Rage Against The NHS Fax Machine

fax-amarys

So I haven’t posted on this blog in a while, largely due to recently getting my first full-time position in a year as a Specialty Trainee in Critical Care i.e. the path to becoming a consultant in Intensive Care Medicine (yay!). Also, there’s been a lot of depressing Brexit chat to avoid.

This post is just me complaining about a relatively minor but still important thing.

I hate fax machines

To become a critical care trainee, you need a background in internal medicine, emergency medicine or anaesthetics. It’s all very complicated but because my background is anaesthetics, I don’t have the requisite competencies in medicine. This August, I started work on an acute medical unit doing acute medicine, a specialty I’ve not been involved with for three years.

One of the frustrating things about working in acute medicine is drug histories. Trying to determine what drugs a patient is on is difficult if they don’t bring a prescription or their medications with them. Trust me, no doctor knows what “the little blue pill” is unless they’re science-fiction fans and you happen to be Neo from The Matrix.

As such, during the day if you’re seeing a patient, you’ll often have to phone their GP’s surgery (though now some trusts have a centralised record system). If the list of drugs is long, rather than bother a GP, secretaries will often just send you the list.

However, they always, always insist on fax. I had to organise this for the first time in a long time a couple of weeks ago; fax is bad for a number of reasons.

Why not just use email?

Evidently, confidentiality is an issue in healthcare. Clearly, you shouldn’t send confidential information via Facebook chat. However, we have trust NHS email addresses. These end .nhs.uk and generally have the initialisation of the trust ie Leeds Teaching Hospitals use @lth.nhs.uk, Nottingham University Hospitals @nuh.nhs.uk etc. These are given to staff when they start at a particular trust and deleted when their contract ends.

It’s generally considered safe to send confidential information via email within the trust using this system (though nobody has actually confirmed this with me). However, for sending information outside of the trust, you need an NHSmail email address. These end @nhs.net and are personal ie they go with you as long as you work within the NHS.

At least, that’s my understanding. A few days ago, I tweeted NHS England and received a response from @grant_me who according to his bio is an “IT Professional working in NHS Primary Care”. That’s the best I’ve got to go on after not really trying very hard.

Given the lack of clarity about this, secretaries stick to the tried and trusted method of fax.

What’s wrong with fax?

1. It’s really annoying

I don’t use fax machines because it’s not 1992. I’m not particularly technophobic, I like my smartphone. However, I’ve used a fax machine about twice in my entire life.

Whenever a doctor needs to use the fax machine, we find a friendly ward clerk or secretary and look forlorn at them until they realise we’re not going away until they send the fax. I can be very good at looking forlorn.

(NB: any medical students reading this: make friends with the secretaries. I’ve seen them ignore a surgeon they didn’t like who asked for a form, saying they didn’t know where it was. They then found the exact same form for me 10 minutes later, and sent it for me because I’m all sweetness and light.)

2. It’s hilariously unsecure

I rang the GP. I explained I was a doctor at the local hospital on the acute medical unit. I gave my name and – after them insisting they wouldn’t send it to an email address – faxed me a copy after I eventually found out the fax number.

I could have been any muppet who bought a fax machine. There was no security or check to see if had gone to the right machine. No check to see I was actually a doctor. Literally, you could ring up a GP and do this yourself if you have a fax machine (but don’t because you’ll go to jail).

3. It can be incredibly complicated

At the hospital I work at, to make a referral to the anticoagulation clinic on discharge, you have to fill out a form, fax it to the clinic then ring them to make sure they’ve received the fax. This means that if you discharge a patient at 6pm, after the clinic has closed, you can’t ensure a referral unless you’re in the next working day.

There’s no guarantee you’re going to be in. The patient will have gone home. If it’s a Friday and you’re on nights the next week, it means you may not be able to check for about 10 days at which point, the patient hasn’t got their anticoagulation appointment and they’re at risk of stroke or blood clots or being struck by lightning. OK, anticoagulation does not decrease lightning strike risk but it is important.

