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5:05 PM - 15 April 13

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10:32 AM - 6 March 13

TRIAGE 3

THE MAGAZINE FOR JUNIOR DOCTORS

Presenting HistoryJuniorDr is a free lifestyle magazine aimed

at trainee doctors from their first day at

medical school, through their sleepless

foundation years and tough specialist

training until they become a consultant. It’s

proudly produced entirely by junior doctors

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Find us quarterly in hospitals throughout

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What’s inside

04091420

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26

LATEST NEWS

LivErpooL CARE PATHWAy

GETTING coNSENt

WritiNg CASE REPORTS

GETTING INTO mEdicaL SchooL

courSES AND CONFERENCES

T he Liverpool Care Pathway was established in the late 1990s to provide a model of care for patients in their last hours and days of life. It formed GMC and NICE guid-ance and 90% of palliative care consultants said they had a preference for it at the

end of their own lives.Today however, the LCP is progressing down its own end of life pathway. Over the next

year it will be phased out across the NHS and replaced with new individualised end of life care plans.

The decision is controversial and was played out in the media with headlines in the Daily Mail including “I survived the death pathway” and “Now sick babies go on the death path-way”. Many doctors supported the pathway publicly but came under attack.

In our feature on page 9 JuniorDr’s Laura James looks at the aims of the LCP, why the media branded it the “death pathway” and what happens next.

Whether you support the continued use of the LCP or the proposed alternative, repeat-ed surveys have shown that junior doctors are unprepared for managing end of life care. On p12 Laura James asks Dr Vincent Crosby, palliative medicine consultant at Nottingham University Hospitals NHS Trust, for his advice for junior doctors.

You can find medicolegal advice from Charlotte Hudson at MPS on p14 about how to manage consent for end of life decisions.

Also in this issue Ben Chandler looks at the unusual role of animals in medical training (p16) and Rayna Patel considers the pros and cons of out of programme (OoP) time (p20).

We hope you enjoy issue 30!The JuniorDr Team

A MATTER OF LifE aNd dEath

NEWS PULSE4

N HS workers in England took an estimated 9.5 working days off sick last year according to a Health and

Social Care Information Centre (HSCIC) report, which also points to a slight rise in sickness absence rates.

The study which covered 1.05 mil-lion full time equivalent workers found that hospital doctors were the least likely to take sick leave of all staff. They took on average 2.8 days per year - though this was a slight rise from 2.7 days in 2011-12 and 2009-10.

Ambulance staff took the most days off sick with 14.7 days on average recorded per employee - an increase from 13.9 last year. Qualified nursing, midwifery and health visit-ing staff were the next most frequent sickness

group with an average of 10.6 days per year.Sue Covill, director of employment ser-

vices at the NHS Employers said:“It is important to put these figures in

perspective. Major staff groups, including nurses, are taking less sick-leave now than at the beginning of the decade, and systems to support their health and wellbeing have undeniably improved.”

“The simple fact is the NHS environ-ment has become more challenging for eve-ryone, making supportive approaches essen-tial to mitigate the pressures and help staff work within them.”

Regionally the North East had the high-est sickness absence rate, with 4.74 per cent of staff ill on an average day. The lowest rate was in London at 3.52 per cent.

Levels of pay also appeared to have an impact on sickness. Six per cent of staff with-in the second lowest pay band were ill on an average day - the highest rate of any pay band. The lowest rate was in the highest pay band with 1.22 per cent ill on an average day.

www.hscic.gov.uk

tell us your news. Email team@juniordr.com or call 020 7193 6750.

HOSPITAL DOCTORS LEAST LIkELy TO TAkE Sick LEavE of aLL NhS Staff

workinG conDiTions

cArEErs

T wo thirds (65%) of junior doctors chose a career in medicine because they wanted to help people but a third are now think-ing of changing career, according to a survey of 357 founda-

tion year 1 doctors by the Medical Protection Society (MPS). The survey revealed that 70% had enjoyed their first year, how-

ever 75% agreed that they had struggled with long hours, 62% had struggled with heavy workload and 34% had felt isolated.

When asked what they had found most challenging when deal-ing with patients during their first year as a junior doctor, 73% said

that they didn’t have enough time to give patients the care they require. Nearly half (47%) had often worked beyond their contract-ed hours, despite the European Working Time Directive (EWTD) limiting the working hours of doctors in training.

Dr Pallavi Bradshaw, medicolegal adviser at MPS says:“It is encouraging to see that despite the struggles of their first

year, 34% of respondents said that being a junior doctor was bet-ter than imagined and 32% were excited about their future career.”

www.mps.org.uk

THIRD OF JUNIOR DOCTORS CONSIDERING carEEr chaNgE

Qualified ambulance staff

Qualified nurses, midwifes and health visitors

Infrastructure Support (including managers)

Doctors (excluding GPs)

COMPARISON OF AvERAGE SICk DAyS by NHS STAFF GROUP: 2012-13

14.7

10.6

8.4

2.8NHS AvG 9.5 DAyS

T he number of written complaints about NHS organisations in England was 162,000 during 2012-13, equivalent to more than

3,000 written complaints a week over the year.The figures are contained in Data on written

complaints in the NHS, published by the Health and Social Care Information Centre (HSCIC). The figures show a 1.9% increase in complaints on the previous year.

The profession attracting the biggest number of written complaints was the ‘medical profession’ (which includes hospital doctors and surgeons), making up 47.1 per cent (51,500) followed by ‘nursing, midwifery and health visiting’ at 22.1 per cent (24,100).

The service area receiving the greatest number of written complaints was ‘inpatient hospital acute services’ accounting for 31.9 per cent (34,900), followed by ‘outpatient acute services’ (27.5 per cent or 30,000), ‘mental health services’ (10.7 per cent or 11,700) and ‘A&E’ (8.9 per cent or 9,680).

The subject area receiving the largest number of written complaints was ‘all aspects of clinical treat-ment’, making up 46.2 per cent (51,100) followed by ‘attitude of staff’ (11.1 per cent or 12,300), ‘communication/information to patients’ (10.5 per cent or 11,600) and ‘appointments, delay/can-cellation (outpatient)’ (8.0 per cent or 8,890).

www.hscic.gov.uk/pubs/nhscomplaints1213

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Quarter page ad.indd 1 13/09/2013 14:56

M ore than 7,500 doctors, including some of the UK’s most senior clinicians, have been revalidated by the General Medical

Council (GMC) during the first six months of its new system of checks.

Medical leaders - including Professor Sir Peter Rubin, Chair of the GMC, Professor Sir Bruce Keogh, NHS Medical Director for England and Dr Clare Gerada, Chair of the Royal College of General Practitioners - were among the first to be revalidated following introduction of the checks on 3 December 2012.

In the first six months, 7,663 doctors had their recommendation for revalidation approved by the GMC. They will continue to have annual checks over the next five years, after which they will be due to be revalidated again. By the end of this year the GMC expects to confirm that up to 30,000 UK doc-tors have revalidated. The aim is for the vast majority of doctors to go through the process by 2016.

The UK is the first country in the world to introduce revalidation across its whole healthcare system, covering GPs, hospital doctors, locums

and those working in the independent sector. The GMC has already begun work on how to evaluate the system as it rolls out.

Niall Dickson, the GMC’s Chief Executive and Registrar, said:

“After years of debate and planning we are now on the road with revalidation and delighted with the way it is working so far. The success of the first six months is a significant achievement for the doctors who have revalidated and the organi-sations they work for.”

www.gmc-uk.org

ovEr 7,500 doctorS NOW REvALIDATED

rEVALiDATion

Niall DicksonGMC ChIEf ExECUTIvE

“The success of the first six months is a signif-icant achievement for the doctors who have revalidated and the organisations they work for.”

ovEr 3,000 WrittEN compLaiNtS AGAINST NHS PER WEEk

PATiEnT cArE

NEWS PULSE6

A lmost nine out of 10 (86%) GPs say their morale has decreased over the last 12 months, according to the largest sur-

vey of opinion since changes to the GP con-tract took effect in April 2013.

The BMA survey found GPs need to be freed from increased bureaucracy, box ticking and administration so they can spend more time meeting the needs of their patients. In total, 3,629 GPs completed the survey, just over 10% of all GPs in England.

The key findings included:• 97% said that bureaucracy and box ticking

had increased in the past year while 94% said their workload has increased.

• 82% felt that some of the new targets were actually reducing the number of appoint-ments available to the majority of patients.

• 89% said that more targets will not improve patient care.

• 90% said their practice’s resources are likely to fall in the next year.

• 45% of GPs said they are less engaged with the new clinical commissioning groups (CCGs) because of increased workload.

• 86% of GPs reported a reduction in their morale in the past year.Dr Chaand Nagpaul, Chair of the BMA’s

GP committee said:“The results of this survey demonstrate that

an increase in bureaucracy, box ticking and administration has damaged GP services and patient care, mirroring a government funded report into GP’s working lives that made simi-lar findings.”

