· There is the need for data to be available for both patients to make informed decisions on their choice of hospital, and trusts to monitor how well or badly they are doing.

· One possible problem with league/performance tables is that surgeons may not take on difficult or sick patients, as the possibility of a poor result would affect their results. This has already happened in the US where cardiothoracic surgeons have their results published, and there have been reported problems with cardiologists finding surgeons to take on sick patients.

· The key element to any successful performance indicator is the relevance and the accuracy of the data. It is often the case that something is measured simply because it is easy to measure, and this may result in the information not being relevant. It is important to decide on what is important and then measure that, even if it difficult.

· E.g. Outcomes following total joint replacement…important measures would include:

o Patient satisfaction

o Validated outcome score (WOMAC, Oxford etc)

o Infection rate

o Wound problem rate

o Dislocation rate (for THR)

o Aseptic loosening rate

o Thromboembolic rate

· There are few centres in the country that would be able to accurately get hold of this data. My experience with the revision knee study at Wrightington has shown me how hard accurate data collection can be when there are people specifically working for the project, which then bodes poorly for other areas of data collection where there are staff shortages and the staff involved do not understand the relevance of the data being collected.

League Tables for NMGH and SMUHT

	Hope	SMUHT	NMGH	Best in country
Dr Foster stars	5	5	4	6
DOH stars	2	2	2	3
#NOF mortality	103%	85%	105%	25% 50% Peterborough
THR wait (days)	452	341	189	53
TKR wait (days)	478	442	209	42
Arthroscopy wait	104	127	64	13
% OPA <13 weeks	59	46	72	100
% IP <6 months	61	53	72	100
Hand OPD waiting time (weeks)	56
Shoulder OPD waiting time (weeks)	87

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CPD/appraisal

· How good a consultant am I?

· How well do I perform?

· How up to date am I?

· How well do I work in a team?

· What resources and support do I need?

· How well am I meeting my service objectives?

· What are my development needs?

Personal development plan

Aspect	1 year	5 year
Clinical practice	Set up database for personal Upper Limb data Set up a shoulder & elbow service Develop my surgical skills Trauma Admissions Database	Develop databse
Teaching	Medical students · Attend PBL course HO/SHO continue with departmental and BST teaching HST teaching Orthoteers · Clinical examination course · Basic science course · Publication of Orthoteers books o Orthopaedic Facts o Clinical Examination Attend for AO teaching course	Become involved in the structure of the HST programme
Audit	Set up tools required for data collection, to make the information for audit more readily available
Research	Complete current projects Develop new projects Links with University: Computer Science – wireless Trauma Patient Management System MVU – Simple Shoulder Anatomy Model Engineering – Shoulder Simulator for Instability Radiology – DEXA shoulder
CME	Courses arranged: Ultrasound Edinburgh Reading AAOS, ASES AO Fellowship – Boston	M(Ed) course (?) Maastricht / Dubdee university correspondence course
Management	Appraisal course Interviewer course Examiner course
Personal	New Baby; Badminton league

The ‘Three Ages’ of Consultant Practice:

Phased sequence of responsibilities

First Ten years – teaching & development of a clinical practice

Second ten years – further teaching & administrative responsibilities

Third ten years – more time to areas of professional responsibility, such as in the governance of professional bodies.

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10 minute talks

"How would you improve the patient's experience of arthroplasty at Stepping Hill Hospital"

“Team working – Has the time of the single handed consultant passed”

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How do you know you have been fully trained?

· What is the definition of fully trained?

o A safe and competent clinician that recognizes his/her limitations, and takes appropriate steps to get help from colleagues when needed.

o The responsibility for awarding the CCST lies with the training committee, and if there are concerns about a trainee, then these should be dealt with during the training period, not after the CCST is awarded.

o There are going to be improvements made to all skills as I gain experience

· Clinical skills/diagnosis (This is the most important component of the training)

· Decision making

· Operative skills

· Interpersonal skills

· Management skills

· Teaching skills

· Personally, I feel that I have had a broad and safe training, with the majority of my decisions and operative work being supervised directly by my consultant at the time. I have been gradually exposed to more difficult procedures as I have progressed, to the point now where I feel confident in managing most problems related to trauma and lower limb surgery (Hip and knee). This has been reinforced by seeing patients get better and recover following surgical procedures performed by myself.

· Methods Confirming the Above:

o Feedback from training Appraisals, Consultants & staff

o Logbook

o Feedback from RITA (Assessments)

o My own satisfaction

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What are the limitations to your abilities and how would you approach the problem areas in your practice? - eg spinal or pelvic injuries

· Surgical / Managerial / Research / Teaching

· Firstly identify that there is a difficult case. This requires self awareness and humility.

· There would be a number of ways to manage the problem.

· Make sure that you are up to speed on the most recent developments in that particular field.

· Discuss with another colleague.

· Discuss with a special interest group. If there isn’t one then perhaps I could be the one to initiate the formation of such a group.

· The Managed Clinical Network, if available would be an ideal forum in which to discuss cases.

· If the surgical procedure is one which is new, or one I had not been trained in, then it would be my responsibility to visit another surgeon who is competent at the technique, or have another colleague working together with you on the case.

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Give an example of evidence based medicine and how you've used it in your practice.

