Dr Bhaskar DuttaDr Clare Watkinson

Northern IrelandDr Dragan NenadicDr Samuel DawsonDr Leanne LavertyDr Christopher Wasson

oxfordDr Bianca-Lea Tingle

Scotland South east ScotlandDr Alexander TrotmanDr Andrew Goddard

Dear Editor,

Confirming fire risk safety: Anne Thornberry’s Fires and explosions (RCoA Bulletin;110:58)

During long-duration-prone surgery stabilising fractured spines of patients at Stoke Mandeville, our Senior Scrub Sister was distressed by aromas of coffee (or soup) from the other side of my blood–brain barrier. My surgical colleague reassured her; he travelled the world performing pro-bono surgery and, as a heavy smoker and strong coffee drinker, he had smelt both while operating in Italy. There, peering over the screen, he was greeted by a cheery ‘Ciao!’ from the anaesthetist who looked up from his seat, lighted cigarette in hand, ashtray and an espresso on his machine.

This story took the wind out of Sister’s sails, but sensitive to her wishes, Marks I, II and III ‘Trojan sharps boxes’ with a side-door were constructed to secrete cups, with drinks delivered on request by the ODP. Mark I did not last long; Mark II had the lid closed to stop sharps going in; Mark III had suction attached and the enhancement of an upper sandwich platform. Sister knew stuff was being consumed in her theatre, but she never discovered how.

Dr William F S Sellers, Leicestershire

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DEATHSWith regret, we record the death of those listed below.

Dr Geoffrey W Burton, BristolDr Allan S Brown, EdinburghDr John O Griffiths, Lancashire

Dr Peter Jackson, New Brunswick, CanadaDr Janet M Ferris, HertfordshireDr A June Porterfield, Kent

Please submit obituaries of no more than 500 words, with a photo if desired, of fellows, members or trainees to: website@rcoa.ac.uk. All obituaries received will be published on the College website (www.rcoa.ac.uk/obituaries).

APPOINTMENT OF MEMBERS, ASSOCIATE MEMBERS AND ASSOCIATE FELLOWSmemberDr Albert Francis Brennan

Associate membersDr Deepak Matthew GregoryDr Mindaugas BalcuinasDr Deirdre MorleyDr Hisham Mohamed Abdelfatah AllamDr Anirban SomDr Elias Chukwujioke OnworaDr Jessica De Bois

Dr Hewa Wattakgodage Manjula AtapattuDr Edward William RintoulDr Abhinav AnghotraDr Mohamed Ashiq Mohamed SalimDr Suraj Sampath VidanageDr Prakash Chabium SubramaniamDr Daniel Stuart RobertsDr Mostafa Mohammed Salaheldeen F MohammedDr Dur E Hira

Dr Kannangara Liyanage Sasika Prabath WijayasingheDr Veena GeethaDr Mohamed Alaaeldin RadwanDr Malka Rangali Jayasinghe ArachcigeDr Michael BurnsDr Maria HerincsDr Lina AndriuskeviciuteDr Tomas Martos Van PottelberghDr Bruce Liu

APPOINTMENT OF FELLOWS TO CONSULTANT AND SIMILAR POSTSThe College congratulates the following fellows on their consultant appointments:

Dr Ibukunoluwapo O M Adedugbe, The National Hospital for Neurology and Neurosurgery, London

Dr Toni Brunning, Worcestershire Royal Hospital

Dr Nick Dennison, Frimley Park NHS Trust, Surrey

Dr Ben Eden-Green, Lewisham and Greenwich NHS Trust

Dr Leanne Laverty, Altnagelvin Area Hospital, Londonderry, Northern Ireland

Dr Vazira Moosajee, London North West Hospitals Trust

Lt Col JD Pearson, South Tees Foundation Trust

Dr Stafan Valdinger, Royal Derby Hospital

On 19 September 2018, Professor Ravi Mahajan (third left) was admitted as President of the College for the year 2018–2019. Dr Janice Fazackerley (right) and Dr Simon Fletcher (left) were admitted as Vice-Presidents for the year 2018–2019, and Dr Liam Brennan (second left) was presented with a Past President’s Medal.