“Recently introduced targets included encouraging GPs to carry out a large number of lengthy and clinically dubious question-naires that ask how many hours patients spend on gardening, cooking and DIY. They are also offering appointments to all healthy 35-40 year olds simply to check their blood pressure. GPs are very worried that the time taken for this programme and questionnaires is resulting in fewer appointments for other patients who are in need of care.”

www.bma.org.uk

N HS staff in England take home an esti-mated average annual pay packet of just over £29,543 - a rise of one per cent on

last year and of almost nine per cent on four years ago, new figures show.

The average basic wage for a full time NHS worker in England was £29,543 for the 12 months to June 2013,

according to the Health and Social Care Information Cen-

tre (HSCIC). This is 1.0 per cent more

than in the 12 months to June 2012 and 8.6 per

cent more than in the 12 months to June 2009.By individual staff group, senior manag-

ers saw the largest percentage pay increase in the last year while health visitors saw a slight decrease according to today’s report, which considers the earnings of the 1.18 million staff working in NHS hospital and community ser-vices in England (excluding GP surgeries).

Doctors (including consultants and regis-trars, but excluding locums and GPs), earned £58,813 on average, a 1.4 per cent increase on 2012 and a 5.5 per cent increase on 2009. Doctors in training saw the lowest pay increase last year of just 1 per cent.

www.hscic.gov.uk/pubs/staffearntojun13

avEragE NhS pay up ONE PER CENT LAST yEAR

PAY AnD conDiTions

9 OUT OF 10 GPS SAy moraLE haS faLLEN IN THE PAST yEAR

GEnErAL PrAcTicE Half of older GPs plan to quit

More than half (54.1%) of all GPs

aged 50 and over plan to quit within

five years, according to the Seventh

National GP Worklife Survey. The an-

nual study of almost 2,000 GPs is

funded by the Department of Health.

It also found that fewer than 1 in 10

GPs aged under 50 years indicated

that there was a considerable or high

likelihood of leaving direct patient

care within five years.

www.dh.gov.uk

MRCP exam fees frozen

MRCP(UK) has announced that

fees will not increase for any of the

MRCP(UK) examinations in 2014.

Fees will be frozen for all three parts

of the MRCP(UK) Diploma examina-

tion and all of the Specialty Certificate

Examinations (SCEs). The decision

was taken in the knowledge that the

financial environment is difficult for

NHS trainees, who had a basic pay

increase of just 1% for 2013.

www.mrcpuk.org

New bMA junior doctor chair for Scotland

West of Scotland trainee, Dr David

Reid has been elected Chair of the

BMA’s Scottish Junior Doctors Com-

mittee (SJDC). Dr Reid, graduated

from Edinburgh University Medical

School in 2008 and is currently a spe-

cialty trainee in renal medicine. He

previously held the position of deputy

chair of the committee leading on ed-

ucation and training issues.

www.bma.org.uk

Working overseas guide

A new guide which encourages doc-

tors to develop skills in overseas

health systems has been launched

by the BMA this month. Broadening

Your Horizons explains what doctors

need to know if they are consider-

ing working or training in developing

countries. It also aims to help NHS

employers and medical educators un-

derstand how best to assist those who

choose to undertake work abroad.

http://bit.ly/16cbTUc

Dr Chaand NagpaulChAIR, BMA GP CoMMITTEE

“Recent changes to the GP contract have created additional and unnecessary work-load that is diverting valuable time away from treating patients.”

NEWS PULSE 7

C hecks to ensure the English language skills of doctors from Europe are good enough to safely treat patients were revealed by the General Medical Council (GMC) this month.

The regulator has launched a three-month consultation to seek views on changes which will allow it to check the language skills of doctors from the European Economic Area when a concern is raised during their registration process.

This runs in line with the Department of Health’s consultation on changes to the Medical Act to give the GMC the new powers, which are due to come into effect in 2014. It will mean the GMC can carry out further checks and investigations where it believes the safety of patients might be at risk because a doctor cannot speak English.

Currently, the GMC is able to check the English language skills of doctors who qualified outside Europe, and can refuse to grant those doctors registration with a licence to practise if they do not meet its standards. However, current UK law stops the GMC from checking the English language skills of European doctors – which the regulator is working with the Department of Health to change.

There are over 26,000 doctors from the EEA on the medi-cal register. Organisations employing doctors will still have a

responsibility, as they do now, to ensure all doctors, including those from Europe, can com-municate safely in English.

Niall Dickson, Chief Exec-utive of the General Medical Council, said:

“The safety of patients must always come first. That means doctors wanting to practise in this country must be able to speak English clearly and communicate effectively. If a doctor can-not do this we should be able to prevent them from practising in the UK.”

“We have been working hard for some time to close this loop-hole in UK legislation and are pleased that government has lis-tened to what we have been saying. It has caused much concern to patients and their families and this consultation is the next step in making sure these changes are made as quickly as possible.”

www.gmc-uk.org

GMC SEEkS vIEWS ON LaNguagE chEckS for EuropEaN doctorS

TrAininG

info@IMRmedical.comwww.IMRmedical.com0871 284 7100 (UK)

+61 3 8506 0185 (Int’l)

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H alf of patients would like to communicate with their GP by email but less than two in ten (18%) are able to so at present, according to research by Global Market Insite.

A similar picture exists for text and via the website. At present, only 23% of respondents have communicated with the GP’s sur-gery via their website, 18% by email, and 13% via text.

Two thirds (67%) would like to book appointments via a GP’s web-site, half (48%) by email and one third (33%) by text. The picture is similar for receiving test results, where email is the most preferred method by two thirds (66%), fol-lowed by access via a GP’s website at 39% and text at 37%.

The highest number of responses for remote communication came for requesting repeat prescriptions where a GP’s website was the most popular method at 69%, followed by email at 65% and text at 41%.

Respondents did express concerns ranging from fears of mis-diagnosis, ability to adequately describe their symptoms, and concerns that remote consultation would not be as thorough as in person.

www.gmi-mr.com

HIGH PATIENT DEMAND FOR gp commuNicatioN by EmaiL

TEcHnoLoGY

2013

The Nursing and Midwifery Council will require all new nurses qualifying in England to hold a degree qualification.

The NHS launches employing 144,000 members of staff.

1949

The Nurses Act modernises the role of nursing providing the catalyst for reform to nursing education and training.

Health Education England

Celebrating our people 1940s

Art Therapists, an allied health profession, begin to be employed in the NHS.

65 years of NHS workforce development

1962Enoch Powell’s Hospital Plan recommends that teaching hospitals should act as district general hospitals and that students should be taught where patients required treatment.

1966The Charter for General Practice provided better terms and conditions and a proper training system for GPs.

1974Podiatry services begin to emerge across the NHS. Today, a podiatrist must undertake extensive postgraduate education and training, usually taking a minimum of 10 years to complete.

1975The Merrison Report concluded that postgraduate medical education and training was in need of a regulatory framework

– the Education Committee of the GMC was created. 19

80s

Healthcare assistants are introduced as a new category of support worker and the healthcare assistant (HCA) initiative is proposed.

Training is widely introduced in mental health to help staff manage the transition of patients from hospitals to community care settings.

1984The UK Central Council for Nursing, Midwifery and Health Visiting leads a reform of nurse education and training, looking ahead to the demands of the 21st century.

1986

began to pave the way for nurse training in universities, instead of hospitals, introducing the academic award.

1988The National Council for Vocational Qualifications is established and begins to develop NCVQs in healthcare.

Project 2000

2000The Government publishes The NHS Plan – a 10-year modernisation programme of investment and reform - proposing investment in an additional:

7,500consultants

2,000GPs

20,000nurses

6,500therapists

1,000more medical

places

2001

The Improving Working Lives Standard (IWL) is developed to ensure that all NHS employers are committed to improving the working lives of all staff.

2002Assistant Practitioners in nursing were piloted in Manchester.

2003

Standardisation of pay and conditions for the majority of NHS staff as part of

the Agenda for change.

2004NHS takes on responsibility of prison healthcare and the education and development of prison healthcare staff.

2005Postgraduate Medical Education and Training Board (PMETB) established to develop a single, unifying framework for postgraduate medical education and training.

20052009

The medical and dental workforce increases from just under:

15,000 100,000

1950s 2005

2009

The NHS Constitution is published and outlines a revised set of rights and responsibilities for patients and staff.

The Government agrees plans for nursing in England to become a degree-only profession.

2010 PMETB merges with GMC. 2012London

2012

Publication of The Health and Social Care Act to safeguard the future of the NHS and proposes the streamlining of arms-length bodies, including establishing Health Education England.

The contribution of the NHS is recognised at the Olympic Opening Ceremony with hundreds of NHS staff participating.