Communication within the NHS

This is generally bad, particularly because we deal with a lot of sensitive data. I have worked in hospitals where non-urgent referrals were done by an A6 piece of card to the secretary of the relevant specialty. Like they never got lost. Some services ask for fax (like anticoagluation). Some are on the hospital intranet. Some are Word forms filled out and sent via email. Some are via an online request system. And don’t get me started on the bleep system (something for another time I feel).

I worked with a cardiology team who set up an email address at the trust that was “cardiology@trust.nhs.uk” to replace the aforementioned card system. They went from seeing something like 60-70% of their referrals within 24 hours to seeing 100% of their referrals by the end of the next day, and 100% within the same day if the referral was sent by email.

Firstly, given NHSmail exists, all NHS staff who handle confidential information should have an NHS.net account. This should be the standard form of written communication between NHS bodies. Fax should be banned. Tomorrow.

Secondly, trust emails should exist for all specialties and services to which referrals can be made, with delivery reports. This gives a clear trail as to whether a service has received an email. Creating an email address is presumably not a massive step for an IT dept and it’s a familiar system to most people.

Obviously, this is more complicated than I’m making out. But also, you know, it’s not. Especially, given it’s been done already. Pff. Unfortunately, I’m not sure anybody’s that bothered and so many people seem to love fax machines. Sigh.

‘7 day NHS’ sounds more stupid every time I hear it

Most people when they hear “7 day NHS” probably think, “GPs open 7 days a week”. Beyond that, nobody knows what it means. The more I’ve thought about it, the more ridiculous it sounds.

Let’s ignore GPs for a second. I’m a hospital specialist so I tend to ignore them because they probably save thousands more lives than me and that makes me feel inferior. Bastards.

To put this into context, there is no elective service that runs 7 days a week.

Specialist stuff

For instance, there is a neurologist – let’s call him Dr Brain (obviously) – who comes to the hospital I work at once a week. He’s does an outpatient clinic there and occasionally sees inpatients if he gets the referral at the right time.

Dr Brain works primarily at a central teaching hospital. He does this clinic to facilitate patients requiring neurological outpatient care who live nearer my district general hospital. This is a good service and most patients will make time in their day to attend their neuro appointment at the local hospital on a Tuesday rather than have to travel into the city, though that option is still available.

However, this is not a 7 day-a-week service. Arguably, for a true 7 day-a-week service, Dr Brain would provide a clinic every day, am and pm for the whole week. This would be a colossal waste of resources.

Not-so-specialist stuff

110405-N-KA543-028

Bum…hole

Let’s take something more routine.

Colonoscopy is a procedure where a surgeon or gastroenterologist inserts a fibreoptic camera into your colon via your anus to look at the inside of your colon. Lets assume a colorectal surgeon – let’s call him Mr Bumcutter – does a colonoscopy list once a week. There may be one or two other surgeons who perform colonoscopies – Ms Bottomcamera and Miss Anusvideoer.

Altogether, let’s say there is a colonoscopy clinic on Monday and Thursday, am and pm. This is probably not an unreasonable representation of a district general hospital. However, a theoretical 7-day NHS would have colonoscopies performed every day because, well, 7 day-NHS.

Why this matters

I’m being slightly facetious here but “7 day-NHS” is completely meaningless. Either, the Health Secretary is suggesting every single service should be provided 7 days a week, a clearly ridiculous proposition (see above).

Or he’s suggesting that instead of colonoscopies happening on Thursdays, they should happen on Saturdays or Sundays. If you can find me a study that shows more patients would rather have their colon examined on a Sunday than a Thursday or that inconveniencing Ms Bumcamera by asking her to attend on Sunday improves her performance, please do. Otherwise, it would serve no worldly purpose other than inconveniencing what are currently perfectly functional services.

If the Health Secretary is arguing that certain services should be provided 7-days a week, fair enough. He should make that case. He isn’t.

I have no idea what it means

Being somebody who was a young adult during the social media boom of the past 10 years, I struggle not to instinctively add “literally” to everything. But I do literally have no idea what 7 day NHS means.

