Welcome

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Welcome IntroductionDebbie KendallProject
DirectorJD Advisory Team
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Professor Jacky HaydenPostgraduate DeanNW
Deanery
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Welcome

• Professor Jacky Hayden

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Working and training in a 48 hour week

• For safe patient care trainees need
• Working patterns with time to hand over patient
  care in the presence of a senior clinician
• Graded supervision throughout the 24 hours
• Time to reflect, think and discuss

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Working and training in a 48 hour week

• For effective learning trainees need
• Clear post descriptions matched to the curriculum
• Work experience that will deliver the agreed
  competencies
• Graded supervision
• Time to reflect, think and discuss

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Working and training in a 48 hour week

• To meet the goals of the curriculum without
  prolonging training trainees need
• Minimal time spent on empty tasks
• Sufficient clinical and leadership opportunities
• Effective use of their time with their clinical
  supervisor
• Effective educational supervision with clear goal
  setting

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Working and training in a 48 hour week

• Graded Supervision
• Fellows junior doctors are assigned
  incrementally increasing responsibility and
  independence during their training, appropriate
  for their demonstrated level of competency and
  professional development (as assessed by the
  supervising physicians)
• (University of Minnesota)

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Working and training in a 48 hour week

• It is every ones job to ensure that we have safe
  care for patients today and safe care for
  patients in the future

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International RecruitmentMr Pramod Luthra,
Associate Dean Dr Chris Till, Head of School,
Anaesthesia
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MTI and Anaesthesia in the North West

• Chris Till
• Head of School
• North Western Deanery

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Where are we now?

• Multiple vacancies on ST3 rotation

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Why do we have vacancies?

• MTAS/MMC
• Run through trainees not completing ST2 in time
• Once a year August recruitment
• SpRs get their CCT throughout the year
• No need for period of grace
• No suitable candidates to fill LAT posts
• Limited number of ST3 training opportunities

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How can we fill these training posts?

• LAS
• LAT
• More rounds of ST recruitment
• Let the trusts fill them locally
• Let trainees do locums (48 hour compliance)
• Tier 2 recruitment
• Tier 5 MTI recruitment

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The Differing View

• Gaps in the rota are service problems
• Gaps in rotas affect training opportunities
• Gaps should be sorted out locally
• Gaps should be coordinated centrally

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NW School Plan

• MTI route (2 year specified training)
• Coordinated school recruitment
• Split into 3 sub-regional sectors with rotations
  in each sector
• HR/employment issues led by one host trust in
  each sector
• Recruitment company facilitated

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What is needed?

• Clinical Director engagement
• College Tutor engagement
• Deanery support
• RCoA support
• No detriment to local trainees
• MTI trainees treated as trainees and not rota
  fodder
• Guaranteed return after 2 years

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Achievable?

• Trust support
• School support
• Deanery support
• ?RCoA support
• ?Time frame
• ?Cost
• ?Method of recruitment

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Moving On 8 October 2008
Pramod Luthra Associate Postgraduate Dean North
Western Deanery
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Vacant posts

• Unfilled training posts within a training
  programme
• Vacant non training posts

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UKBA Points based Tier system for leave to
stay, work and or train in UK

• Tier 1
• Tier 2
• Tier 3
• Tier 4
• Tier 5

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Tier 1

• Tier 1- is points based (29 Feb 2008)
  Do not require a job offer
• Restricted- employment but not for training
• Unrestricted

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Tier 2

• Require the Resident labour market test
• If employing UK graduate (non UK or EEA resident)
  do NOT need RLM
• If already in training before 28 Feb 2008 and
  have job can employ without RLM
• New spouse visa cannot work in training job
• Sponsor employing Trust

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Tier 3

• Tier 3 for temporary workers, not for doctors.
  Suspended indefinitely

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Tier 4

• Tier 4 UK Med school graduate doing
  Foundation training- student visa
• Covered by FPO letter
• Does not require Deanery input
• (flexible training being looked at- re duration
  of stay)

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Tier 5

• Covers Doctors on MTI scheme
• Sponsored by NHS Professionals
• Require Trust, College/specialty and Deanery
  involvement