2012Compassion in Practice recommends ways in which staff are trained and developed to demonstrate behaviours and values within the six Cs.

2013Robert Francis QC, chair of the Mid Staffordshire NHS Foundation Trust Public Inquiry, presents his final report to the Secretary of State for Health. HEE is taking forward a number of Francis recommendations, including developing the pre-degree care pilots.

2013Health Education England takes up its formal responsibilities.

2013Government launches its mandate to HEE.

5th The NHS is the fifth largest employer in the world and employs more than

1.35 million people

77%of the NHS workforce is female 30%

nurses make up the largest part of the workforce at just under

HEE

1955The nursing auxiliary/nursing assistant role achieves formal recognition.

1950sThe 1956 Jameson Report into Health Visiting and the 1959 Younghusband Report on Social Workers urges a national scheme for the training of health visitors and social workers.

1956The NHS Graduate Management Training Scheme started.

1957 The Willink Report looks at future numbers of medical practitioners and the appropriate intake of medical students is published.

5 July 1948

HEE recognises and supports all healthcare professions - this infographic is a merely a snapshot of the countless, significant, milestones in the education, training and development of all healthcare staff since 1948.

65 yEARS OF NhS Staff

T he NHS celebrated it’s 65th birthday in July. It employs 144,000 members of staff - one of the biggest single employ-ers in the world. This infographic created by Health Education England celebrates the people who created our National Health Service and their journey to the current day. Image credit: Health Education England.

ENd of LIfE 9

THE ENd of LifEFOR THE LivErpooL carE pathWay

ENd of LIfE10

What is the Liverpool care pathway (Lcp)?

The LCP was established in the late 1990s and was designed to incorporate the hospices model of care into hospital and commu-nity care settings. At the time it was felt that some hospices were providing excellent end of life care, where as hospitals had tended not to meet the same high standards.2

The LCP was recommended as a model of good practice for patients in the last days or hours of life by a number of national policy frameworks including the General Medical Council and the NICE quality standard. Its name was derived from where it was designed - the Royal Liverpool University Hospital. It was creat-ed in conjunction with the Marie Curie Palliative Care Institute.

The main principles of the LCP include:•Accommodating the person’s individual needs considering

their physical, social, spiritual and psychological needs•Requiring senior clinical decision making, good communica-

tion, a management plan and regular assessment• Is not a treatment but a framework for good practice•Aiming to support but not replace clinical judgement•A focus on care in the last days or hours of life, when death is

expected•Good communication, care and compassion must come from

all staff for the patient and their family 3

media attention

In late 2012 and early 2013 there was a flood of negative news-paper headlines surrounding patient and family experiences with the Liverpool care pathway which raised much public concern, misunderstanding and criticism about the incentives of the LCP.

Headlines in national newspapers included:“I survived the death pathway…” The Daily Mail October 2012 4“Family ‘not told’ grandmother was put on Liverpool Care Path-way” The Telegraph July 2013 5

“Family say dying man on Liverpool Care Pathway was denied drink” The Times November 2012 6

One common misunderstanding was that patients who were not dying were purposefully placed on the LCP as the hospital would receive money for it.7 In fact, the financial gain was to encourage medical staff to follow the LCP when patients were

imminently dying, as it what was designed to be the gold standard for end of life care.2

It was also believed that patients would be cruelly refused food and drink to speed up the dying process - another misunderstand-ing. The LCP was meant to neither prolong nor shorten life and states that there is no “blanket policy” for giving or withhold-ing nutrition and hydration but is decided on an “individual case basis”.8 This could and perhaps did lead to a wide variation of interpretation.

Professor Irene Higginson, Professor of Palliative Care at Kings College London, was interviewed in an audio module with BMJ Learning regarding the Liverpool Care Pathway and said:

“It is fair to say that the early versions of the LCP before this one did take a more restrictive view and did talk about stopping food and fluids … the ideal is that the patient is supported by taking fluids by the mouth for as long as possible, but in many instances, although artificial hydration is not needed, in some instances it is and I do think that this is an important clinical judgement … If you put in too much fluid and they don’t need it because they’re not dehydrated you could fill up the lungs with fluid, you could hasten death.”9

Families of dying patients were also concerned that their rela-tives were being given a large amount of sedatives and pain kill-ers that would make them drowsy and do more harm than good.

oNE CoMMoN MISUNdERSTANdING WAS ThAT PATIENTS Who WERE NoT dyING WERE PURPoSEfULLy PLACEd oN ThE LCP AS ThE hoSPITAL WoULd RECEIvE

MoNEy foR IT.

After almost a year of negative publicity and little in the press to defend its good intentions, the Liverpool Care Pathway is now gradually being phased out.

This model of care for patients in their last hours or days of life was analysed by a government commissioned review. It concluded that although the pathway itself is a model of good practice, it has not been applied properly in too many cases1.

While some members of the public may be cheering its departure, it has left many questions for health care professionals, in particular, what went wrong, and what next? JuniorDr’s Laura James attempts to provide the answers.

ENd of LIfE 11

THE ENd of LifE FOR THE LivErpooL carE pathWay

In some cases it was not clear if the drugs were even needed. The commissioned review of the LCP stated, “It seems that at least some of the distress experienced could have been mitigated by bet-ter communication.”1

the review

The national newspaper headlines could not be ignored, and in January 2013 a review of the LCP was commissioned by Norman Lamb, Care and Support Minister. The independent review was car-ried out by a panel, which was chaired by a Senior Rabbi at the West London Synagogue and crossbench peer, Baroness Neuberger.

The panel met members of the public who had experiences of the LCP, they looked at surveys, academic literature and written submissions from health care professionals.

The review raised concerns that the LCP was being used as a protocol rather than a guideline and the tick box nature of the LCP documentation was leading to poor decision making. Rabbi Neuberger advised more funding to “ensure that guidance on care for the dying is properly understood and acted upon, and tick-box exercises are confined to the waste paper basket for ever”.

There is also strong mention that the term “Liverpool Care Pathway” is most unhelpful, with one interpretation of it being “a conveyer belt to death”. The term “end of life care plan” was thought to better convey its meaning.

Communication was felt to be an issue. The panel said that there was “shocking unwillingness” amongst clinicians to discuss the prospect of death with patients and their families and carers. It was reported that, “Placing patients on the LCP can lead to con-siderable distress in relatives or carers when the patient does not die with hours or days, or recovers. Doctors and nurses must com-municate with patients and relatives far more honestly about these clinical uncertainties”.

But they also wrote, “No matter how much effort is put into training clinicians in good communication skills, unless everyone in society – members of the public, the press, clinicians, public fig-ures – is prepared to talk openly and honestly about dying, death and bereavement, accepting these as a normal part of life, the qual-ity of care and the range of services for the dying, their relatives and carers will remain inconsistent.”1

Junior doctors

The panel noted that junior doctors were making decisions that were beyond their expertise. For example, titrating opiate pain kill-ers, sedatives and anti-secretory drugs which they were sometimes getting wrong. The panel said that juniors told them they wanted more training and support from the palliative care team and assis-tance with titrating drugs to the correct therapeutic response.

It was also highlighted at the BMA junior doctors forum in May this year that junior doctors are often at the forefront of providing end of life care and therefore should have better training in it.10

There is growing evidence to support this conclusion. In a 2013 paper in the Royal College of Physicians of Edinburgh, Founda-tion Year 1 (FY1) doctors and supervising consultants were sent questionnaires to ask if newly qualified doctors were prepared to deliver end-of-life care. Results showed that FY1 doctors did not feel or appear prepared, particularly when it came to managing distress and social issues, with a high proportion of them report-ing distress themselves.11

The review panel said, “We heard from junior doctors that, whilst they may have had some training or exposure to palliative care at medical school, once qualified, they felt their training had not fully prepared them for the task of looking after dying patients.”1

What happens next

The LCP will be phased out over the next 6–12 months and replaced with individualised end of life care plans, taking into con-sideration the issues raised from the report. Guidance will be giv-en for different disease groups and the plans will require sign off by senior clinicians. Any financial gain for using an end of life pathway will be stopped.12

response

Before the plans had been put in place to phase out the LCP, doctors had backed its use with 90% of palliative care doctors say-ing that they would have a preference for the LCP at the end of their own life.13

However, doctors had also mentioned the need for further train-ing in the area, particularly in good communication and safeguard-ing systems to ensure its good use.14 This argument still holds for end of life care in the future as well as other issues such as funding.

RESULTS ShoWEd ThAT fy1 doCToRS dId NoT fEEL oR APPEAR PREPAREd, PARTICULARLy WhEN IT CAME To MANAGING dISTRESS ANd SoCIAL ISSUES, WITh A hIGh PRoPoRTIoN of ThEM REPoRTING dISTRESS

ThEMSELvES.