CONSULTATIONSThe following is a list of consultations which the College has responded to in the last two months. Those published on the College website via our Responses to Consultations area (bit.ly/rcoa-consultations) are marked with an asterisk.

originator Consultation

Association of Anaesthetists

Endorsement for concise practice guidance on the prevention and management of accidental awareness during GA (NAP5)

Academy of Medical Royal Colleges

Guidelines for writing outpaitnet clinic letters to patients

NHS England Design of the NHS Assembly

Association of Anaesthetists

Quick Reference Books on anaesthetic emergencies

Health Education England

What do we call an anaesthetist in training' online survey

Getting It Right First Time

GIRFT National Specialty Report in Oral and Maxillofacial Surgery Stakeholder Consultation

Association of Anaesthetists

Anaesthesia and perioperative care for Jehovah’s Witnesses and patients who refuse blood

National Insitute for Health and Care Excellence

Guideline CG103 Delirium: prevention, diagnosis and management

Association of Anaesthetists

Controlled drugs in peri-operative care 2018 guideline

Association of Anaesthetists

Perioperative Care for People with Dementia

Royal College of Ophthalmologists/British Ophthalmic Anaesthesia Society

Patient safety alert – gas in the vitrectomised eye

Faculty of Intensive Care Medicine

Guidelines for the Provision of Intensive Care Services

Association of Anaesthetists

The need to update NICE clinical Guideline CG112 Sedation in under 19s

NHS England Developing the long term plan for the NHS*

NHS England Integrated Care Providers (ICPs) contract*

ANAESTHESIA RECRUITMENT UPDATEDr rachael Ford and Dr Justine elliott, rCoA recruitment Committee

The first round of recruitment under the new national recruitment model for anaesthesia was very successful, and has achieved an improved 95 per cent ST3 fill rate. There continues to be national variation in post fill rates and this is being tackled regionally.

Changes to self-assessment scoringThe self-assessment scoring system used by applicants to anaesthesia training posts has been undergoing extensive review and fine tuning over the last 18 months. The new scoring system will be implemented for those applying for posts commencing in August 2019. The key changes are:

■ a new section on leadership and activities outside medicine

■ the weighting of the scores has changed – for ST3 applications, there is reduced emphasis on undergraduate achievements and more importance is placed on activities undertaken while in anaesthetic training

■ a reduced ability to ‘double count’, ie to get points for the same activity in multiple sections

■ more detailed information, making it clearer how many points candidates should be awarded in each section.

The scoring system continues to be out of 50 points, and makes up 25 per cent of the total interview mark. The new self-assessment scoring system will be available to view on the Anaesthetic National Recruitment Office (ANRO) website: https://anro.wm.hee.nhs.uk) at the end of the year.

West of ScotlandDr David FinnDual ICM

Dr Deirdre ConwayDr Maura HuttonDr Andrew Nath

South West PeninsulaDr Andrew Biffen

SevernDr Matthew MartinDual ICM

Dr Annabel PearsonDr Sonja Payne

WalesDr Catrin WilliamsDr Dylan JohnDr Lee BealeDr Lewis Connolly

WessexDr Duncan TarryDual ICM

Dr Ross Cruickshank

West midlands birminghamDr Matthew Davies

StokeDr Szilvia BertokDr Syma Sunny

Yorkshire & The Humber South YorkshireDr Deborah KerrJoint ICM

Dr John WhitakerDr Caroline LowrieDr Alexander KojroDr James Briscoe

West YorkshireDr Natalie BaldryDr Mark GreasleyDr John StonesDr Mairi Crawford

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eXAm revISIoN CoUrSeS

Primary FRCA Masterclass15–18 January 2019 24–27 June 2019 | RCoA, London

Final FRCA Revision Course11–15 February 2019 1–5 July 2019 | RCoA, London

Offering a combination of learning methods, including lectures, small group tutorials and practice MCQ and SAQ papers, these revision courses will inspire confidence and ensure trainees are well prepared for the Primary and Final FRCA written examinations.