· Subacromial Plica

· Arthroscopic release for post-traumatic stiffness

· (PEP Trial)

· (Use of drains in Hip & knee surgery)

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General questions on Clinical governance

CHI defines clinical governance as the system of steps and procedures adopted by the NHS to ensure that patients receive the highest possible quality of care. It includes:

a patient centred approach
an accountability for quality
ensuring high standards and safety
improvement in patient services and care

· DoH definition –

"The framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish"

· “Corporate responsibility for the standards of clinical care delivered to patients”

It therefore differs from audit as audit is observational, not an allocation of responsibility. However, good audit underpins successful governance

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NICE

NICE - The National Institute for Clinical Excellence - was set up as a Special Health Authority for England and Wales on 1 April 1999.

It is part of the National Health Service (NHS), and its role is to provide patients, health professionals and the public with authoritative, robust and reliable guidance on current “best practice”.

NICE guideline on pressure ulcer risk management and prevention , 18 July 2001

NICE has issued its guideline on Pressure Ulcer Risk Assessment and Prevention. The guideline, provides advice on best practice for clinicians and patient/ carers on avoiding getting a pressure ulcer and is derived from a detailed guideline, which the Department of Health commissioned from the Royal College of Nursing. This guideline is part of the inherited work programme of the Institute.

Relevant Guidelines in progress:

Pre-Operative Tests
Falls
Infection Control

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Clinical Audit

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in health-care delivery.

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National Service Frameworks

The New NHS and A First Class Service introduced a range of measures to raise quality and decrease variations in service including National Service Frameworks (NSFs) The NHS Plan re-emphasised the role of NSFs as drivers in delivering the Modernisation Agenda.

National Service Frameworks:

set national standards and define service models for a defined service or care group;
put in place strategies to support implementation; and
establish performance milestones against which progress within an agreed time-scale will be measured.

The rolling programme of NSFs, launched in April 1998, takes forward established frameworks on cancer and paediatric intensive care and published NSFs include mental health, coronary heart disease (CHD), and older people. Diabetes is the next NSF to be published.

The Secretary of State announced the next phase of the NSF programme in spring 2001. It will include NSFs for:

renal services,
children services, and;
long term conditions focusing on neurological conditions

Key Facts

The mental health NSF was published on September 30th 1999.
The CHD NSF was published on March 6th 2000.
The National Cancer Plan was published in September 2000.
The Older People NSF was published on March 27th 2001
The next NSF to be published is Diabetes.

There will usually be only one new framework a year.

Each NSF is developed with the assistance of an external reference group (ERG) which brings together health professionals, service users and carers, health service managers, partner agencies, and other advocates. ERGs adopt an inclusive process to engage the full range of views. The Department of Health supports the ERGs and manages the overall process.

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Research Governance Framework

The Research Governance Framework for Health and Social Care sets out the standards that must apply to all research that relates to the responsibilities of the Secretary of State for Health.

It explains the responsibilities of participants, researchers (including principal investigators), research funders and sponsors, universities and other organisations employing researchers, care organisations and professionals, and research ethics committees.

· Sets National Standards for research

· Defines mechanisms to deliver standards

· Describes monitoring and assessment arrangements

· Improves research quality and safeguards the public by:

- Enhancing ethical and scientific quality

- Promoting good practice

- Reducing adverse incidents and ensuring lessons are learned

- Preventing poor performance and misconduct

Main Areas:

1. Ethics.

Science.
Information.
Health, Safety and Employment.
Finance and Intellectual Property.

Ethics

o Information about ethical approval, including Research Ethics Committee (REC) reference number, date of submission and approval, any amendments or conditions applying to the approval, and any deviations from the original protocol submitted/approved by REC.

o Details of any arrangements the REC has decided are required to respond to claims for compensation in the case of non-negligent harm.

o Details of indemnity arrangements

o Information about requirements for reports to the REC.

o Confirmation that the protocol describes satisfactory arrangements for obtaining informed consent, including in relation to research involving tissues or organs of the deceased

o Confirmation that satisfactory arrangements are in place to ensure confidentiality of personal information

o Information about the involvement of consumers in the design, conduct, analysis and reporting of the research.

Science

o Confirmation that the need for the research has been demonstrated, including by reference to existing sources of evidence.

o Confirmation that the quality of the proposed research and the necessary expertise of the Principal Investigator and other researchers has been established through appropriate independent review.

o Information about the notification to, and approval of the research by, the Medicines Control Agency for trials of medicinal products on people.

o Information about the notification to, and approval of the research by, the Medical Devices Agency for research involving new medical devices.

o Information about approval of research involving the use of human embryos or the release of genetically modified organisms and food or food processes.

o Details of any animal licences required.

o Information about any adverse incidents and how they have been reported.

Information

o Details of the research being conducted (as required for the National Research Register)

o Confirmation that the findings of the research have been subjected to critical review prior to publication.

o A structured summary of the findings of the research (as required for the Research Findings Register).

o Record of publications describing the findings of the research and other information demonstrating that the findings have been made available through accepted scientific and professional channels.

o Information about how the findings have been made available to those participating in the research (including the relatives of deceased patients who have consented to the use of organs or tissues in the research) and to all those who could benefit from them.

Health and safety

o Confirmation that the protocol identifies any health and safety risks of the research and describes how such risks have been minimised in accordance with good clinical practice and in adherance to health and safety regulations.

Finance and exploitation of intellectual property

o Details of the income and expenditure relating to the research, including size and scope of grant(s).

o Details of arrangements for compensation of anyone harmed by the research, where required.

o Details of intellectual property that has the potential for commercial development.

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How do you manage stress?

· Prevention

· Proactive organization of time & demands

· Service configuration

· Recognition

· Identify that there is stress present. Is the stress good or bad?

· Manage the cause of the stress

· Identify the cause of the stress, and then try to recognize which components of the cause you can manage on your own and which need help from colleagues/management.