I don’t know who anybody does.

PS: colonoscopy is a safe procedure and if your doctor, surgeon or gastroenterologist recommend you have one, after discussing risks and benefits, you should have a very good reason for saying no (though it’s your absolute right to do so). Although it can be uncomfortable, most are sedated during the procedure and so remember very little.

Click here for a link to Guy’s and St Thomas’s Having A Colonoscopy leaflet.

 

MEDICINE: a complicated guide to junior doctors’ pay

UPDATE 13/2/16: NHS Employers has sent more specifics about the contract out rendering this post somewhat inaccurate. Will be adjusting it soon.

UPDATE 14/2/16: now adjusted to take into consideration the specific changes NHS Employers sent out on 13/2/16 to junior doctors.

A significant component of the current dispute between Health Secretary Jeremy Hunt and junior doctors is pay. It is not the whole dispute.

Part of the new proposals involve a hospital ‘guardian’. The ‘guardian’ would be responsible for ensuring doctors do not breach their hours. Where they do, guardians would enforce financial penalties. (It’s really hard to Google ‘guardian’ and ‘junior doctors’ strike’ without just getting articles from the Guardian.)

However, they would be employed by hospitals; the conflict of interest between an employee deciding whether to fine his or her employer is obvious. As yet, this issue has not been addressed by government. The practical effect on hours worked that having a guardian will have is unclear.

There are many other issues too. However, the question for this post is, what are the differences in pay going to be?

I’m going to use the last full-time rota I was on as an example. (NB: this is not the same rota for the whole country.)

I’m going to be using ‘old’ to represent the system at the moment and ‘new’ to represent to prospective system. Using the term ‘current’ could get a bit confusing.

If you can’t be bothered look at the maths, just go to the end. There’s a section called, The punchline, which summarises the key numbers.

The old system

This worked via something called ‘banding’. If you Google ‘NHS banding’ you get the bands for nursing and other healthcare professions.

The old banding system for doctors looked like this:

OH MY GOD WHAT EVEN IS THAT?

It looks complicated but the hospital tallies up the number of hours you’ve worked, the proportion that’s ‘antisocial’ and gives you a pay supplement based on that proportion.

Antisocial hours are considered the weekend and 1900-0700 during the week.

How do you figure out whether you’re moderately, most or least antisocial? You can use the following helpful chart:

SERIOUSLY THEY ARE JUST TAKING THE MICHAEL NOW!

Suffice it to say, it’s fairly complicated. I say this with some trepidation but most first- and second-year doctors (F1 and F2 or Foundation Year 1 & 2) will be on 1A or 1B. I think.

This means, for the number of antisocial hours they work, they get a pay supplement of 40% of their basic salary.

The F1 year is usually split into 3 x 4-month placements. Assuming that all of these jobs have a fairly standard on-call rota for medicine or surgery, an F1 will receive a 40% supplement on the basic salary of £22,636

They’re paid 22636 x 1.4 = £31690 pa.

Placements vary. F1s often do jobs like medical microbiology or general practice which many only require social hours work – they do not receive a supplement for these jobs.

They may also work in emergency medicine (A&E) where they would receive an even bigger supplement but the shifts are largely antisocial.

The same applies to any hospital medic. They have a basic salary. The hospital calculates the proportion of antisocial hours; determines what band they’re in; and gives them the requisite pay supplement.

The key misunderstanding is that you get a percentage supplement on total hours under the old system, not just on the out-of-hours work as some of the press have suggested.

Now, I hope you enjoyed the arithmetic – there’s loads more to come.

The rise in basic pay 

When I originally wrote this post, the government had been suggesting a 13.5% pay rise. Subsequently, NHS Employers have sent out this pay letter which has more specifics about the new pay scale. The old pay scale can be found here on the BMA website.