ENd of LIfE12

MANAGING ENd of LifE

have you got any suggestions on communication when talking to families of those who are dying?

I think it’s approaching the communication in a way that you would want someone to speak to you, if you were in that situation. When peo-ple come into hospital and they’ve deteri-orated quickly, the family need to know that we’ll firstly see if there is a reversible cause for the persons deterioration and if there is we will do what we can to improve things.

I think it’s really important at that stage to always sew the seed that there may not be a revers-ible cause. It may be that we are approaching the end of life and I think it’s important for us to try to be open and explicit with the family and say we will try what we can do but there is a risk that your mum or dad might die during this episode. If whatever we’re doing isn’t working then our focus would be on keeping them comfortable and making sure that they’re not suffering.

There’s a useful phrase that says, “we can hope for the best, but fear the worst”. That gives people that feeling that we’ll try and do what we can but we can’t promise that they’ll defi-nitely get better.

What do you think is the most difficult part of the Liverpool care pathway?

I think it’s really important at that stage to always sew the seed that there may not be a reversible cause. It may be that we are approaching the end of life and I think it’s important for us to try to be open and explicit with the family and say we will try what we can do but there is a risk that your mum or dad might die during this episode. If whatever we’re doing isn’t working then our focus would be on keeping them com-fortable and making sure that they’re not suffering.

Aside from the controversy surrounding the Liverpool Care Pathway, managing end of life care can be a difficult process for junior doctors.

JuniorDr’s Laura James asks Dr Vincent Crosby, palliative medicine consultant at Nottingham University Hospitals NHS Trust, for his advice.

rEfErENcES

1. doh. Review of Liverpool Care Pathway for dying patients. 2013. https://www.gov.uk/government/publications/review-of-liverpool-care-pathway-for-dying-patients

2. NhS choices. What is the Liverpool care pathway. 2012. http://www.nhs.uk/news/2012/11November/Pages/What-is-the-Liverpool-Care-Pathway.aspx

3. Marie Curie Palliative Care Institute. LCP Model Pathway – UK Core documentation. 2012. http://www.sii-mcpcil.org.uk/media/10843/lcp%20core%20documentation.pdf

4. Stevens J. I survived the death pathway: Patricia, 82, was given two days to live, but her family defied doctors and gave her water through a straw - now she’s planning a world cruise. 2012. http://www.dailymail.co.uk/news/article-2223836/I-survived-death-pathway-Patricia-82-given-days-live-family-defied-doctors-gave-water-straw--shes-planning-world-cruise.html

5. Adams S. family ‘not told’ grandmother was put on Liverpool Care Pathway. 2013. http://www.telegraph.co.uk/health/healthnews/9612091/family-not-told-grandmother-was-put-on-Liverpool-Care-Pathway.html

6. Jenkins R. family say dying man on Liverpool Care Pathway was denied drink. 2012. http://www.thetimes.co.uk/tto/health/news/article3593596.ece

7. Sturdy J. Liverpool Care Pathway: More than 10,000 patients placed on plan . 2013. http://www.bbc.co.uk/news/uk-england-21141281

8. LCP. healthcare professional documenting the MdT decision. 2012. Page 2.

9. Prof. higginson I. The Liverpool Care Pathway audio module. 2013. http://learning.bmj.com/learning/user/login.html

10. BMA. Call to improve care pathway traiing. 2013. http://bma.org.uk/news-views-analysis/news/2013/may/call-to-improve-care-pathway-training

11. Bowden J et al. Are newly qualified doctors prepared to provide supportive and end-of-life care? A ssurvey of foundation year 1 doctors and consultants. 2013. JR Coll Physicians Edinb 43:24-8

12. BMA. Personalised care to replace controversial end-of-life pathway. 2013. http://bma.org.uk/news-views-analysis/news/2013/july/personalised-care-to-replace-controversial-end-of-life-pathway

13. Kaffash J. 90% of specialists would put themselves on the Liverpool care pathway. 2013. http://www.pulsetoday.co.uk/clinical/therapy-areas/elderly-care/90-of-specialists-would-put-themselves-on-liverpool-care-pathway/20002098.article#.UgoJG0bv68g

14. BMA. doctors overwhelmingly back end-of-life care pathway. 2013. http://bma.org.uk/news-views-analysis/news/2013/june/doctors-overwhelmingly-back-end-of-life-care-pathway

15. Kings College London. Response to the LCP review from Kings palliative care experts. 2013. http://www.kcl.ac.uk/newsevents/news/newsrecords/2013/07-July/Response-to-the-LCP-review-from-Kings-palliative-care-experts.aspx

Professor Irene Higginson said in response to the review:“With the number of deaths expected to rise by 17 per cent

over the next 20 years, there has never been a more important time to consider how we are going to cope with this increase in demand for palliative care … We already know there are inequities for patients and families.”

“Expenditure on palliative care services is inconsistent across England, with the average spend per person at end of life about £900 in total. However, some Primary Care Trusts spend as little as £186 per person.”15

There have also been a number of online petitions to try and reverse the decision to phase out the Liverpool Care Pathway with over 31,000 signatures on one. However there are no signs from the government to back this.

It is likely that over the next year some may find the change dif-ficult. The attention the LCP has received has focused on improve-ment and we can hope that it will mean better end of life care in the future.

ENd of LIfE 13

MANAGING ENd of LifEThe more experience you get and the longer you ve

been working in medicine, the better you become at it. But we’re not perfect and we will think that

people are reaching the end of their life, put them on the pathway and they’ll survive.

I think one of the worst things you can do is be very black and white and give the impression that this will definitely happen, because then if it doesn’t, it can come back and haunt you. The hardest bit with-out a doubt is communication - expressing that ambiguity; that uncertainty to families.

in what sort of scenario would we think about referring to palliative care?

End of life care should be eve-rybody’s business and we should

all be able to do the basics. How-ever, if patient’s families are strug-

gling to accept the opinion that a patient is dying it might be an indica-

tion to get a second opinion from a palli-ative care team. I do however think that for

the majority of patients who die on standard medical wards the clinical teams should have

the skills and abilities to look after them.

What further self-learning opportunities would you suggest for junior doctors?

There are certainly plenty of resources online and lots of training available. I’d recommend that everybody post F1, after they’ve encountered some difficult situations, seeks out a communication skills training course and refreshes every-thing they learnt in medical school.

is there anything you think that doctors could have done better?

I think most, if not all, of the doctors I’ve come across want to do a good job and do the best for all of the patients they come into contact with. There’s natural variation in how far people go sometimes with tests and with treatment, which will vary from doctor to doctor.

It’s making sure that doctors who are perhaps more inter-ventional in their treatment are constantly challenging them-selves to think - is pursuing these extra tests beneficial? Does adding in these extra treatments make care better for the patient? This patient looks like they’re dying, but have I thought about every reversible cause? Have I done every-thing that I possibly can to make sure that this patient is improving?

So I think it’s about all doctors constantly evaluating their own practice in end of life care and striving to improve them.

Dr VincEnT crosbY

ENd of LIfE CARE ShoULd BE EvERyBody’S BUSINESS ANd WE ShoULd ALL BE ABLE To do

ThE BASICS.

14

FOR END OF LIFE DECISIONS

P atients who are approaching the end of their life have the same entitlement to high quality care as other patients,

and the GMC clearly sets out this expecta-tion. You must treat patients and those close to them with dignity, respect and compas-sion, especially when they are facing diffi-cult situations and decisions about care.

The GMC states that if you are under-taking an investigation or providing treat-ment, it is your responsibility to discuss it with the patient and ensure that they understand the risks and side effects as well as alternatives, including no treatment. If you delegate this responsibility to some-one else, you are still responsible for mak-ing sure that the patient has been given enough time and information to make an informed decision, and has given their val-id consent.

The Liverpool Care Pathway (LCP) was designed to allow people with a ter-minal illness to die with dignity, but there have been a number of high-profile allega-tions in the media that patients have been

placed on the LCP without their consent or their friend’s or family’s knowledge. The LCP recommendations make it very clear that “while legal consent is not required to place a patient on the LCP, the fact that the plan is being considered should always be discussed with a relative or carer and, if possible, the patient themselves”.

The LCP is to be phased out over the next six to 12 months following a govern-ment-commissioned review which heard that hospital staff wrongly interpreted its guidance for care of the dying. In its place, individual care plans for the dying will be brought in, and recommendations state that only senior clinicians must make the decision to give end-of-life care, along with the healthcare team.

END OF LIFE DECISIONS

Before people lose the capacity to con-sent to, or refuse treatment, particularly as a result of a progressive condition, they may make an advance decision (AD) or directive (or living will).

If the AD statement was made by a competent adult, and there is no reason to believe that they have changed their mind, it should be respected. The Mental Capacity Act 2005 (MCA) provides a safeguard for doctors acting on advance decisions.

