1. Service versus Training Who Wins? C P Shearman

2. Why Change? “I once found it quite stimulating but now it is just a job”

4. 1. Reason to change – New Technology

5. Interventions for leg ischaemia www.dh.gov.uk

6. So what is the problem ! Look if it was electric could I do this? Who is going to do this? Formal Endovascular Training Complex open surgery 2. Reason to change - Training

7. Unfinished Business 2002 SHO training poorly structured Inadequately supervised No definitive end point Needed Reform

8. Vascular Syllabus Basic science+surgical skills Basic Imaging and IR skills Vascular biology Vascular medicine Professional skills Critical care Ultrasound Lower limb Venous Trauma Diabetes and vascular disease Aneurysms (aortic) Extra-cranial arterial disease Upper limb Visceral artery Renal vascular disease Vascular access Lymphodema Vascular malformations Congenital vascular disease Paediatric vascular

9. VASCULAR ACCESS Template 15 Indicative training years: Intermediate, Final – ST3-4 Section Aim – To be aware of a range of techniques and to able to provide vascular access Subject / TopicKnowledgeClinical SkillsRelevant Professional Skills Assessment Vascular access Diagnosis and Investigation Subject objective – ability to diagnose and investigate patients requiring vascular access Anatomy of upper and lower limb arteries and veins List indications for the establishment of vascular access Knowledge of methods of renal support; advantages and disadvantages. Physiology of an a-v fistula; including velocity, resistance, flow patterns and energy losses Knowledge of conduit material Knowledge of suture material Able to describe anatomy of upper and lower limb arteries and veins and common variations. Able to describe methods of providing renal replacement therapy Able to describe various vascular access procedures in detail Able to describe hierarchy of investigation of patient needing vascular access Able to describe ultrasound characteristics of acceptable artery and vein for access surgery Able to perform ultrasound assessment of patient needing vascular access (2/3) Able to describe standard flow patterns in a-v fistula Able to describe a-v graft types and indications for use. Able to communicate with patient and obtain informed consent. Able to communicate with vascular laboratory Able to communicate with radiology department Ability to prioritise patients for surgery In service assessment, Exams Workshops/courses Vascular Curriculum - Modular

10. Reason to change – Professional Performance Medical Expert/Clinical Decision Maker Communicator Collaborator Manager Health Advocate Scholar Professional The fuel light is on, Frank we are all going to die, we are all going to die. Whoops my mistake that’s the intercom light Medical Teacher 2000;22:549

11. European Working Time Directive 48 hours per week 1 st August 2009 37 hours Denmark 80 hours United States

12. How Long to Train? Annual US trainee log book Operating 2753 hours Assisting 272 hours Post op-care 938 hours total 3963 hours 10-20,000 hours Duration vs. competency UK 2+6 years Purcell Jackson and Tarpley BMJ 2009;339:1069

13. Time to Train Max hours per week No of weeks leave No of hours per year Total no hours in 8 years 802400032,000 804384030,720 564268821,504 484230418,432 374177614,208 Modified from Purcell Jackson and Tarpley BMJ 2009;339:1069

14. Vascular Training in General Surgery? Broad base General Training Skills acquired late Shifts Hospital at Night Service Provision Limited simulators

15. 3. Case for Change - Outcomes The European Society for Vascular Surgery. (2008). Second Vascular Database Report

16. Volume / Outcome Relationship : Holt et al, Br J Surg 2007 Elective AAA Repair

17. Variation in Amputation Rates Holt P et al BJS 2010

18. Variation in Mortality Holt P et al BJS 2010

19. Case for Change – Public Concern “Death rates in planned vascular surgery for abdominal aortic aneurysm (AAA – to prevent a burst artery) vary from under 2% in some hospitals to at least 10% in 10 of them.” “Patients are less likely to die in the bigger, busier hospital units where surgical teams are more skilled because they do more of the operations. The results strongly suggest that smaller units should close.”

20. 4. Reason to change – AAA screening

21. Quality Improvement Framework for Aortic Aneurysms MDT – radiology, anaesthetist, renal, cardiology Procedures undertaken/supervised by consultant 24/7 on site vascular cover >33 cases per year NVD – stop if >6% mortality

22. All hospitals and specialists comply with VSGBI QIF Usually only one intervention centre with inpatient services Screening Network for min 800,000 Vascular specialists travel to intervention centre Network provides full range of services for hospitals without vascular inpatients

23. 5. Reason to change - Unmet need Diabetes –Rising amputation rate cf. Finland –68% no attempt at revascularisation before amputation –3 million with diabetes 2010 Carotid Surgery –48hr access times –Under provision (15/100000) Vascular Access –17,140 per year –66% by vascular teams –waiting list! Cardiovascular Risk –30% PAD patients risk factors treated

24. Trend in amputation in England and Wales Vamos Diabetes Care and Clinical Research 2009 1996-2006 Type 1 Minor 11.4%↓ Major 41% ↓ Type 2 Minor 95%↑ Major 83.5% ↑