· Manage the symptoms of the stress

· Discuss with colleagues, spouse, friends

· Have quality time away from work to recharge your batteries

· Have hobbies and interests which are important to you

· Exercise

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Can you tell me of a situation you have been in where patient care could have been better and how you managed it once you realised the problem.

o IV fluid management of septicaemic patient

If you were in an annual appraisal now, what goals would you like to achieve over the next year.

· See personal development plan

If appointed, how will we know, say in a year's time, that we made the correct decision in appointing you.

· Appraisal

· Data

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Why did you apply for this job?

· Job which will allow me to practice knee surgery as a special interest

· Colleagues

· Location

· Teaching Opportunities

· Opportunity to develop a Shoulder & Elbow service for the local community

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What do you know about the Kennedy report?( report on Bristol)

· To reflect the patient’s journey, the Recommendations are divided into categories as follows:

· Respect and honesty;

· a health service which is well led;

· competent healthcare professionals;

· the safety of care;

· care of an appropriate standard;

· public involvement through empowerment; and

· the care of children.

What lessons did we learn from the Bristol case?

· Transparency

· Personal accountability

· Continued personal development

Opinions on the Kennedy Report on Bristol (from ASIT)

Specific points:

Communicating with patients

Pts 10,17 & 18

The requirement for tape recording consultations and providing copy letters is in theory a good one. It will impose upon surgeons the need to be clear and concise about the details of management planned. However there will be large cost implications and there needs to be clear evidence of funding for these issues.

The regulation of the quality and safety of healthcare

Pt 39, 40, 41

We would question the need for a Council for the regulation of Healthcare Professionals, which would appear simply to add another body at more cost. However if it is to be set up we are pleased to see the insistence on independence form government. Likewise in points 40 &41 the further mention of finance and independence is to be applauded.

The management of the NHS at the local level

Pt 43

The trainees have long suggested that a clear definition and contractual statement of a consultants NHS commitment is vital to emphasise to the public and media the role of the consultant.

Pt 44

The distinction award system has always been seen as a bit of an old boys network and any attempt to clear this up will be appreciated. The recent media pressure to remove the merit award from one of the Bristol surgeons only shows a lack of understanding.

Pt 47

The option for the trust to deal with breaches of professional code as well as or instead of the professional body is unacceptable. This could end up with a system of "double jeopardy" and must be resisted.

Broadening the notion of professional competence.

Pts 58,59 &60

The assessment and emphasis upon the importance of competence in the non-clinical skills in medicine has diminished significantly in recent years. The recommendation for formal assessment of these skills is good. There should also be clear evidence of review of these skills in the revalidation process throughout a medical career.

Post-qualification training and CPD

Pt 81

The endorsement of the concept of the Medical Education and Standards Board (MESB) is interesting. The report states that this should be part of and answerable to the GMC. In point 42 the report states that bodies who regulate healthcare must be independent of government. This would appear to request the MESB be independent of the DoH. This may allay a concern which has been expressed that a DoH controlled MESB would interfere too much in post-graduate training.

The acquisition and development of new clinical skills

Pt 99

It would simply appear common sense that new skills should be learnt under direct supervision. We all know that this does not always happen and emphasis on this is welcomed. However there will be cases where innovation is required and as long as the patient is aware, this should clearly continue to allow progress.

Pt 103

This comment smacks of ageism. The question of who should operate when must be governed by competence assessment and not by any arbitrary age limit.

Care of an appropriate standard

Pts 122 & 123

Again the emphasis on the independence of NICE is welcomed. The comment that the DoH should not rescind or detract from NICE guidelines is of vital importance if this body is to gain the respect of the profession and not continue to be seen as the government's organ to cut costs at all opportunities.

Information systems

The requirement for audit is accepted by all. The emphasis on proper data collection is vital. Double collection is a waste of time and can be very confusing to both clinicians and the public.

The requests for "league table" type data will continue and mount. Until proper verifiable data collection can be shown to be in place these must be resisted. However we must accept the concept and help work towards this goal. Each surgeon should have his own data and be willing to share this with patients. If this means some work ourselves to supervise the data collection, maybe we should ask is this not worthwhile in able to be competent to answer questions from patients before and after surgery.

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ASSESSMENT, APPRAISAL & REVALIDATION

What do you think of assessment and appraisal?

· I think that this is essential to enable both doctors and patients to see that there are mechanisms by which good practice is acknowledged by peers and ultimately revalidation, and bad practice is identified and then addressed.

· It will probably be similar to the annual appraisal that has been happening over the last 6 years of my SpR training.

Difference between Assessment and Appraisal:

The difference between Assessment and Appraisal has been summarised thus: "Ticking boxes set by others" (Assessment) and "Ticking boxes that I have helped to set myself" (Appraisal)

The purpose behind appraisal for Medical Staff under training is to set goals for training. In this context, it is inevitable that career options will be discussed.

Appraisal Framework: BOGERD

· Background – discuss CV and long and short-term goals.
· Opportunity - departmental timetable and departmental protocols.

· Goals - This is the essential part of any appraisal process. The goals should be simple and attainable.
· Evaluation - Having set the goals it is important to think about how to establish whether the goals have been achieved. If they have not been reached, the evaluation process will help to establish why they have not been successfully attained.
· Rescue - Most people's experience of life is that if a goal is not achieved, it has a negative effect on further efforts. Consider mechanisms for ensuring that these or alternative goals are achieved.
· Deal – A commitment to achieving goals.