PATIENTS WHO LACk CAPACITy

The MCA has provisions allowing for the appointment of proxy decision makers for incapacitated adults. If an adult patient lacks capacity to decide, the decisions you

coNSENtMedicolegal Advice - in association with the Medical Protection Society

Respect for patients’ autonomy is expressed in consent law; to impose care or treatment on a patient without their consent is not only unethical, but unlawful. Charlotte Hudson looks into why it is important to obtain consent for end of life decisions.

•The patient must be competent – as-sessment of a person’s capacity should be based on his/her ability to understand, retain and weigh in the balance of infor-mation relevant to a particular decision.

•The person must also be able to commu-nicate the decision.

•The patient must have sufficient infor-mation to make a choice.

•The patient must be able to give their consent freely.

FOR CONSENT TO bE vaLid:

IN 44% of CASES WhEN CoNSCIoUS PATIENTS WERE PLACEd oN ThE PAThWAy, ThERE WAS No RECoRd ThAT ThE dECISIoN hAd

BEEN dISCUSSEd WITh ThEM.

NATIoNAL AUdIT (2011) By ThE MARIE CURIE PALLIATIvE CARE INSTITUTE LIvERPooL ANd ThE RoyAL CoLLEGE of PhySICIANS

1515

or others make on the patient’s behalf must be based on whether treatment would be of overall benefit to the patient, and which option would be least restrictive of the patient’s future choices. When no legal proxy exists and you are responsible for making the decision about overall benefit, you must con-sult with those close to the patient who lacks capacity, to help you reach a view.

For patients who lack capacity to decide, you must check the patient’s medi-cal record for any information suggesting

that they have made a potentially legal-ly binding advance decision or directive refusing treatment.

FAILURE TO ObTAIN vALID CONSENT

The European Convention on Human Rights states that patients have a right to life and that there is a positive duty on public authorities to protect life. Towards the end of a patient’s life, it is important to remember this and to gain, and docu-ment, valid consent for any treatment or

withdrawal of treatment.A failure to follow the GMC’s guidance

on consent can raise a question about a doctor’s fitness to practise, and place their registration at risk.

A significant proportion of clinical neg-ligence claims are settled simply because of a lack of evidence of valid consent being obtained. In extreme circumstances, touching without consent can give rise to allegations of battery or assault, and even criminal charges, but this is unusual.

Medicolegal Advice - in association with the Medical Protection Society

MPS is the world’s leading medical defence organisation, putting members first by providing professional support and expert advice throughout their careers.

MPS supports members through the world’s largest network of medicolegal experts. We have a unique team of more than 100 specialist lawyers and medicolegal advisers (doctors with legal training).

We are also committed to sharing our experience with members to help them avoid problems and provide the very best care for their patients. The educational portfolio available includes publications, conferences, lectures, presentations, workshops, E-learning and clinical risk assessments.

MPS members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.

www.mps.org.uk

The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.

rEfErENcES/furthEr iNformatioN MPS factsheet, Consent – The basics www.medicalprotection.org/uk/england-factsheets/consent-basics

GMC, Consent Guidance: Patients and Doctors Making Decisions Together (2008) www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp

DH, Reference guide to consent for examination or treatment Second edition www.gov.uk/government/publications/reference-guide-to-consent-for-examination-or-treatment-second-edition

The Mental Capacity Act (2005) www.legislation.gov.uk/ukpga/2005/9/contents

GMC, Treatment and Care Towards the End of Life: Good Practice in Decision Making www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp

MPS Practice Matters, Doctor’s Orders vs Patient Choice, June 2013 www.medicalprotection.org/uk/practice-matters/issue-2/doctors-orders-vs-patient-choice

The Marie Curie Palliative Care Institute Liverpool website, National Care of the Dying Audit of Hospitals – Round 3 (NCDAH) Results: www.liv.ac.uk/php/mcpcil/index.htm

NHS Choices, What is the Liverpool Care Pathway? www.nhs.uk/news/2012/11November/Pages/What-is-the-Liverpool-Care-Pathway.aspx

16 ANIMALS IN TRAINING

aNimaLS IN TRAININGScientific advisor to the government, The Royal Society, claim that virtually every medical achievement in the 20th century relied on the use of animals in some way. Today about 50-100 million vertebrate animals continue to be used for medical experimentation each year.

JuniorDr’s Ben Chandler looks at the current use of animals in clinical treatment and their role in medical training.

I watched anxiously as the patient’s saturations started drop-ping, the monitors shrieking that the oxygen levels were becoming dangerously low. Urgent action was needed before

a hypoxic cardiac arrest occurred. Intubation or any other inter-vention via the mouth or nose was impossible. As the tension levels rose another doctor undertook a procedure often talked about but very rarely performed - a cricothyroid puncture.

Using a cannula to enter the airway then ventilating the patient’s lungs with oxygen, the doctor was successful at the first attempt and the oxygen levels rose to a safer level; the immediate threat to life avoided. As the atmosphere calmed an instructor gave extra tips on how to undertake this life-saving procedure. For the ‘patient’ - a live sheep - the morning’s training was far from over.

Using animals for any kind of experiment is controversial. The dispute surrounding the use of animals for teaching medical stu-dents can be traced back over a hundred years. In the early 1900`s Sir William Bayliss, an eminent physiologist (and the discoverer

of hormones) was accused of cruelty to animals based on a dem-onstration he gave to a group of medical students.

During the experiment he had dissected a dog which the Anti-Vivisection Society claimed was not fully anaesthetised. The dog had also previously been used for experimentation and both activ-ities were illegal at the time. In the following uproar Bayliss suc-cessfully sued for libel.

However the Anti-Vivisection Society were not finished with the issue, and following a public donation of funds, proceeded to commission a statue of the dog. The monument to the little brown dog became a battle ground for the opposing groups and was a target for numerous episodes of vandalism.

Events came to a head in 1907 when a large group of medical students marched to the monument intent on knocking it down led to full scale riots. The local council unhappy at the costs of guarding the monument pulled it down three years later. It was not until 1985 that a new version of the little brown dog statue was unveiled and still exists in Battersea Park, London.

aNimaLS iN SimuLatEd traiNiNg

Until recently trauma training in the USA commonly involved the use of live anaesthetised pigs on which various surgical tech-niques, such as chest drains and emergency airway interven-tions, were practised. Following the training session the pigs were euthanised with the aim of avoiding exposure to any pain that may occur.

Advocates for the use of live animals claim that undertaking a procedure on a warm creature replicates reality more closely. The muscle tone, feel of tissues and response to intervention reflect the changes seen in a real human patient. Aside from the animal rights issues, critics argue the differences in anatomy are a huge limita-tion in the actual surgical experience gained - a view confirmed by at least one clinical trial of candidates learning experience.

17ANIMALS IN TRAINING

In the face of mounting criticism from various groups the number of centres in the United States using live animals as part of their Advanced Trauma Life Support (ATLS) training has now fallen to only 11 out of 280 centres. In the UK the use of live ani-mals for medical training is illegal.

hiStory of SimuLatEd LEarNiNg

Medical simulators were first used in the 1960s. Over recent years their use has become much more widespread and the tech-nology has evolved greatly from the basic ‘Resusci-Anne’ to the latest ‘SimMan’.

Since 2001 the ‘TraumaMan’ system has been approved for trauma training. It has become the most widely used surgical trainer device in the world and over 30,000 clinicians are trained with this device annually. TraumaMan consists of a human-like torso, covered with a pliable ‘skin’.

Numerous procedures can be practised on it, including crico-thyroidotomy and chest tube insertion. When cut it will mim-ic bleeding and recent upgrades even allow for integration of focused trauma ultrasound (FAST) scanning into the system. All this technology is not cheap though and a TraumaMan system costs around $24,000 (£15,000 pounds) and to allow optimal use it needs a supply of disposable skins as well.

Mannequins have numerous advantages over using animals - they have human anatomical landmarks, give a more reproducible learning experience and they are much more portable, allowing courses to be run almost anywhere, without the need for animal facilities.

doctorS agaiNSt aNimaL uSE

Some of the most vocal criticism of animal use in medical edu-cation comes from doctors in the form of the Physicians Com-munity for Responsible Medicine (PCRM). Founded in 1985, the organisation has 9,000 doctors in its membership. As well as opposing animal experimentation it also promotes vegetarianism.

The PCRM exerts pressure on numerous universities and hospitals using email based campaigns to highlight ongoing animal cruelty.

John Hopkins Medical School is one of PCRMs current tar-gets. Regarded as one of the top medical schools in the US it remains one of the only medical schools where live animals are used for teaching. During the students surgical placement they have the opportunity to attend a surgical skills session using live anaesthetised pigs. The session offers students the chance to suture wounds and operate on various organs, however pressure is now mounting on the university to abandon this practice.