I’ve summarised them in this table:

Comparative hours table

Pay and percentage increases relative to year

F1 and F2 refer to the first and second year of the foundation programme. If you look at the old pay scale, these consider pay for up to three years in each of these posts. These are relevant to part-time doctors which I’ve ignored, largely because it’s something I don’t have a lot of experience of.

CT/ST (core/specialty training) year refers to years in specialist training (surgery, internal medicine, pathology etc.). From the point of view of pay, the difference between core and specialty training posts is a technical one, not relevant here.

Otherwise, there are two changes. The first is simply there is an increase in basic salary across the board (though this doesn’t necessarily lead to a final salary increase).

Secondly, you’ll note the new ‘nodes’. Previously, there was a year -on-year increase in salary. Now doctors will have the same salary during certain blocks of training, particularly ST3-7.

Government argues that the responsibility of these doctors is the same regardless of grade. For anaesthetics and critical care, this is true when looking purely at on-call responsibility. However, it doesn’t consider the assessments and exams one has to pass to progress from year to year.

Most doctors require revalidation every 5 years. Junior doctors go through an equivalent process every year which is more onerous that revalidation.

How the new system’s supplements work

Oh, the fun I’ve had with this. My last job was as a CT2 anaesthetist. Looking at the table above, that means I would be paid 7.5% extra basic pay. I’ve also calculated my comparative pay as a CT1 anaesthetist which involves a 16.21% increase.

You can download the spreadsheet here but I’m going to use a couple of screenshots.

I’m not sure how well this will show up on whatever device you’re using. The top row is hours. 0700 means 0700-0800. I’ve put a ‘1’ for every hour I’ve worked and also to make the spreadsheet work.

Hours 1

As a CT2, under the new contract:

  • Basic hours, 0700-2100, Mon-Fri, +7.55% from the old system, dark green
  • Saturday and Sunday, 0700-2100, +30% (on top of the 7.55%), middle green
  • Antisocial hours, 2100-0700 Mon-Sun, +50% (on top of the 7.55%),  light green (this says light green though you probably can’t see it)

(NB: if I were to work fewer the 1 in 4 Saturdays – I work 2 in 7 – I would get no supplement 0700-1700 on a Saturday which would further complicated payment. Also, it’s possible that because one of those shifts is day and one night, that they would be considered different shifts and I would not get a Saturday supplement. That would be pretty shifty.)

So you can see, the arithmetic gets a little complicated.

Broadly my job consists of three different types of shift:

  • Normal day – 0800-1800
  • Long day – 0800-2100
  • Night – 2000-0900

There’s an hour overlap in the morning and evenings between the person coming and the person leaving. This is to facilitate handover. It doesn’t happen in every hospital but we got paid for it.

Hours 2

This is the bottom half of that spreadsheet. I was on a 1 in 7 rota. That means that there were 7 anaesthetists on the rota. Whilst I was on week 1, another was on week 2, another week 3 etc. This works out at 48.14 hours/week.

I should note, rota coordinators get a lot of stick in hospital but trying to design one of these things is hard. This one doesn’t show how, in order to be EWTD compliant (ie <48 hours/week), I have to get days off after weekend days and nights. Booking annual leave on top of that makes these things a nightmare.

In the ‘CT2’ column for Mon-Fri, I’ve used the following formula:

=1.0755*SUM(C2:P2)+1.5*1.0755*SUM(Q2:Z2)

That’s 1.0755 x the number of basic hours (to calculate the 7.55% pay rise) + 1.5 x 1.135 x the number of antisocial hours (to calculate the 7.55% pay rise and 50% antisocial hours supplement).

In the ‘CT2’ column for Saturday and Sunday I’ve used the following formula:

=1.3*1.0755*SUM(C7:P7)+1.5*1.0755*SUM(Q7:Z7)

That’s 1.3 x 1.0755 x the number of weekend day hours (to calculate the 30% supplement for weekend day hours and the 7.5% pay rise) + 1.5 x 1.0755 x the number of antisocial hours (to calculate the 50% antisocial hours supplement and 7.5% pay rise).

Phew!