Revalidation

Revalidation is a process whereby doctors will have to demonstrate regularity to the GMC that they are fit to practice medicine. Doctors who are successful will be granted licence to practice.

chart

GMC’s PLANS FOR REVALIDATION

1. Alter the Medical Act, allowing the council to draw up registers from Spring 2002

2. Communicate with doctors to ensure they understand what will be expected of them

3. Assess fitness to practise by getting doctors to compile information folders

4. Assess a first wave of doctors in 2004 based on two years’ evidence

5. Doctors holding GMC registration numbers with a penultimate digit 1 or 6 will form the second wave the following year, and so on

6. All doctors will be required to demonstrate their fitness to practise every five years

In the current climate, hospital consultants are feeling the heat more than ever before. Following the Bristol Inquiry. the Government is determined to ensure patient safety by creating an array of bodies and processes to monitor performance. The Commission for Health Improvement, the National Clinical Assessment Authority, the emerging National Standards Agency and annual appraisals all place doctors working practices under intense scrutiny.

On top of these checks comes revalidation, which from 2004 will require all doctors to produce evidence that they remain fit to practise in their chosen fields. Results from pilots carried out to date reveal most doctors support the principle that their skills should be assessed every five years.

Important questions

But the imminent advent of revalidation raises a number of important questions for hospital consultants. Will it expose weak points in a doctor’s range of skills, requiring hours of extra training they will have to make time for? If so, who is going to provide the training and who will pay for it?

Mr Stephen Brearley. consultant vascular surgeon at Whipps Cross Hospital. Leytonstone. east London, believes revalidation will be a culture shock for some consultants in particular those who have not kept up to speed with technological advancements. Mr Brearley says skills training is vital to ensure consultants do not ‘slip through the net. ‘Revalidation is hound to pick up on certain areas in which a surgeon needs extra training.’ he says, 'I am strongly in favour of revalidalion as a concept hut while 98 per cent of doctors might pass. it behoves the Department of Health to think about those that don’t.’ Mr Brearley believes the

DoH should provide additional funds in the form of ‘retraining bursaries to be made available for consultants needing to refresh their skills. ‘There is a serious shortage of doctors in the health service as it is, and we need to think about interest-free or low -interest loans to ensure we don’t lose any more because they can’t afford to retrain.’

The DoH is investing £20m in continuing professional development for NHS staff this year. with a further £60m spread over the following two years.

However, a DoH spokesperson says he is unable to say precisely how much will be allocated towards retraining for consultants. But he is keen to emphasise ‘development needs will be met’.

‘Precisely how much, depends on the need,’ he says. ‘We are working with the GMC. colleges and others to improve CPD. Revalidation is not a big hurdle designed to catch out very many doctors - it won’t. It is there to ensure the problem is picked up and then

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What do you think about research?

· Research is fundamental to the progress of medical knowledge. It is important that research is properly allocated resources such as time and money, because if it is poorly resourced then “good” research will be difficult to perform.

· It must be led by people that are interested in research, as this will enable projects to be structured and executed correctly.

· The process of research allows an individual to develop skills in critical appraisal, methodology and stats, which consequently gives the individual greater abilities to assess research as it is published.

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How would you improve the quality of research performed in the department, especially with respect to the rotating juniors?

· Firstly it important to set up research projects with the end in mind. Try and answer one question per project. If the completion of one project brings up more questions then these can be dealt with separately.

· It is important to have the projects set up correctly in the beginning, with advice taken from statisticians, and other people involved in the field (e.g. to pick the most appropriate outcome measure).

· It is important to have projects which are up and running, so that the junior staff can pick these up as they arrive, and then also encourage them to ask their own questions, to hopefully set up a project of their own, which can then be continued by the subsequent junior staff.

· Research methodology teaching sessions

· Regular research meetings

· Research Diary

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How do you consent a patient?

· The process starts in the OPD. Once a diagnosis has been made and the treatment options have been explained, a decision can be made between the patient and the surgeon on the best way forward for that individual. At this point the patient would have a full description of the intended procedure, possible complications that may occur, and the likely time spent in hospital and the length of the recovery.

· The patient would then have an information sheet/leaflet which would have all this information down in plain language. The patient is advised to discuss the prospective treatment with family and friends, and to write down any questions that arise, and ask these when they next see the team.

· When the patient attends for surgery the whole process is repeated, to ensure that the patient fully understands what is going to happen. This would be done by the operating surgeon, or someone who is capable of performing the operation.

· Clearly check and mark the limb with a permanent marker

· E.g. For THR risks stated would include dislocation, infection, DVT/PE, stiffness, leg length discrepancy and wear(aseptic loosening)

Different forms of consent

· Consent can be written, oral or non- verbal

· The validity of consent does not depend on the form in which it is given. Written consent merely serves as evidence of consent: if the elements of voluntariness, appropriate information and capacity have not been satisfied, a signature on a form will not make the consent valid.

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What do you think of the government initiative to send patients abroad?

· It is wrong to send patients to other countries for treatment if there are ways of dealing with the problem locally.

· If there are problems with quality of care, who would be responsible and accountable for any shortcomings

· Follow- up issues – who will deal with the complications later, especially if there has been medical mishaps.

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What would you do to address the waiting list problem?

· All problems of this nature would not be solely the responsibility of a single clinician or manager, but the team as a whole, and should be dealt with as a team.

· Identify the true nature of the waiting list problem, in terms of numbers and types of cases that are on the waiting list. These figures would also need to include the “forecast” for the coming year.

· Once the figures are available, the department would formulate a plan over the short and long term which would address the demand.