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Medical Training InitiativeNHSP-055

• Support for the Application of a UKBA Certificate
  of Sponsorship under the Tier 5 Government
  Authorised Exchange
• Document is to support application to be made by
  the Employer to the National Sponsor to allow the
  following doctor from Overseas to undergo
  training in the UK for a period of no longer than
  24 months under the above Scheme

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• Name of post International Training Fellowship
• at ST3 (ST4 Paeds Psychiatry) or above
• For a maximum period of 2 years
• Will not lead to award of CCT

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• Part 1 - to be completed by the Employer and
  Supervising Consultant
• Part 2 - to be completed by the Deanery
• Part 3 - to be completed by NHS Professionals.

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Deanery section requires

• Evidence of Funding
• overseas scholarship - letter from the overseas
  body awarding the scholarship
• NHS Salary letter from Trust offering contract
• This must confirm funding will be appropriate to
  level of post appointed to

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Professional Educational

• From Royal College/specialty letter or email.
• Letter confirming provision of education and
  training from TPD and DME
• Copy of educational contract work plan- matched
  to
• Will be offered formative summative appraisal

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GMC

• Evidence of GMC registration approval (email
  Inviting the migrant to attend an identity check
  is sufficient).
• GMC registration (PLAB).

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Effect on training programme

• Confirmation letter from TPD and DME post will
  not diminish the training opportunities available
  to the
• specialty programme trainees
• other trainees in Trust

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Working time New Deal compliance

• Copy of provisional timetable demonstrating
  compliance with New Deal

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MTI scheme application

• The application and/or supporting letter from the
  Trust along with the above should be posted to
  the Deanery or emailed,( if there are pdf copies
  of the documents), to -
• Emma James, Education Manager,
  e.james_at_nwpgmd.nhs.uk and
• Pramod Luthra, Associate Postgraduate Dean,
  p.luthra_at_nwpgmd.nhs.uk.

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The Resident Consultant ModelMr Matt
BluckChildrens Young personsNetwork
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Resident Consultants? Matthew Bluck 8th October
2009
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• What does it mean?
• Consultants who spend their on-call duties
  resident in the hospital
• Unfortunate title
• Alternative meanings of Residency
• Consultants undertaking a role which is perhaps
  not aligned with the traditional ideas of what a
  consultant should do

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• A New Idea?
• No!
• Happening all over the country
• Small or geographically isolated units
• Illustration of commitment to deliver care
• Formalised agreement and appropriate remuneration
  may be new, as may the introduction across a city
• Royal Free

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• Why do we need Doctors?
• Medicine is developing and moving forward
• Nursing and Professions Allied to Medicine are
  moving forward
• But they are fundamentally different

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• What about New Ways of Working?
• What / where is the value?
• Trained doctor vs untrained doctors vs nurses vs
  AHPs
• Trained doctor untrained doctors nurses
  AHPs
• Qualified multidisciplinary team
• This IS a new way of working

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• What about Current Consultants?
• High value in non-resident tier
• Consultant networks
• Governance
• Clearly defined

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• What Prompted the Idea?
• EWTD?
• New Deal?
• Quality International practice
• Clinical incidents in August and September
• Support in hospitals overnight
• 24 hour specialties Obstetrics / NICU / PICU

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• What About my Family?
• Expert if possible the Expert
• Expert fully trained fully qualified doctor
• Expert fully trained fully qualified nurse
• Expert fully trained fully qualified AHP

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• What have we been doing?
• Cells of 11
• Unfilled posts
• EWTD compliance
• Reconfiguration

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• What are we doing?
• Making it Better
• Provide care at home, or care closer to home,
  wherever safe and appropriate to do so
• Safer services by concentrating specialist staff
  and expertise in fewer, bigger units
• Standardised neonatal service with improved
  staffing levels. Regional neonatal intensive care
  services

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• What is the configuration?
• Community Paediatric Nursing Teams
• 8 In-patient Paediatric Units
• 8 Obstetric Units
• Co-located Midwifery Led Units
• ? Standalone Midwifery Led Units
• 3 Level 3 Neonatal Units
• 8 Level 2 Neonatal Units