In February this year a criminal complaint was filed with the state attorney claiming that the university ‘should be held criminally lia-ble for cruelty to animals’ and requesting an investigation to halt the live animal component of the school’s medical student curriculum.

W ould you ever consider injecting a product taken from a pig’s intestine into a patient

then reversing its effects with a syringe full of fish sperm? Believe it or not these are just some of the wacky products we use in everyday medi-cine. Ben Chandler takes a trip to the pharma-ceutical zoo, to uncover some of the strangest uses of animal parts he can find.

• PIGS

Pigs have the misfortune of having similar sized organs to humans and being readily available. Porcine tissues are already used throughout nu-merous fields of medicine and the humble pig is felt to be one of the best candidates for fu-ture production of organs for transplant into hu-mans. Among the many porcine derived prod-ucts include:Heparin - One of the oldest drugs still in cur-rent use, heparin was initially extracted from dogs liver. Controversy was sparked in the USA in 2008 when a number of patients suffered adverse effects from heparin with numerous

deaths. When the drug was traced back to its sources it was discovered that some of the hep-arin was extracted from pig intestines on small unregulated farms in China. A potentially ex-tremely expensive lawsuit is ongoing. Insulin - Although newer insulin formulations are human insulin, porcine insulin is still avail-able. It only differs from human insulin by a sin-gle amino acid - another example of how geneti-cally similar we are to pigs!Pig skin - Aside from being a key ingredient in pork scratching production, pig skin is also used in some special wound dressings.

• MAGGOTS

Observers noted over a hundred years ago that maggots did a great job of cleaning wounds and that soldiers who had maggots in their wounds seemed to be more likely to survive. The inven-tion of penicillin stifled interest for a while but with the advent of drug resistant bacteria mag-gots are back.

• LEECHESAnother medieval sounding treatment that is also making a comeback. Leeches have been used for over 3,000 years and modern medi-cine still finds them useful. Historically leeches were used to treat many ailments but today their use is mainly in plastic surgery to extract blood from swollen grafts. Unlocking the components of leech saliva has also given a new range of an-ticoagulant medications.

• SALMON

Possibly the most surreal use of an animal prod-uct. Protamine sulphate is derived from salm-on sperm and it is used to reverse the effect of heparin. It is associated with some nasty side ef-fects when injected.

• bEES

Honey has been used as a medicine for thou-sands of years, and recently has been shown to have antibacterial properties. It may even be a useful weapon against MRSA.

StraNgE mEdicaL productS FROM ANIMALS

18 ANIMALS IN TRAINING

MEDICINEoN thE movEbEGinninGs

The Medicine on the Move Series was born in 2007 when we produced a revision handout on microbiology for junior students at our Medical School. Such was the success of the result we recruited two other authors to contribute to the fast-developing volume. To ensure reli-ability of content, we had a Professor of Infectious Dis-eases review the work and he suggested we submit it for publication. Six years later we have six volumes on the shelves with eight more in development as the series has expanded to cover the breadth of medicine and surgery.

bY mEDics, for mEDicsMedicine on the Move is written with you, the read-

er, in mind. With author teams drawn from our target audience of medical students and junior doctors, we have ensured that the material covered within each volume is designed specifically for use in today’s healthcare envi-ronment. Relevant, concise text, pitched appropriately for those who will use it, has been thoroughly reviewed by our team of Editors and a Consultant in the relevant specialty. This ensures that everything you learn is sup-ported by experience and expertise at the highest level.

UP To DATEAll of our texts are evidence-based, drawing from

national and international guidelines in the relevant

Two former students along with the PCRM were behind the action. Dr John Pippin, spokesperson for PCRM is quoted at the time as saying that “animal use at Johns Hopkins is inhumane and violates Maryland’s anti-cruelty statute”. Despite being faced with this criticism the director of surgery at John Hopkins University has so far refused to withdraw the pig based training lab.

miLitary SErvicE

Trauma and surgery are not the only specialities that use live animals for training procedures. In the US live ferrets have been used in paediatric training programmes for practising tracheal intubation, and live rabbits for paediatricians to learn chest tube insertion. Pressure is mounting on all of these hospitals to stop such practices.

As more medical schools and hospitals stop using live animals in trauma training the focus has shifted to the US military and its use of live animals. As recently as 2009 the US military were using 8,000 live animals a year for training during which the animals would suffer severe injuries for medics to cope with.

Other animal use within military training includes the use of monkeys exposed to chemical agents to observe the clinical signs and response to treatment. The PCRM has obtained videos of this practice via freedom of information acts and posted them on the internet, increasing public awareness.

thE ExpEriENcE

Our ‘patient’ died at the end of the training session. It was giv-en a lethal injection by the attending veterinary anaesthetist hav-ing shown no signs of distress or pain during the procedures.

Seeing this type of training first hand left me with mixed feel-ings. Using live animals for surgical training is illegal in the UK and my description of the experience is based on time spent overseas.

Anaesthetising a sheep to allow training is extreme and requires serious justification. However some procedures and the stressful circumstances in which they may be needed cannot be replicated as well on a mannequin and a live anaesthetised animal may pro-vide the best learning opportunity. The sheep used for this train-ing was also used to provide blood for the microbiology depart-ment and following euthanasia it was used for surgical training and research.

As new working time directives curtail the amount of time spent in training for junior doctors, exposure to true emergencies is reducing and high quality emergency training becomes more important. More acceptable alternatives already exist for much of the training that is done on live animals. As simulator technology continues to evolve the use of live animals will be increasingly dif-ficult to justify but in the mean time some continue to argue that the UK is ignoring an important educational resource too soon.

aNimaLS IN TRAINING

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subject areas. What you read has been referenced against the most up-to-date research and guidance available, with links to the original sources provided in our “Micro-reference” boxes embedded in the text.

GrEAT for ExAmsEach volume has a minimum of 50 self-assessment

questions written according to UK Medical Schools Guidelines which will prepare you for success in your examinations. Extended Matching Questions (EMQs) and Single Best Answer (SBA) problems help you test what you have learned and assess your knowledge in a clinical context. “Micro-case” boxes provide clinical examples to show you how the information you read is applied in real patient care.

innoVATiVE AnD PorTAbLEThe Medicine on the Move Series provides complete

flexibility. All the content is offered in both print and electronic formats, the latter readily accessible through a unique code printed in the book, at a price comparable to print-only resources. This makes the information you want accessible at the touch of a button via our custom-made app, with advanced search capabilities taking you directly to the facts. The books themselves are compact and easy to carry with you on the wards or to refer to at home at your leisure.

concisE AnD EAsiLY AccEssibLEOur books are written in bullet-point style with infor-

mation presented in a clear, concise format. The text is supported with tables, diagrams and clinical images to help you understand the subject whatever your learn-ing style. The series is not intended to replace core texts, rather to bring together the key information you need to pass exams or work in a particular area. Indeed, many junior doctors would never have the time to devote to working through a whole textbook in preparation for a four month rotation, whereas our guides allow quick access to the core knowledge needed on a day to day basis as required. “Micro-fact” boxes highlight key learn-ing points from the text whilst “Micro-print” boxes cov-er some of the fine detail which may be of interest to enthusiasts.

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Rory Mackinnon and Andy Walker on behalf of the Medicine on the Move Series Editorial Team.

Rory Mackinnon is a GP Trainee Year 2 in the Northern Deanery

Andy Walker is a BHF Clinical Research Fellow and Honorary Specialist Registrar in

Cardiology at the University of Leeds

MEdICAL STUdENTSSUPPoRT20

out of programmE timE:Whether it is for the experience of working abroad or to undertake additional research, an increasing number of doctors are deciding to take time out of training. Some feel a need for greater flexibility within their training programme while others use the time to gain a competitive edge in their chosen future career.

Although many may not have previously considered an out of programme (OoP) experience as an option there are a growing number of opportunities to suit a wide range of preferences. Rayna Patel looks at the possibilities.

O ne of the first things to understand when considering an OoP experience are the types of out of programme time which are acceptable. The options available vary between

local education and training boards but four broad categories are currently recognised:

1. Approved clinical training (OoPT)Clinical training might include a higher degree in a subject

allied to medicine and might also count towards your certificate of completion of training (CCT). In the past, these have includ-ed leadership positions, vocational or academic qualifications and overseas posts that are not part of an approved programme. OoPTs require prospective approval from the General Medical Council (GMC) and candidates can retain their national training numbers during this period.

2. Research (OoPR)Most commonly, OoPRs are taken to complete a PhD in an

area of research although they may also be taken for MD or Mas-ter’s degrees. The abolishment of mandatory research for career progression by the MMC was intended to encourage those with a genuine interest in academic medicine and thus raise the quality of research published.

Bearing this in mind, those with an aptitude for research should seriously consider the merits of being able to dedicate a significant period of time to produce worthwhile results. This time can con-tribute to CCT if optional research is stipulated by the relevant speciality curriculum but requires prospective GMC approval to ensure that clinical competencies can continue to be met during this time.