· Short term solutions would include ensuring that current resources are being fully utilised. If any problems are identified such as ops cancelled on the day of surgery, then the cause for this should be identified and dealt with.

· If there are urgent targets to be met then the only way of dealing with the extra workload would be with waiting list initiatives.

· In the long term there must be realistic expectations of the amount of work that can be carried out in a unit. If there is too much work for the number of consultants then there would be a case for expansion of consultant numbers to meet the demand.

· OPD Waiting List:

o Community education

o Referral Protocols

o Triage systems

o Multi-disciplinary Teams seeing new patients

o Restricting new-patient referrals so as to avoid a large surgical waiting list

· Surgical Waiting List:

o Increase the number of day-case surgical cases

o Reduce in-patient stays

o Pre-admission clinics can prevent day-of-surgery cancellations – Consultant should be present at these clinics.

o All patients listed for surgery discussed with Consultant

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How would you deal with a complaint from a patient?

Different levels of complaints: dealt with in different ways -

Bad food
Rude staff
Complication of treatment
Negligence

The GMC requires doctors to give a patient who complains "a prompt, open, constructive and honest response. This will include an explanation of what has happened, and where appropriate, an apology."

General principles

Don't forget patient confidentiality. A competent adult must give fully informed, expressed consent before you can disclose clinical information to a third party who is not involved in their clinical care. It can be a complex matter, so don't hesitate to seek expert advice from the MDU on this issue.

There is a 10 day time limit for providing a response at the Local Resolution stage (the first stage) of the NHS patient complaints procedure. The time limit is flexible provided you keep the complainant informed of progress. Avoid the urge to give an instant reaction.

Some complainants may be distressed, but the tone of your response needs to be professional, measured and sympathetic.

Do not tamper with the notes. This may sound obvious, but it can lead to more serious trouble than the original complaint. If you want to amend the patient's record in any way, you will need to make the date and time of the amend clear and you should not alter or try to disguise the original.

The response should be capable of standing on its own. Do not assume the reader has any background knowledge of the case. Several people may have to read the response apart from the complainant, particularly if matters proceed beyond local resolution.

You should type the response on headed paper or alternatively type your full postal address and telephone number at work. You should identify yourself with your full name and describe your relationship with the patient (e.g. registered GP, registrar, locum etc).

Chronology of events

Give a factual description of the chronology of events as you saw them, using the clinical notes as a framework. Refer to the clinical records whenever you can. Describe each and every consultation or telephone contact in turn and this description should include your working diagnosis or your differential diagnoses. State if you saw the patient alone or accompanied by another person. Give the name and status of the other person, e.g. spouse, mother etc.

Move on to respond to each and every concern raised by the complainant in so far as you can, including your opinion on what happened. Sometimes you can combine this with the chronology of events, but often it is better to deal with one and then the other. Many complaints arise from a misunderstanding and a detailed description of the pathophysiology involved can be helpful, and in some cases this might include references to journal articles or standard medical textbooks.

The complaint may involve more than one clinician. It is hardly ever appropriate to express an opinion on the acts & omissions of a colleague, unless they are under your direct supervision, even if it is with their consent. On some occasions a joint response, for example by the complaints officer, may be appropriate. However, it will usually give a better impression, and help speed resolution, for each clinician to provide their own full response. These may be sent with a covering letter from the complaints officer.

Many complaints arise because there has been a breakdown in communication and perceived rudeness is common. If it is appropriate, you may wish to apologise, and you are encouraged to do so.

No doctor can get it right every time. Medicine is a life-long learning experience and every doctor can learn something from every complaint. Complainants often want an assurance that what happened to them will not happen to anyone else.

The practice should consider analysing each complaint as part of its adverse incident reporting procedure. In that way the practice can see what can be learned from the event and take steps to prevent or reduce the risk of the problem happening again. For complaints that are more complex, perhaps involving more than one member of the practice team, for example you could hold a significant event meeting. This will allow the practice to discuss the case in detail, analyse what went wrong, if anything, and make necessary changes.

Your response to the patient can then include details of the action taken by the practice to remedy the situation and to ensure the problem is not repeated. This process also encourages the practice as a whole to adopt a positive approach if things go wrong.

Clinical notes

It is usually helpful to enclose a photocopy of the contemporaneous clinical notes and where appropriate it might even be necessary for you to provide a word-for-word, line-by-line, typewritten transcript plus abbreviations written out in full.

Style of writing

Avoid the use of any medical abbreviations in your response. Many lay people understand something like "BP", but few will know "SOB" (shortness of breath ), for example, so all medical abbreviations are best written in full. If you mention a drug, give an idea what type of drug it is (e.g. antidepressant, antihypertensive). Give the full generic name, dosage and route of administration of it as well (e.g. capsules, inhaler, intra-muscular injection, suppository etc.). This will provide any independent medical adviser who may read your response with a complete picture.

Write in the first person. It is very tempting to write in the passive tense because that is the accepted format in a clinical report. The reader should have a good idea who did what, why, when, to whom, and how you know this occurred. In other words, rather than, "The patient was examined again later in the day....", it is far more helpful to say, "I remember asking my registrar, Dr. Jim Brown, to examine the patient again later on the same day, and according to the notes, he did so."

Clear descriptions

Your description of both the history and the examination should enable a medically-qualified third person to put themselves in your shoes. It is important to say not only what you found, but also what you looked for, but failed to find. In the course of a clinical report, the positive findings alone may be sufficient. It may be reasonable to assume that where important symptoms and signs are not mentioned, they were looked for, but found to be negative. In a medico-legal response this assumption cannot be relied upon.