In the bottom right, in box AA51, there is a number calculated from the formula

=SUM(AC2:AC50)

which is the sum of all the ‘CT2’ hours. I’ve done the same for CT1 except I’ve used the 1.1621 instead of 1.0755 (to indicate the 16.21% basic salary pay rise). This gives total equivalent hours of 443.51 and 410.411 respectively which I will explain shortly.

The old system – calculations

The ‘Old’column is a lot simpler because the supplement is added at the end. Every cell in the ‘Old’ column has the formula:

=1.5*SUM(C2:Z2)

which is 1.5 x the number hours worked that day (for the 50% banding supplement).

Then I’ve used:

=SUM(AD2:AD50)

to add up all the ‘old’ hours.

There is also an ‘hours’ column using:

=SUM(C2:Z2)

for each cell. This is simply to calculate the raw number of hours I worked without any supplementation. These are summed at the bottom of the column with:

=SUM(AA2:AA50)

How have I got more hours under the new system but I’m also working the same hours?

What I’ve calculated is my pay equivalent to basic hours under the old system. It is not the actual hours I worked but is way of comparing the different rates of pay.

The punchline

  • I worked 337 hours in 7 weeks
  • That’s 48.14 hours/week
  • Under the old system, I was paid the equivalent of 505.5 old system basic hours with my 50% banding supplement
  • Under the new system,
    • At CT2 I was paid the equivalent of 410.411 old system basic hours with the plethora of supplement
    • At CT1 I was paid the equivalent of 443.5 old system basic hours with the plethora of supplement
  • That’s an 18% pay cut for CT2 and a 12.27% pay cut CT1

Now, you can’t just average the two pay cuts to get my total pay cut over two years. My pay was different for the two years under the old pay scale but hopefully this gives you an idea of the sort of cuts in pay we’re looking at.

There are caveats. There is a large variation between hospitals and an even bigger one between specialties. Surgeons’ rotas are different to anaesthetists’ rotas are different to medics’ rotas which are all different to the rota of a chemical pathologist.

Further, rotas will change. Given the new obligations, it is highly likely many hospitals will adjust their rotas meaning any sort of calculation based on new or old systems will be rendered irrelevant. That said, I doubt this particular anaesthetic rota will change very much. It already adheres to the new guidelines and it would be considerable hassle to change it.

This post isn’t making a judgement about whether it’s wrong. However, given the number of antisocial hours worked, I cannot fathom a situation where the acute specialties end up getting paid more unless the premiums are quite significant.

What I will say is I’m not sure how the new system is any simpler than the old system. Whatever. Maybe I’ll just go to Canada.

MEDICINE: Why you’ll be safe in hospital during a strike

Thousands of junior doctors will go on strike on Wednesday 10th February from 8am for 24 hours. I used to be one and may be one again. How, if juniors are so important, will a hospital run without them?

Broadly speaking, juniors hold a couple of roles. Firstly, it involves seeing patients every day with a senior doctor, ensuring they have been well since they were last seen and making plans for that patient. This usually takes most of the morning and occasionally into the afternoon.

After the ward round, these plans are put into place. Ordering scans, making referrals, organising discharges, taking bloods, prescribing drugs for discharge.

The more senior ‘juniors’ (for want of a better term) will do other things. A respiratory registrar may be involved in a bronchoscopy list or a clinic; a surgical registrar may have to do a day case list; or an elderly care registrar who needs to see referrals to his team.

If consultant take over this work, who’s going to do their job?

Much of what consultants do is elective work. It’s essential but non-urgent. It’s inconvenient for patients and unfortunately that’s the price of this strike.

Further, the cover that juniors will provide is the same as weekends, Christmas and Easter.

Let me reiterate this – it’s the same cover as every weekend, every bank holiday, Christmas, Easter, New Year. If this is dangerous, it’s dangerous all year round but it demonstrates the problem with the 7-day plan.

edinburghroyalinfirmary

What does 7 day NHS really mean?