3. Clinical experience (OoPE)OoP clinical experiences may relate to opportunities not offered

by your deanery e.g. experiences of humanitarian situations or posi-tions with the British Council or Voluntary Service Overseas (VSO). Overwhelmingly, trainees are keen to supplement their training with time spent abroad, and this is usually recognised by employers as a valid and useful means of expanding your medical expertise by prac-tising in differing healthcare organisations and structures.

OoPEs will not count towards CCT. Nevertheless, for exam-ple, OoPE time as a locum consultant, while not being credited for CCT, can provide invaluable support for subsequent career progression.

4. Planned career break (OoPC)Planned breaks are no longer considered to be the career trans-

gression that they once were. Although these will not count towards CCT. Such breaks may include domestic responsibilities, work in industry or time to deal with a period of ill health. Dura-tion is usually limited to two years. Longer OoPCs may require relinquishment of a national training number although they may be granted in exceptional circumstances.

ORGANISATION OF OOP TIME

When to take OoP time during trainingOoP has traditionally been more available to senior trainees

but is increasingly being taken by doctors early in their training. NHS guidance states that trainees should have completed at least one year of their training programme before applying for OoP and must be able to demonstrate satisfactory progress thus far. At least 12 months should be allowed for planning of OoP time. For those wishing to undertake research, this time should include sourcing supervisors and ensuring that intended projects are viable.

Deciding what to doIt is important that you have a genuine interest in your chosen

OoP and that this complements or is at least compatible with your chosen career. Be aware that you will need to be able to justify any time out of programme during applications for your next post. In addition, consider your personal objectives for reaching consultan-cy and whether the OoP time you want may count towards CCT.

Requirements/eligibilityAny time out of programme must be approved by your edu-

cational supervisor or postgraduate dean and the necessary forms completed (see www.medicalcareers.nhs.uk). Plans usually need to be finalised at least three to six months in advance of the start date, depending on the Deanery.

Brought to you by

“BE AWARE ThAT yoU WILL NEEd To BE ABLE To JUSTIfy ANy TIME oUT of PRoGRAMME dURING

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MEdICAL STUdENTSSUPPoRT 21

Support4Doctors is an online portal of information for UK doctors. It o�ers specialist advice and support for doctors and their families on career, health and financial issues. The site also o�ers a database of organisations that can provide further help.

The Royal Medical Benevolent Fund is the leading UK charity for doctors, medical students and their families. The RMBF provides financial support, money advice and information when it is most needed due to age, youth, ill health, disability and bereavement.

The RMBF aims to make a real di�erence to the lives of doctors and their families in times of need. The role of the RMBF is to help beneficiaries to become independent and self-su�cient again wherever possible, whilst maintaining longer term support for those for whom this is not possible.

The RMBF also aims to make a real di�erence in the lives of medical students and their dependants facing financial hardship due to unforeseen di�cult circumstances.

The RMBF is committed to leading the way in providing support and advice to members of the medical profession and their dependants. To find out more about the work of the RMBF, or how you can get involved visit the RMBF website.

Registered o�ce: 24 King’s Road, Wimbledon, London SW19 8QN.

A charity registered with the Charity Commission No 207275. A company limited by guarantee. Registered in England No 139113

www.rmbf.org

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For those organising time out of specialty training, the ‘Gold Guide’ produced by MMC provides information regarding exam-ples of approved OoP experiences and the relevant application pro-cesses. Two years is normally the maximum time allowed out of training (three years if undertaking a PhD), and at least six month’s notice must be given before your return to the training programme.

FundingIncreasingly, funding is becoming notoriously difficult to

secure and the effect on earnings and your pension should be clear before you embark on any OoP time.

Is OoP for me?Deciding to take time out of programme shouldn’t be under-

taken lightly. In addition to the financial considerations, poorly planned or executed experiences can be detrimental to your career in the long-run. Equally, well-thought out OoP time can be huge-ly beneficial in both professional and personal capacities. Allow-ing sufficient time to consider the available options and make an informed decision is crucial in achieving the experience you want.

rEfErENcES

Modernising Medical Careers NHS website. Accessed on 21 June 2013 www.medicalcareers.nhs.uk/postgraduate_doctors/out_of_programme_opportunities.aspx

MMC Gold Guide 4th edition June 2010. A Reference Guide for Postgraduate Specialty Training in the UK. Accessed on 21 June 2013 www.mmc.nhs.uk/pdf/Gold%20Guide%202010%20Fourth%20Edition%20v08.pdf

proS coNS

•ADD GREATER FLExIBILITY AND VARIETY TO YOUR TRAINING

•TIME TO REKINDLE INTEREST IN YOUR CHOSEN SPECIALITY

•DEMONSTRATE EARLY COMMITMENT TO A PARTICULAR SUB-SPECIALTY

•MAY CONTRIBUTE TO CCT

•APPLYING FOR YOUR NExT POST AS A MORE WELL-ROUNDED, ExPERIENCED, AND THEREFORE EMPLOYABLE, INDIVIDUAL

•PLANS THAT FALL THROUGH OR PROJECTS THAT NEVER REACH COMPLETION MAY BE DIFFICULT TO ExPLAIN LATER ON

•GREATER DEGREE OF ORGANISATION AND DECISION-MAKING REQUIRED IN COMPARISON TO PROGRESSING THROUGH A CENTRALLY-ORGANISED TRAINING PROGRAMME

•REQUIREMENT OF LONG-TERM SELF-MOTIVATION AND LESS TEAMWORK, PARTICULARLY FOR RESEARCH POSITIONS

•POSSIBLE DELAY IN REACHING CCT AND THEREFORE CONSULTANCY

Wesleyan Medical Sickness is a trading name of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Ltd is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham, B4 6AR. Telephone calls may be recorded for monitoring and training purposes.

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fINANCE 23

W hether you’re thinking about climb-ing onto the housing ladder for the first time, gradually moving up it

or buying a property as a buy-to-let invest-ment, it is important to get the right kind of mortgage to suit you and work out the best way to repay it.

CHOOSING A MORTGAGE

There are a variety of mortgages available and the size of the loan, the deposit you’ve saved, your income and other personal cir-cumstances will all play a part in which one you choose.

Two of the most common types of mort-gage are:

• Fixed rate – These have a set level of in-terest for a designated period of time. Many first time buyers prefer this type of mortgage as it helps them to budget more effectively.

•Variable rate – Borrowers who are able to adjust their budgets to cope with changeable payments may decide they would be better off with this type of mortgage, which falls into two main cat-egories: Trackers and Standard Variable Rate (SVR).

Interest rates on tracker mortgages typi-cally move up or down in line with the Bank of England base rate. This benefits the bor-rower when the rates fall but payments will rise when rates go up.

With SVR mortgages, each lender sets its own rate of interest and these can go or down depending on market forces.

Those looking to use a property as an in-vestment may choose a buy-to-let mortgage. These work like a standard mortgage, but lenders take into account your income, as

well as potential rental income, when decid-ing how much they will lend.

HOW TO REPAy

Once you have decided on the kind of mortgage you want, you need to consider how you will repay it. Two of the main op-tions are repayment or interest only.

If you opt for repayment, it means that over the length of the mortgage you will eventually pay off the full amount borrowed plus interest. Interest only is where you pay off the interest element only as it accrues each month. The payments will be lower, but at the end of the mortgage term you will still owe the amount you originally borrowed, and most lenders will insist you have a strat-egy in place to pay this off.

bUy-TO-LET

Property can also be a good long term investment. According to Halifax House Price Index, over the past ten years the av-erage house price has risen by 29% and over 20 years by 168%. Growth like this could be one of the reasons why almost a quarter (23%) of doctors surveyed by Wesleyan, say they are investing the majority of their mon-ey in bricks and mortar.

Those investors who buy a property to then rent out to tenants traditionally take out buy-to-let mortgages. These are normally interest only and generally the cash from the sale of the property is used to repay part or all of the outstanding amount.

If you have a large lump sum to invest and are considering building up a buy-to-let portfolio, you might want to consider using the cash to put deposits on a number of dif-ferent properties.

Having more than one property to rent

will help minimise your exposure to risk, so if one property is vacant, rent generated from the others may help cover it. As the economy recovers, there could be long-term returns if property values increase.

There are however tax implications for buy-to-let investors. HMRC regards any in-come that comes from rental properties as investment income, so it can be subject to income tax at 20%, 40% or even 45%. How-ever, landlords are able to deduct costs from the taxable portions of their rental income. These can include the interest of their buy-to-let mortgage repayments.