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• What are the outcomes?
• What started as a Safety issue
• Became a compliance issue
• Returned to a safety issue
• Weeks of nights
• 56 / 72 hour working weeks
• gt72 hour working weeks
• EWTD compliance is now a by-product of this model

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• Conclusion
• EWTD is actually about safety
• NHS North West, The North Western Deanery and the
  Children Young People and Families Network
  spotted this
• Clinical Leads supported the changes
• Well the majority

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• The Challenge Ahead
• Acceptance of the model
• The detail
• Fixed vs unfixed night duties etc
• Working with other grades on the resident tier
• Managing other grades on the resident tier
• Job planning
• Career progression

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• The Challenge Ahead
• The changing workforce profile

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Any Questions? For further Information please
contact Matthew Bluck Principal Consultant,
Teamwork Management Services mbluck_at_teamwork-ms.c
o.uk or Halcyon Edwards Associate Director,
Greater Manchester Children, Young People and
Families Network halcyon.edwards_at_Northwest.nhs.uk

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North West RosteringDr Jenny Harrop Deputy
Project Director, JD Advisory TeamwithDr Jon
Bright Anna Finbow
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North West Rostering

• A solution for complex rota management within
  working time regulations

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A Collaborative Approach
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Identifying the need!

• Recognising the team within a rota
• Working with EWTD New Deal
• On call vs. daytime staffing requirements
• Auditable rostering with a comms facility
• Management of Annual Study leave
• Real time consequences of those actions
• Anticipate and alert future issues

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Rota Work Flow
Rota Design
Population
Monitoring
My Ward My Team My Shifts My Swaps
Management
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Management??

• Doctors names, Grade Rotation dates
• Bleep and phone numbers
• Emails
• On call lists for switchboard/acute areas
• Leave approvals
• Swaps
• Locum availability

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Live Demo

• Administration pages
• Ward, team, doctor views
• Individualised rota per doctor
• Proformas for swaps

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Hot Cold RotasDr John CoakleyHomerton
University Hospital
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Hot and cold rotas

• Dr JH Coakley MD FRCPMedical Director and
  Intensive Care ConsultantHomerton University
  Hospital NHS FTHomerton RowLondon E9
  6SRjohn.coakley_at_homerton.nhs.uk

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Homerton University Hospital

• 550 beds (300 acute medical) in Hackney
• Emergency care predominates (106,000 AE, 160,000
  OPD, 35,000 IP, 5,000 births)
• Medical take 25 40 patients
• Surgical take 8 10 patients
• Orthopaedic and urology take small numbers

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Night staff August 2003
5pm
10pm
12mid
8am
11pm
Medical PRHO Medical PRHO Medical SHO Medical
SHO Medical SpR Surgical PRHO Surgical
PRHO Surgical SHO Surgical SpR Orthopaedic
SpR ITU SpR Anaesthetic SHO Clinical Site Manager
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Night staff October 2003
5pm
10pm
12mid
8am
11pm
Medical PRHO Medical PRHO Medical SHO Medical
SHO Medical SpR Surgical PRHO Surgical
SHO Surgical SpR Orthopaedic SpR ITU
SpR Anaesthetic SHO Clin Site Manager Clin Site
Manager
Oncall from home
Oncall from home
handover
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Reality check - EWTD 2009

• Continuity of care by individual juniors is dead
• We therefore have to introduce continuity by
  system and/or team
• We have to get as many people away at night as
  possible
• We cannot afford to lose continuity of training
  either

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Total football..
Put simply, it means all 10 outfield players in a
team are comfortable in any position. So if a
defender wants to go on a mazy run towards goal,
a midfielder will fill in for him at the back -
and stay there. It may sound crazy, but it was a
style of play that made Holland the greatest side
of the 1970s.
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Whats the vision for emergency care?