25. Amputation trends in People with Diabetes in Finland The number of 1 st Amputations of diabetics in Finland 1988-2002 Incidence of 1 st Amputation per 100,000 diabetics Lepantalo 2006

26. 6. Reason to change - Emergency work 30-40% of total workload –High risk –Cost –Immediate availability Clinical Governance risk –Commissioners – SHA reviews Specialty requirements –Endovascular rAAA –Out of hours imaging –Diabetic foot complications

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

28. Hospital patients 'more likely to die at weekends' By Nick Triggle Health correspondent, BBC News A shortage of senior doctors is said to be at the heart of the problem Being admitted to hospital in England at the weekend is risky, experts say. BBC News A shortage of senior doctors is said to be at the heart of the problem

29. Temple Report– Consultant expansion

30. 7. Reason to Change Manpower NHS Workforce Review Team Headcount - HC Anticipated number of trained specialists in General Surgery

31. 8. Reason to change - Financial Highest spending since 1982–83 Lowest tax burden since 1960–61 Highest borrowing since WWII £178bn borrowing this year Receipts Expenditure During the recession, government expenditure has continued to grow whilst receipts have fallen

32. What does this all mean? Improve outcomes/quality –low volumes –AAA Screening Adopt new technologies – endovascular Training –More focused –Fewer trainees Increased work load –diabetes –AAA screening –unmet need Emergency provision –Clinical governance/consultant delivered Financial downturn in NHS/save money Weasel didn’t like the sound of this

33. Solutions New ways of working “Interventions should be planned, executed and measured” Training Consultant role Service structure Hamster Health Care. Morrison I,Smith R. BMJ 2000 Technology Redesign health care delivery

34. 250 to learn to fly; 8 years to do an appendectomy Accelerated pilot training: simulators Richard Reznick

35. Solution 1 - Training Simulators Competency based Relevant skills early Service Focused Disease focused Generic Skills Specific Skills

36. Solution 1 Training The Toronto Experiment 6 orthopaedic trainees Early Entry into specialty training Supernumerary to service Early acquisition of skills Progression by competency Richard Reznick

37. Make Training Cost Effective The other birds suspected Owl hadn’t worked in a DEANERY at all

38. Getting Value for Money Professional Trainers –Job plan tariff + assessment –Standards for training units Budget (£9.3m) –Withhold and invite bids –Competition for posts –Reward success eg ARCP1s

39. Fit for purpose training -Train for Service Core Training ST1-2 Intermediate Stage ST3-4 Advanced Stage ST5-6 Final Stage ST7-8 National Selection Vascular FRCS 1 Vascular FRCS 2 Standards for Vascular Training VSGBI 2011

40. Outline of the content of vascular specialty training Intermediate StageFinal Stage ST3 ST4ST5 ST6 ST7 ST8 One year of elective and one or two years of emergency vascular surgery. One year of elective and one or two years of emergency GI surgery Four years of elective and at least three years of emergency vascular and endovascular surgery. Vascular Medicine Vascular Access Duplex Ultrasound Axial imaging, interpretation, reformatting and planning Professional behaviour, leadership, teaching, audit, research Standards for Vascular Training 2011 VSGBI

41. Pre-specialty Training Role of Medical School, Foundation Schools service training?

42. Solution 2 Role of Consultants

43. NHS Employers Confederation Role of Consultants Front line delivery Career structure/Teams Systems Management Quality improvement frameworks IT and new technology Utilisation of Facilities 6-7 day working Step down beds Outcome based standards mortality Commissioning Standards national providers met www.nhsconfed.org/publications

44. Consultant Working Practice – value for money No elective commitments Daily unit ward round Emergency walk in clinic Emergency list Evening ward round Reduce admissions Reduce length of stay Allow better training Value for money Intermediate/complex Routine Added value consultants trainees

45. Solution 3 - Restructuring of Services Fewer, larger units (50) Consultant teams - min 6 (8-9) Change in consultant role –Service delivery –Sub-specialisation (EVAR vs Open) –Designated trainers Surgeon specific outcomes (NVD) Fewer Trainees (1per unit?) Provision of Services for Patients with Vascular Disease VSGBI 2011 High quality, cost effective, sustainable

46. “ Centralisation…is the preferred method of providing high standard vascular services” “There is evidence that even with transfers of more than one hour, transfer to a vascular unit improves patient outcomes” “There has been little strategic planning in the way vascular services are commissioned and delivered. As far back as the original Provision of Vascular Services document, it was recommended that coalescence of adjacent vascular services onto a single site is the optimal model for service delivery” “Access to specialist care will often involve transfer of patients to the nearest hospital where emergency vascular treatment is available. In certain geographical areas this may involve travelling some distance, but there is good evidence that patient outcomes are not related to the distance travelled if they reach a centre where vascular expertise is available” Solution – Centralisation

47. A Bright Future Embrace service change Role of consultant Focus on training needs Training fit for service “What do you mean it’s a bit muddy!”