If your evidence is to be challenged, it may be on the basis that you failed to put yourself in a position to make an adequate assessment. If your response at the outset clearly describes the full extent of the patient's history & your examination, the patient is likely to be satisfied with the thoroughness of your approach and is less likely to pursue the matter to an Independent Review, for example.

Your notes are not likely, in many cases, to contain the "negative" information described above. No one expects you to make copious clinical notes of every last detail, nor will you be expected to remember every detail of a consultation which at the time appeared to be routine, and which may have been one of several thousand similar cases you have dealt with during the intervening time. It is perfectly acceptable to quote from memory, but if you cannot recall the details of a case, then it is acceptable to state what your "usual" or "normal" practice would have been in the circumstances of the case.

In your response you should specify which details are based on:

1. your memory

2. the contemporaneous notes and

3. your "usual" or "normal" practice.

Complainants sometimes say, "The doctor never examined me". This normally means the doctor did not touch the patient, but that is not the same thing. If you saw the patient, then you will have seen or been aware of many features without the need to touch him. Examples include emotional distress, breathlessness, cyanosis, jaundice, sweating and many other things, which if present, you as a doctor would have noticed.

Conclusion

A good Local Resolution response takes time and careful thought. It is worth the effort. Remember, over 97% are successful. The prime purpose of the NHS complaints procedure is to address the concerns of the complainant and to help you identify changes that may be needed to improve your practice. It is not a disciplinary process.

A thorough and detailed first response should help to minimise the risk of:

· further correspondence from the complainant asking for clarification and

· further medico-legal complications.

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How would you set up your service? How exactly are you going to develop a lower limb service?

Acute knee service

Visit different units in the UK to see how their acute knee service was set up and what extra resources they found that they needed, and what problems they encountered.

· Background

o It has been shown that over the past decade, the diagnosis of acute ACL injury has not improved significantly (approx only 10% are diagnosed acutely)

· Quantify demand

o All patients with acute haemarthroses, obvious collateral ligament injuries and possible meniscal injuries

o Patient sources would be AE, GP(direct access to advice from consultant) and physiotherapy

o The numbers of acute knee injuries that occur would be found from AE stats

o With the cooperation and help of the AE department, find out what current practices are in place. Also, find out what the AE department would want have included in such a service

o There is scope to improve the service that patients receive, by liaising with the AE department, to establish a protocol to enable the initial treatment of acute knee injuries to be standardised

o Using fracture clinics and OPD clinics, these patients would be assessed soon after the injury, and a management plan made.

· Resources

o Physiotherapy services

o Radiology

o Orthotics (knee braces)

o Day surgery arthroscopy places reserved for acute cases

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What will you bring to the hospital?

several questions regarding my cv and my research and training. (not tricky ones)

What are your strengths and weaknesses.

· Strengths

o Good communicator

o Keen teacher

o Attention to detail

· Weaknesses

o Trying to do too much, I must keep realistic goals

o Take myself and my work too seriously

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European Working Time Directive

· August 2004 58 hour max for resident doctors, 72 hour max for non-resident

· August 2007 56 hour max

· August 2009 48 hour max for all doctors

· Longest shift that we are currently allowed to do would be 13 hours, but we may be able to negotiate (derogation) out of this as long as the total amount of hours worked remains legal.

· With respect to training it is not can you train an orthopaedic surgeon within the confines of the EWTD, but how we can achieve it.

· Resident on-call is ruled as being at work, thus all hours count towards the working week

· Non-resident on-call is not counted as long as you are not working in any way.

Example for an Orthopaedic SpR

1. Ten person 24-hour partial shifts. This needs to be trailed in a large unit with ten on each tier and in a smaller unit where the SHO and SpR tiers would have to be combined and the effect on the consultant workload investigated.
2. Separating the education and service parts of the job. I believe the SAC are looking at this at present.
3. Is it possible to make the SpR posts non-resident and so allow a
traditional on call rota to be compliant.
4. An on call rota where the SpR works only until 10pm and the service covered after that by consultants.

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New Consultant Contract

o Still being negotiated

Summary so far

· A higher starting salary 'perhaps as high as £60,000' (1 April 2001 rate £50,810 minimum).

· Presumably no salary scale, but 'access to two new pay thresholds each giving salary enhancements of up to £10,000 on basic salary, dependent at both points on completion of a portfolio demonstrating high standards of commitment and performance'.

· Movement to the thresholds not automatic, but expectations

· 2/3 of eligible consultants at first threshold within 5 to 8 years

· all except for poor performers within 10 years

· 2/3 of eligible consultants at second threshold within 10 to 16 years

· majority of the rest within 20 years.

· New 'clinical excellence awards' to replace discretionary points/distinction awards system. (Separate document). First point (£2,500) normally after two years, thereafter on merit up to £65,000 (pensionable).

· Basic salary on new system would thus be £70,000 by year 8, £80,000 by year 16, plus at least one £2,500 award.

· Intensity supplements based on present scheme but can be reviewed in negotiations.

· Additional payments for agreed extra contractual commitments, presumably as now.

· New job planning and appraisal systems.

· For 'perhaps 7 years' newly appointed consultant (full and part-time) prevented from 'engaging in similar work outside the NHS'. Now excludes category 2 and NHS work in private sector as part of NHS contract. During this period they bear the greatest burden of 'high intensity work patterns'. Ban enforced by contractual restriction.

· Thereafter, a choice of 2 forms of contract, with ability to do private practice in own time.