• 98 in 4 hours basic minimum acceptable
  standard
• Emergency care delivered across boundaries by
  specialists who are interested and committed
• Set up cold team and hot team for training
  and service delivery
• Over time (say five years) integration of acute,
  emergency and critical care medicine to provide a
  seamless service
• Improve training while complying with EWTD 2009
• Extend consultants normal working day -

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Taking Care 24/7 how we ran it

• Project Board meetings every 2 weeks
• Medical Director
• Operations Director
• Clinical Director of Medicine
• Director of PGME
• Associate director of HR
• Junior doctor representative
• Senior nursing representative
• Project manager
• Representative of NWP

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Taking Care 24/7 - obstacles

• Dislike of change
• Risk aversion
• MMC
• EWTD
• Custom and practice
• the college says.
• the dean says.
• my boss says.
• Im not covered to.

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Taking Care 24/7 - enablers

• Dislike of change
• Risk aversion
• MMC
• EWTD
• Custom and practice
• the college says.
• the dean says.
• my boss says.
• Im not covered to.

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Taking Care 24/7 - enablers

• Communication
• Medical Council, Directorate Boards, Clinical
  Board, Postgraduate meetings.
• Reference Groups for medical and nursing staff
• Discussion documents e-mailed
• E-mail discussion encouraged
• Homerton Life CEOs Brief etc
• Lots of corridor and canteen conversations
• People can still hear the wrong message

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Acute Care Unit

• 56 beds
• Planning based on 48 hour LOS
• Receives all acute admissions in surgery,
  orthopaedics, urology and medicine
• Junior staffing proportionate to emergency
  activity
• Busy!

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Acute Care Team (ACT)

• Consultant led 24/7 team with no commitments
  other than acute care
• Extended normal working hours for acute care
  (including consultants) and improved handovers
• Consider which clinicians are best able to
  deliver the required competencies
• Integrate delivery of acute care across
  specialties
• Develop sustainable acute rotas

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Acute Care Team

• Consultants (12P, 6S, 5TO, 3U)
• 6 Medical ST 3 or SpRs (AM or EM)
• 8 Medical ST 1 or 2, FY2 (ACCS or AM)
• 3 Surgical ST 2 to 6
• 1 Orthopaedic ST 2 to 6 (0800 - 2200 only)
• 1 ICM ST 1 to 6 (0800 1600 only)
• 6 Foundation Trainees FY1
• CCO
• CSM

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Handovers

• 0800 very brief
• 1030 to discuss PTWR issues ACT
• 1600 brief, to hand over jobs etc from cold to
  hot team
• 2100 for night

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Weekday and night ACT
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Weekend ACT
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Example most FY2 - ST2

• 16 weeks per year acute work
• Full shift for acute work
• Protected training time in cold specialty for
  rest of year no nights no weekends

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Example most ST3

• 12 weeks per year acute work
• Full shift for acute work
• Protected training time in cold specialty for
  rest of year no nights no weekends

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What is the impact on training?

• For a typical junior doctor the time available
  for the delivery of daytime service rose from 52
  of the year to 60 of the year, and the shifts
  devoted to acute care fell from 78 to 60 per
  year. This allows more time to be spent in
  daytime training learning the skills required to
  deliver elective work.
• The costs saved on junior doctors rotas amounted
  to about 0.25m recurrent .

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What worked well?

• Doctors hours
• Relationships between physicians, surgeons,
  critical care and outreach have improved
• Night handover is very good
• Patients seen by a consultant very quickly
• Emergency / elective split works well for cold
  team juniors
• The change in surgical and orthopaedic rotas
  works well for the ED.