LeADerSHIP AND mANAGemeNT CoUrSeS

Working Well in Teams and Making an Impact14 November 2018 | RCoA, London

Leading and Managing Change5 February 2019 | RCoA, London

Introduction to Leadership and Management: The Essentials2–3 April 2019 | Sheffield 2–3 May 2019 | RCoA, London

Consisting of interactive group exercises, plenary sessions and discussions, with an emphasis on real life issues, these workshops will help you develop the necessary skills to become an impactful leader in today’s NHS.

CPD approved

CPD credits 5

Tracheostomy Masterclass11 January 2019 | RCoA, London

Combining small group discussions, skill stations and simulation scenarios, this masterclass brings together a multidisciplinary faculty, including anaesthetists, ENT surgeons, speech therapists and physiotherapists, to address the major issues from tracheostomy insertion to decannulation.

Suitable for anaesthetic consultants, SAS Doctors and ST3+ trainees.

‘Lots of new learning and experiences to apply to day-to-day care’ March 2018

Airway Workshops15 January 2019 | 25 June 2019 | RCoA, London

Appropriate for all grades of anaesthetic trainees, specialty doctors and consultants, these workshops enable you to learn core technical and non-technical skills including:

■ flexible bronchoscopy

■ awake tracheal intubation

■ front-of-neck access

■ supraglottic airway devices

■ videolaryngoscopy

■ airway guidelines.

‘Great for all levels and a vital reminder of some potentially lifesaving airway techniques’ June 2018

Airway Management: Training the Trainer6 June 2019 | RCoA, London

Through a combination of lectures and workshops, this day will provide you with the skills and confidence to set up courses and deliver effective airway teaching in hospitals, for multidisciplinary teams, in a cost-effective manner.

Aimed at airway leads, anaesthetic consultants and senior trainees wishing to advance their airway teaching and training skills.

‘Excellent faculty, credible, experienced, well prepared, very approachable and knowledgeable’ May 2018

AIRWAY WorKSHoPS

Bulletin | Issue 112 | November 2018

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Discounts available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

EVENTS CALENDARFurther information about all of our events can be found on our website.www.rcoa.ac.uk/events events@rcoa.ac.uk

@RCoANews

NOVEMBERLeadership and Management: Working Well in Teams and Making an Impact14 November 2018RCoA, London

Joint Winter Scientific Meeting with the Scottish Society of Anaesthetists15–16 November 2018Apex City Quay Hotel, Dundee

UK Perioperative Medicine Clinical Trials Network Meeting19–20 November 2018RCoA, London

SALG Patient Safety Conference22 November 2018Civic Centre, Newcastle

Ultrasound Workshop23 November 2018RCoA, London

Anaesthetists as Educators: Anaesthetists’ Non-Technical Skills (ANTS)26 November 2018RCoA, London

Updates in Anaesthesia, Critical Care and Pain Management26–28 November 2018Hilton Liverpool City Centre

Clinical Directors Meeting27 November 2018RCoA, London

British Ophthalmic Anaesthesia Society (BOAS) Annual Scientific Meeting and Workshop28–29 November 2018RCoA, London

Faculty of Pain Medicine 11th Annual Meeting: Topical Issues in Pain30 November 2018RCoA, London

DECEMBERWinter Symposium: Innovation12–13 December 2018RCoA, London

JANUARYTracheostomy Masterclass11 January 2019RCoA, London

Airway Workshop15 January 2019RCoA, London

Primary FRCA Masterclass15–18 January 2019RCoA, London

GASagain (Giving Anaesthesia Safely Again)16 January 2019Bradford Royal Infirmary

Anaesthetists as Educators: Advanced Educational Supervision29 January 2019RCoA, London

Patient Safety in Perioperative Practice 31 January 2019RCoA, London

FEBRUARYFaculty of Pain Medicine Study Days: Hot Topics and Case Studies in Acute Pain4–5 February 2019RCoA, London

Leadership and Management: Leading and Managing Change 5 February 2019RCoA, London