Type 1

· 'the standard contract', with 10% limit on private practice earnings, full access to award scheme and pay thresholds. Part-time pro-rata.
OR
Type 2

· A contract based on 'time and service commitments to the NHS, either full-time when these equate to consultants on the standard contract, or on a 'pro rata' basis'. Access to award scheme, no automatic access to pay thresholds though at discretion of employer where commitment is equivalent to full-time. Abolition of maximum part-time concept.

· 10% rule enforced by local employers, type of contract determined by employer who can transfer individuals between contracts.

· three career phases, marked by pay thresholds

· Service delivery, on-call and out of hours working.

· Continuing as phase 1, but more emphasis on leadership role, balance between clinical and other duties.

· At age 55, review of commitments and scope for reducing workload intensity with protection of pension rights.

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`Primary Care Trusts`

Primary Care Trusts bring together the primary care services (eg. GP Practices and Community Nursing Services) in a particular area and work to develop these services in response to the needs of the local community.

The main roles of a PCT are to:

Improve the health of local people and reduce inequalities in health.
Provide effective and responsive local health services.
Commission the best possible services for local people from NHS hospitals (NHS Trusts).

PCTs act as sub-committees of Health Authorities.

PCTs have a duty to work in partnership with other local organisations and neighbourhood services ( e.g. social services, housing, service user and community groups, other PCG/Ts, NHS Trusts).

PCT will control 75% of the health budget by 2003.

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Why did you choose a DGH over a teaching hospital? (or vice versa)

Teaching Hospital

DGH

Advantages:

o Undergraduate Education

o Easier access to University services, such as research collaboration, academic information

o Easier to develop a Tertiary referral service

o Usually smaller and therefore closer relationships with colleagues etc.

o No academic pressures

Disadvantages:

o Possibly less community involvement

o Research pressures

o Educational commitments slowing clinical work

o Big and cold

o Less conducive to sub-specialty service

o More difficult to develop research facilities & support

My clinical work will be basically the same, but can develop special interest more.

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Can meaningful research be performed in a DGH and how are you going to do it.

Clinical Research – Yes.

Basic Science and Laboratory Research – No.

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How are you going to develop the trauma service?

Relationship with A&E – set up Protocols for Upper Limb trauma; close contact with A&E regarding Upper Limb trauma
Improve record-keeping of Trauma admissions for audit & clinical governance purposes - Complications record; Acute Admissions record; Trauma database
Fracture clinic – review all new-patient notes and x-rays in the morning prior to clinic; See all outpatients every 3rd visit myself
Trauma List - Trauma list day after on-call; Present for all my trauma lists
Team working – cross-refer difficult fractures appropriately and accept all complex upper limb trauma myself
On Call – Be present for all surgery and available on-site;
Lead by example
Trauma Admission Guidelines – Details about listing, fasting, consent, investigations, CPR etc.
Care Pathways – develop care pathways for common fractures (Upper Limb)
Hip Fracture Audit – Ensure this is being maintained and service improving.
Relationship with Allied specialties – Anaesthetics, COE, etc.

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How are you going to deal with an incompentent colleague

· Firstly, "act quickly to protect patients from risk if you have good reason to believe you or a colleague my not be fit to practice". This places a clear professional responsibility on each individual to take action where they have serious concerns.

· A first step would be to discuss concerns informally with a senior colleague such as the Clinical Director, Medical Director, Chairman of the Medical Staff Committee, or a colleague in the specialty from another hospital. In doing so, it may be helpful to consider whether the use of locally available informal procedures (counselling services, "Three Wise Men" or equivalent) would be appropriate. The local BMA office is a possible source of advice on the range of informal procedures in the locality. Discuss it with MDU.

· The CCSC believes however, that merely discussing the problem with a colleague does not in itself discharge the responsibility defined by the GMC. Only if the doctor is fully satisfied after any informal action that the problem no longer exists has that responsibility been discharge.

· If doubt remains, the doctor's duty must be to bring the matter formally to the attention of the Trust or other employer. Normally this would require an approach to the Medical Director, though another person having a formal management role, such as the Clinical Director or the Chief Executive, would also be possible. An equivalent formal process would similarly be necessary in the private sector, for example a reference to the independent hospital's Medical Advisory Committee. The doctor should formally record that this step has been taken, for example by means of a letter to the Medical Director, (which need not mention the name of the doctor concerned).

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Standard questions:

Tell me about yourself?
Why did you choose this hospital/university and how did you arrive at this decision?
What factors did you consider in choosing your speciality?
Why do you want this job?
Since you have been in medicine/orthopaedics/surgery, what is it that you are proudest of?
How have you changed personally since starting medicine?
Tell me about your training - good points, bad points?
What was your Best job, Why?
What was your Worst job, Why?
Tell me about your Hobbies/pastimes/adventures?
Of the hobbies and interests listed on your resume what is your favorite and tell me why?
If you could change a decision you made whist in medicine/orthopaedics/surgery what would you change and why?
Tell me about your c.v. ~ some aspect, you need to be able to account for any gaps?
Describe a leadership role of yours and tell why you committed your time to it?
Give me an example of an idea that has come to you and what you did with it?
Give me an example of a problem you solved and the process you used?
Give me an example of the most creative project that you have worked on?
What work experiences have been most valuable to you and why?
What have the experiences on your resume taught you about managing and working with people?
How have your educational and work experiences prepared you for this position?
Give me a situation in which you failed, and how you handled it?
Where do you think your interest in this career comes from?
Why have you chosen this particular profession?
What challenges are you looking for in a position?
What goals have you set for yourself? How are you planning to achieve them?
What is your most significant accomplishment to date?
What motivates you?
What turns you off?
If I asked the people who know you well to describe you, what three words would they use?
If I asked the people who know you for one reason why I shouldn't employ you, what would they say?
Tell me how you have used study leave?
What is the best course you have attended, Why? What did you learn?
What was the worst course you have attended, Why?
Recent political or medical news developments?
What are your team-player qualities? Give examples
What methods have you used or would you use to assess student learning?
What characteristics do you think are important for this position?
Name two management skills that you think you have?
What characteristics are most important in a good manager? How have you displayed one of them?
We are looking at a lot of great candidates; why are you the best person for this position?