Much has been written about the strike. The difficulty is that solving the issue of increased weekend mortality – which many dispute – involves changes to emergency cover. The 7 day plan is not a change to emergency cover. Rather it spreads the juniors covering the day-to-day tasks during the week over the weekend. It’s unclear how increasing elective work over the weekend would improve emergency care.

In other words – how do patients getting bunions removed on a Sunday improve your care if you have a heart attack?

The bottom line: government’s solution doesn’t solve government’s problem.

MEDICINE: the CEX life of junior doctors

“…not everything that can be counted counts, and not everything that counts can be counted.” – 1957, William Bruce Cameron, Informal Sociology

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It’s been a year since I passed the FRCA Primary (I’ll explain what this is shortly). As such, I thought this topic was a good one to start the medical component of this blog.

For doctors, assessment doesn’t stop at medical school. The various Colleges (e.g the Royal College of Physicians, Royal College of Surgeons) are responsible for setting standards within their respective specialties

To that end, a variety of acronyms are used to test trainees. ‘Trainee’ means a fully qualified doctor on a training scheme to be a consultant. (It is not a medical student.)

Firstly, there are exams:

  • SOE (Structured Oral Examination) – a short semi-structured viva.
  • OSCE (Observed Structured Clinical Examination) – a multi-station practical exam on anything from procedures on dummies to communication to anatomy
  • SAQ (Short Answer Question) – short essays
  • MCQ (Multiple-Choice Questions)

Then there are workplace-based assessments (WBAs):

  • CBD (case-based discussion) – the trainee has a structured discussion with an assessor around a case in which they were involved.
  • Mini-CEX (mini clinical examination) – assessor watched the trainee take a history and/or perform an examination and then provides feedback.
  • DOPS (direct observation of procedural skill) – assessor watches the trainee perform a procedure.
  • MSF (multi-source feedback) – the doctor is assessed by 15-20 peers of varying disciplines who comment on competence and professionalism.

Tired of the acronyms yet? This is not exhaustive.

First, let’s talk exams.

You can’t revise at 5am

These exams are hard. Referred to as Fellowship or Membership exams depending on College, failure rates of 40-50% are commonplace in many (possibly most) specialties. They are mandatory to become a consultant.

They’re expensive. Anaesthetists pay £1935 (320 + 590 + 470 + 555) and GPs £2131 (489 + 1642) but this doesn’t include revision courses and retakes.

There is debate about the relevance of some content. (Do I really need to know how a horse hair hygrometer works to be a competent anaesthetist?) But this is not the full story.

Simply, doctors are allocated little or no time to study. As such, one ends up revising on night shifts and at weekends. As an example, the FRCA (Fellowship of the Royal College of Anaesthetists) examinations are split into two sets – Primary and Final.

The general advice is to set aside 6 months for each component. Not 6 months off work – 6 months of your social life on top of a rota working 2 in 7 weekends.

Organise your own exam room

Doctors also need to complete WBAs (including the CEX in the title). There is some issue as to the validity of these. They’re designed to be formative (to aid learning) not summative (to assess competence) but are used for the latter nonetheless.

Rather than being organised by supervising consultants, junior doctors arrange assessments themselves. To my mind, this is akin to asking an A-level students to administer their own exam.

Arguably, it’s an assessment of the ability to find a willing consultant, rather than ability as a clinician.

The sheer volume of WBAs has grown. Anaesthetists need an assessment every other day on top of exams. This doesn’t include reflection, supervisor meetings, personal development plans, probity statements…

The electronic or e-portfolio should make this easier. It doesn’t. Each assessment has to be linked to the correct part of the syllabus in order to pass an appraisal. Doctors have failed to progress due to clerical rather than clinical errors.

Oh, just stop being so whiny

On top of the issues leading to the junior doctor strikes, the number of these assessments is slowly increasing. Assessment does need to happen but the attitude of ‘more, more’, of ignoring the time required to pass exams and a lack of engagement from some consultants adds to what is already a stressful job.

Anaesthetics might be oversubscribed but the last thing we need is another reason for doctors avoid general practice or leave emergency medicine.