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and what didnt

• Stable Medical Leadership daily change of
  consultant (s)
• Junior Doctor Rotas
• too complex
• dont facilitate continuity of care particularly
  for longer stay patients

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Hard to change, easy to stay the same, but

• Don't be so gloomy. After all it's not that
  awful. Like the fella says, in Italy for 30 years
  under the Borgias they had warfare, terror,
  murder, and bloodshed, but they produced
  Michelangelo, Leonardo da Vinci, and the
  Renaissance. In Switzerland they had brotherly
  love - they had 500 years of democracy and peace,
  and what did that produce? The cuckoo clock. So
  long Holly.
• Orson Wells (Third Man)

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Care 24/7 Dr Diana Hamilton-FairleyGuys St
Thomas Hospital
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EWTD A challenging opportunity to improve
careDiana Hamilton Fairley Deputy Medical
Director GSTT
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• Aim

How change to achieve EWTD is an opportunity
to Improve the quality of care for all
patients Improve patient safety through robust
systems based on prioritisation and
competency Maximise training opportunities To
illustrate the changes we have made Compliance
in Cardiac surgery Taking Care 24/7
Team Generic surgical rota
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GSTFT

• Foundation Trust 2004
• Kings Health Partners GSTT, KCL, KCH, SLaM 2009
• Two of the oldest teaching hospitals in London
• 1150 beds
• Guys Hospital mainly elective and tertiary
• St Thomas Hospital Acute and elective
• Evelina Childrens Hospital Acute, secondary and
  tertiary services 120 beds
• 750,000 patient contacts per year
• Annual Budget 680m
• 9000 staff
• Academic Partners London South Bank University
  University of Greenwich
• 2500 Clinical Trainee Placements per year

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• The aim is that patients are cared for day and
  night by
• The right person with
• The right skills at
• The right time
• PATIENT SAFETY

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Changes in Cardiac Surgery

• No SHO grades in training/challenge of EWTD
• New workforce model
• SHOs replaced by
• Surgical Care Practitioners
• Nurse Case Manager
• Pharmacist
• 1 registrar ward-based each week
• The Good - 5 weeks concentrated training
• The not so good - No firm structure

Change is possible without more Drs!
Dissent is OK Keep talking
Dont give up
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Taking Care 24/7

• Improve quality of care for the Acutely ill
  patient
• Separate Emergency from Elective pathway
• And
• Achieve EWTD
• Minimise inappropriate duties for all professions
• Optimise supervision and support of junior staff
• Maximise training opportunities
• Keep costs down (saving of 4.1m recurrent per
  annum)

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Taking Care 24/7 team

• Multi-professional team
• Senior Nurse Practitioners (SNP)
• Doctors
• Physiotherapists
• Clinical Assistant Practitioners / Physicians
  Assistants
• Diagnostics
• Co-ordinated to respond to the patients needs
• Competency based

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East South Wing SNP 2 Cardiology ST1-2
Cardiothoracic ST3-5
H_at_N St. Thomas Hospital (800)The acute site
Evelina Childrens PNP Paed ST3-5 Paed ST1-2
Paed AE ST1-2
North Wing SNP 3 FY1/ PA Periop 2 Anaesthetic
ST3-5 ICU 1 ST3-5, 2 Yr 1-2 Obstetrics 2 ST 3-7,
Yr 1-2, 1 anaesthetist ST3-5 Neonates 1 ST 3-5,
Yr 1-2
Acute Team Covers all areas SNP 1 (Beds) Medicine
ST3-5 ST1-2 Surgery ST3-5 ST1-2 Ortho /
Plastics ST1-2
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H_at_N at Guys Hospital (330)The elective site
SNP 4 Surgical ST 1-2 Renal ST 1-2 Oncology/
Haem ST 1-2 Anaesthetic ST3-5 GCCU ST3-5
Surgery Urology Orthopaedics ENT Thoracics Breast
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In-patient Services at Guys

• ENT / Head and Neck / Maxillo-facial surgery
• Thoracic surgery
• Urology
• Elective Orthopaedics
• Elective Plastic surgery
• Breast surgery
• Oncology
• Haematology including Bone Marrow transplantation
• Renal services
• Transplantation (kidney / bowel / pancreas)
• Guys Critical Care Unit (GCCU)

Single Rota
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Model based on

• Handover x2 per day
• Referral of unwell adults (based on PAR score) to
  SNP
• SATTs assess, treat /or refer
• Priority status 1-5 review
• Clinical management pathways
• Only SNP can call Doctors
• Led by Senior Nurse Practitioners

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Site Nurse Practitioner Skills