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Increasing you may be confronted with more "modern" questions that are designed to make you think:

Describe a time in any job you’ve held when you were faced with problems or pressures which tested your ability to cope. What did you do?
Give an example to a time when you were unable to finish a task because to did not have enough information to go on. Be specific.
Give an example of a time when you have to be relatively quick in coming to a decision.
Tell me about a time when you had to use your spoken communication skills in order to get a point across that was important to you?
Can you tell me about a job experience in which you had to speak up in order to be sure that other people knew what you though or felt?
Give me an example of a time when you felt you were able to motivate your colleagues or subordinates.
What do you do when one of your people is performing badly, just not getting the job done ? Give an example.
When you had to do a job that was particularly uninteresting, how did you deal with it?
Give me an example of a specific occasion when you conformed to a policy with which you did not agree.
Describe a situation in which you felt it necessary to be very attentive to your environment.
Give an example of a time when you have to use your fact-finding skills to gain information in order to solve a problem - then tell me how you analysed the information to come to a decision.
Give me an example of an important goal which you have set in the past and tell me about your success in reaching it.
Describe the most significant written document/report/presentation which you have had to complete.
Give me an example of a time when you have to go above and beyond the call of duty in order to get a job done.
Give me an example of a time when you were able to communicate with another person, even though that individual may not have liked you personally.
Describe a situation in which you were able effectively to "read" another person and tailor your actions according to your understanding of their individual needs or values.
What did you do in your last job in order to be effective with your organisation and planning? Be specific.
Describe a situation in your job when you could structure your own work schedule. What did you do?
Describe the most creative work-related project which you have carried out.
Describe a time when you felt it was necessary to modify or change your actions in order to respond to the needs of another person.
What experience have you had with a misunderstanding with a customer or fellow employee? How did you solve the problem?
What did you do in your last job to contribute towards teamwork? Be specific.
Give me an example of a problem which you faced on any job you have had and tell me how you went about solving it.
Describe a situation in which you were able to influence positively the action of others in a desired direction.

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HOW TO ANSWER QUESTIONS

Make eye contact with the interviewer before speaking
Adopt a relaxed posture sitting squarely in the chair
Facial expressions and gestures should be natural
Do not fidget or appear restless
Keep to the point
Aim to be precise
Give a full answer and do not waffle
Structure your answer; it should be logical and clearly understood
Avoid using jargon
Speak confidently so that you can he heard
Do not speak too quickly or slowly
Use your voice to reflect the meaning of what you are saying
Do not argue with the interviewer

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INTERVIEW ADVICE

1/ ask your consultant, clinical director, medical director and chief executive what management questions they expect you to be asked and what they ask, "Doctor, when appointed how will you develop your clinical service? How do you see the future of your service developing? How will you put together a business plan to get more equipment, How will you deal with a difficult colleague? Incompetent colleague? etc (You could also ask them what they think the answers should be!)

2/ speak to other junior doctors who have recently had interviews and to consultants who have recently been appointed, what were they were asked?

3/ read the articles in the Health Service Journal, BMJ, Times, Guardian and Independent relevant to the areas they raise; primary care groups, clinical governance, The NHS Plan– what impact will it have on your service?, etc. Net doctor is worth getting each morning with abstracts of current health issues from the day’s papers.

4/ then go visit and talk to the consultants, juniors and staff in your future department, the clinical director, the medical director, the finance officer and chief exec, if you can get to them. Ask them about the Trust, its plans in general and your service in particular and finances. Get the Trust plan and annual report before you go and ask questions about them.

5/ Read the advert, job spec and your CV. Prepare to answer questions on each point.

6/ It is really common sense. Remember the committee is (should be) trying to discover

1/ can you do the job? Are you technically competent?

2/ will you do the job? Motivation?

3/ will you fit in? Will you get on with your colleagues, your staff and patients?

Get your colleagues to ask some questions about those issues and practice some answers, but remember you never get the questions you expect, so be prepared to be flexible and think through each question.

Also remember the committee is not a monolith, they will be not necessarily be united. Treat each question on its merits and if you disagree, say so, in a polite way. Look them in the eye, smile, think and say quietly and authoritatively what you think. Be ready to admit you do not know or understand the question and ready to ask questions to clarify what they want. You are after all only just starting on this bit of your career and can not be expected to know everything: be ready to admit your ignorance and open to help. If you get yourself in a mess cope with it maturely. That will probably get you more approval than a glib answer.

When at the end the chair asks, “Do you have any questions?” unless there is something, which has come up during the interview, you want to clarify, the regular answer is “No thank you. During my visit the doctors and managers answered all my questions”.

Show yourself to be open minded and willing to discuss and talk through issues. Management is much less clear cut than medicine. Often you are not looking for the “best” solution, you are looking for something which is better than what you have now. Often you will need the willing help and support of others and you may have to compromise to get that. Management is more a team activity than medicine, in which you gain from discussing with others and learning from others.

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Consultant Interviews