PROTECTION

When you become a home owner, pro-tecting your income becomes essential as you’ll want to ensure you can keep up mort-gage repayments if you fall ill or are unable to work for any reason. An income protec-tion plan will pay you a regular tax-free in-come at, typically, 50% of your pre-incapac-ity earnings until you are able to return to work. If you have a family you may want to consider taking out a life assurance policy in-corporating critical illness cover. These poli-cies will pay out a lump sum if you are diag-nosed with a defined medical condition or if you die. This lump sum can be used by you or your dependents to pay off the mortgage.

CONCLUSION

Buying a property, whether it’s to live in or as part of an investment portfolio, can be time consuming and stressful. You might want to take guidance from a financial adviser to ensure you find the right mortgage to suit your needs. Check that your adviser can make a comprehensive analysis of the market and isn’t restricted to a small number of providers.

Specialist financial services for doctors

0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk

• Savings and Investments

• Retirement Planning

• Life and Income Protection

• Mortgages

• Motor, home and travel insurance

Wesleyan Medical Sickness and Wesleyan for Professionals are trading names of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Limited is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham B4 6AR. Telephone calls may be recorded for monitoring and training purposes.

Motor, home and travel insurance is arranged by Wesleyan for Professionals.

focus on finance - in association with Wesleyan Medical Sickness

CLIMbING ON TO THE propErty LaddEr

The above information does not constitute financial advice. If you would like more information or need specialist financial advice, call Wesleyan Medical Sickness on 0800 358 6060 or visit the website at www.wesleyan.co.uk/doctors.

dIARy24

W as my dream of becoming a doctor over? Having finished all my interviews, I felt as though I hadn’t expressed my true self and had perhaps wasted a lot of my time. All I

could do to find out was wait. And wait. And wait. And then wait some more.

In the meantime, I had Assessed Practicals to contend with which would count towards my final A level grades. But nothing could take my mind off the constant worry hanging over me about whether or not I would receive an offer.

I knew that I would be lucky if I did receive an offer – to get one offer to study Medicine in 2013 is very lucky, two is rare and three is virtually unheard of due to the large number of applicants compared to places. However, it seemed everyone else I met who was hoping to study any other course had five offers. Yes, five. You can’t even apply to five medical schools! Every time someone greet-ed me, whether they were family, my peers or my teachers, their first sentence would be “How many offers do you have?!” followed by a superior expression when I had to reply that I was still waiting.

School life monotonously carried on, packed with yet more Assessed Practicals. I didn’t hear from any of the medical schools, although I was vainly hoping but not really expecting to. As I had nothing to aim towards, I slowly felt my motivation draining away.

One day, feeling tired and weary, I was sat in the Sixth Form Café with my friends comparing UCAS emails. Suddenly, I real-ised I had an unopened UCAS Track email. Thinking it must have been an old one, I opened it to see that it was dated only a few minutes before. I froze, staring at my phone… “Dear Miss Bar-berio, Something has changed on your UCAS application”. Stu-pidly, I blurted it out to my friends whose shock and excitement only made the overwhelming tension that I was feeling worse. “It’s going to be a rejection, don’t get excit-ed”, I kept saying. I clicked the link and time seemed to slow as the page loaded, taking what seemed like forever, whilst my friends watched the screen, will-ing it to hurry up. Final-ly it loaded and I typed my password and 10 dig-it ID number that was deeply ingrained into my head from desperately

checking my application every day. I held my breath as the next page also took forever to load…

“It’s so hard to get in, I didn’t do well enough in my interviews, I’ll have a gap year and just try again”, my thoughts whirled round in my head. “It’s going to be a rejection, it’s going to say ‘Unsuc-cessful’”, I repeated to my friends.

Finally, the page loaded. All I could see was one little word next to the name of my favourite university. One little word that meant so, so much to me. ‘Conditional’.

Collectively, we screamed and then they were hugging me and cheering while I was squealing like a lunatic. I could not believe my luck. When I’d finally calmed down enough to talk, all I could say was “I don’t believe it, I thought I had done so badly!”

After joyfully explaining the reason for our outburst to the shocked dinner ladies, I went out to call my mum who was equally ecstatic. I waited until my Dad came home that night to tell him, so I could see his reaction in person when he asked how my day was and I could reply that it was the best of the year so far. The jump-ing, hugging and screaming could then continue.

However, at the moment nothing is certain. I have to achieve A*AA in Biology, Chemistry & Physics, an offer which few Medi-cal Schools give out, most others giving just AAA.

Although I worked my socks off for the exams, I found them particularly hard on the day. So getting the grades that my offer demands seems unrealistic. I am writing this five days before results day and today is the day that the universities know the results… The thought that they know whether I have got in or not and I don’t is unbearable! If I don’t get in, I will reapply and then make the most of a gap year, hopefully travelling to foreign countries to

do work experience in different healthcare systems, as well

as trying to do more work experience in

England.So, yet again,

I am waiting. I hope that like my last period of waiting, it will end with a hap-py outcome, but who knows? I’m keeping all my fingers crossed!

thE WaitiNgMy JOURNEy TO bECOMING A DOCTOR:

Sixth former Carla Barberio dreams of being a doctor. We were all there once struggling

with exams, trying to perfect UCAS forms and longing to swing a stethoscope around our necks. In this column we join Carla as she

awaits to hear if she has an offer for medical school.

Finally, the page loaded. All I could see was one little word next to the name of my favourite university. One little word that meant so, so

much to me. ‘Conditional’.

Carla Barberio

hoSPITAL MESS 25

Arrange a loan before you attend an outpatients appointment at,

£7.80 Royal Free Hospital, London

Skip the bus at,

Free University Hospital Crosshouse, Ayrshire

Good for your health but not your pocket at,

50p Whipps Cross Hospital, London

Munch-tastic at,

40p Royal Derby Hospital, Derby

Enough to make you choke at,

60p Royal London Hospital, London

Watch your arteries at this price,

53p University Hospital Crosshouse, Ayrshire

Next issue we’re checking the cost of a mince pie, hot chocolate and box of Lemsip. Email prices to hospitalconfidential@juniordr.com

W hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular

column of the best and worse hospital essentials you’ve reported:

What it’s got - Sky HD on 42in high def plas-ma, wireless 16Mb broadband, leather sofas, lava lamps, 3 computers in separate computer

room: 2 for all access broad-band. Kitchen with dishwash-er, microwave, basic food - bread, tea, coffee, biccys etc usually topped up. Separate chill out/quiet room (with a few old sofas!). £10/month.

JuniorDr Score: ★★★★★

Four hours of parking

Packet of ready salted crisps toast

‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.

Writing in the Notes

campaign for hospital messes

Dear Editor,I was glad to read that junior doctors at Ain-

tree University Hospital managed to get their

rest rooms reinstated (Junior doc rest rooms re-

open at Aintree Hospital; Iss 29; p4) but it’s a

much wider problem. The medical director in

your article said it’s not safe for tired junior doc-

tors to drive home after a shift and he’s com-

pletely right. Lorry drivers aren’t allowed to con-

tinue to drive after they’ve been working long

shifts and it’s not safe for us either. We need a

bigger campaign to keep rest rooms and messes

open so junior doctors remain safe.

dAvId (SURNAME WIThhELd)

fy2 MANChESTER

uk messes in a messDear Editor,

I read your recent article about the closure of hospital messes (Junior doc rest rooms re-open at Aintree Hospital; Iss 29; p4) and it seems to be an issue recently in all the places I’ve worked. Hospital messes seem to conveniently get closed due to building work or re-organisation. Where we get rest rooms in exchange they were either in some obscure and far flung part of the hos-pital or not suitable for more than one person. Hopefully now that hospitals have to compete for trainees that might improve facilities.dR S ShARMA CT4, LoNdoN

priNcESS aLExaNdra hoSpitaL, HARLOW

death of intercalation

Dear Editor,Is there a reason why we should be worried

about the gradual decline of intercalated degrees?

(Worries over intercalation; Iss 29; p6) Spend-

ing five years at medical school is surely enough.

Acquiring a further qualification that most often

bears no real benefit to your future career is sim-

ply popular as it adds another line to your CV.

Let’s get trainees into clinical practice sooner,

help them understand where they’ll specialise

and then get them to acquire useful additional

qualifications.K KUMAR

ACAdEMIC fELLoW, LoNdoN

An apple

EvENTSdR.CoM26

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MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

n We are committed to the value of education and training. We have a dedicated educational services department with a team of more than 100 people organising and delivering educational interventions to healthcare professionals worldwide.

n Using our wealth of knowledge and experience we have developed a range of education and risk management resources that will assist members in reducing their exposure to complaints and claims. The portfolio available includes:

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The Medical Protection Society Limited – A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS, UK. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.

The right choice for Education and Risk ManagementWe are committed to helping you avoid problems and provide the best care for your patients

Members can find out more about the support we provide by visiting: www.mps.org.uk/JuniorDr

Non-members can sample some of our support and publications by registering their details at: www.whymps.org.uk