Final FRCA Revision Course11–15 February 2019RCoA, London

Updates in Anaesthesia, Critical Care and Pain Management25–27 February 2019RCoA, London

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Anaesthetists as Educators: Teaching and Training in the Workplace27–28 February 2019RCoA, London

MARCHAfter the Final FRCA: Making the Most of Training Years 5–76 March 2019RCoA, London

Ethics and Law 13 March 2019RCoA, London

Ultrasound Workshop19 March 2019RCoA, London

CPD Study Days 20–21 March 2019RCoA, London

Global Anaesthesia22 March 2019RCoA, London

APRILIntroduction to Leadership and Management: The Essentials2–3 April 2019Sheffield

Cardiac Disease and Anaesthesia Symposium3–4 April 2019RCoA, London

GASagain (Giving Anaesthesia Safely Again)25 April 2019RCoA, London

Developing World Anaesthesia29 April 2019RCoA, London

UK Training in Emergency Airway Management (TEAM)29–30 April 2019Salford Royal Hospital

Anaesthetists as Educators: Teaching and Training in the Workplace30 April – 1 May 2019RCoA, London

MAYIntroduction to Leadership and Management: The Essentials2–3 May 2019RCoA, London

Anaesthetists as Educators: Anaesthetists’ Non-Technical Skills (ANTS)7 May 2019 RCoA, London

ANAESTHESIA 201920–22 May 2019etc.venues St Paul’s, London

JUNEAirway Management: Training the Trainer6 June 2019RCoA, London

UK Training in Emergency Airway Management (TEAM)10–11 June 2019Solihull Hospital

Anaesthetists as Educators: An Introduction11 June 2019RCoA, London

UK Training in Emergency Airway Management (TEAM)20–21 June 2019Royal United Hospital, Bath

Primary FRCA Masterclass24–27 June 2019RCoA, London

Airway Workshop25 June 2019RCoA, London

GASagain (Giving Anaesthesia Safely Again)26 June 2019Royal Bournemouth Hospital

JULYFinal FRCA Revision Course1–5 July 2019RCoA, London

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St Paul’s, London #Anaesthesia2019

Bulletin | Issue 112 | November 2018 Bulletin | Issue 112 | November 2018

book your place at www.rcoa.ac.uk/events70 | book your place at www.rcoa.ac.uk/events | 71

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Discounts available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.%

Discounts available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

WINTER SYMPOSIUM: Innovation12–13 December 2018 rCoA, London

Innovation is the theme for this year’s Winter Symposium and the varied programme features a mix of lectures, short updates and debates with the addition of airway workshops to refresh your front of neck access (FONA) and fibreoptic techniques. The event will also feature an SAS Doctors update and networking session.

Experts will bring you up to speed with recent changes in practice and explore what the next five years may bring.

Key speakers and topics include:

■ Mr Matthew Swindells, National Director: Operations and Information, NHS England

■ PRE-HOSPITAL RESUSCITATION Professor Jerry Nolan, Chair, European Resuscitation Council

■ GENOMICS – WHAT’S IN IT FOR ANAESTHESIA? Professor Jaideep Pandit, RCoA Council Member, Consultant Anaesthetist, Oxford University Hospitals

■ NOVEL ANALGESIC MECHANISMS Professor Anthony Dickenson, Professor of Neuropharmacology, University College London

■ NON-ECLAMPTIC SEIZURES IN OBSTETRICS Dr Felicity Plaat, Consultant Anaesthetist, Imperial College Healthcare NHS Trust

■ PAPERLESS PERIOPERATIVE CARE: OPEN STANDARDS DRIVING INNOVATION FOR IMPROVEMENT Dr Alexander Davey, Locum Consultant Anaesthetist, Western Health and Social Care Trust

book your place at www.rcoa.ac.uk/events

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Discounts available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors and Medical Students. See our website for details.

Feedback from our 2017 Symposium:

‘Really enjoyable conference with excellent speakers’

‘Excellent overview of evolving ideas in many fields of anaesthesia’

‘Great speakers on general trends in anaesthesia’