• Clinical Skill set
• Core clinical skills
• Prescribing
• Airway management
• Cardiac arrest
• Specialty skills
• Managerial Skill set
• Site management escalate to Exec. Director
• Bed management
• Clinical co-ordination
• Hospital coordination
• Leadership

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Referral by specialty
Activity
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Referral
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Total Calls Received by Time of Day (GUYS 2009)
50
Dec
Jan
40
Feb
30
No. of
Referrals
20
10
0
0800
1000
1200
1400
1600
1800
2000
2200
0000
0200
0400
0600
Time
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HSMR Data 2003-2008
H_at_N
H_at_DN
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PMETB
Training National survey 2008
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Finances

• 2004 PCT uplift 1.5m 7 Doctors, 8 SNPs, 3
  Physios
• Savings from Bandings 6 Specialist nurses, 12
  Phlebotomists
• 2009 PCT uplift 1m 7 Doctors, 5 SNPs, 8 CAPs
• Savings from bandings 3 Specialist nurses, 12
  Physiotherapists

If we had made all the rotas compliant with
doctors the cost would have been 5.5m in
2004 1.5m in 2009
Net recurrent saving 4.5m
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Summary
Changes necessary to achieve EWTD can Improve
the quality of care for all patients Improve
patient safety through robust systems based on
prioritisation and competency
THROUGH

• Multi-professional coordinated teams that
• Promote patient safety
• Maintain training and supervision of doctors in
  training
• Provide clinical career opportunities for
  non-doctor grades

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RCoA Overseas Doctors Training SchemeRichard
BryantThe Royal College of Anaesthetists
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RCoA assistance and suggestions for the provision
of junior doctors

• Richard Bryant
• RCoA Training Examinations Director

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Aims of the Overseas Doctors Training Scheme
(ODTS)

• Assist doctors from overseas to gain GMC
• Registration
• Qualified from outside the UK/EEA
• Proven ability in anaesthesia
• Limited period of specialised training in the UK
• GMC registration - PLAB exemption

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Current RCoA criteria for ODTS sponsorship

• Working / worked within last 6 months outside the
  EU
• Minimum 3 years training in anaesthesia
• 2 structured references from supervising
  consultants
• Offer of a training post prospectively approved
  by the BJA (O)

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Criteria for ODTS posts

• Dept should have the training capacity (ratio of
  Consultants to Trainees should be 11)
• Ideally18-24 months
• Specific aims and objectives
• Same training and supervision as other trainees
  on rotation in the hospital e.g.
• DOPS, Anaes-CEX, CbD, MSF
• Average of 3 attached lists per week
• 6 monthly confirmation of achieving the set
  standards / goals
• The trainee will have an ARCP-like appraisal at
  the end of 12 months
• All of the above to be confirmed by the local CT/
  RA.

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Eligibility for FRCA Examinations

• Sponsored under ODTS - subject to some
  restrictions, are eligible to sit FRCA exams
• Overseas doctors not requiring ODTS (i.e. PLAB
  exemption) - post must have been prospectively
  approved by BJA (O) before commencing. Must
  therefore submit an ODTS application
• Further details available in the exams
  regulations, http//www.rcoa.ac.uk/index.asp?PageI
  D1158

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Medical Training Initiative (MTI)

• Enable International Medical Graduates (IMG) to
  experience UK training
• Maximum 24 months
• Training capacity not required for UK/EEA
  trainees
• Posts to be approved by Deaneries Royal
  Colleges
• Tier 5 UK immigration visa regulations

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MTI - How does it work?

• Role of the Postgraduate Deaneries
• Consult with Speciality Trainers
• Level of training capacity in the region
• Annual
• Posts to be approved by the Deaneries

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MTI - How does it work?

• Role of the Royal Colleges
• Set standards of practice for entry to MTI posts
• Identify potential appointees
• Route into MTI for overseas doctors
  Professional Sponsorship
• Sponsor PLAB exemption for GMC if necessary

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MTI - How does it work?

• Role of NHS Professionals
• National scheme sponsor
• Issue certificates of sponsorship for Tier 5
  visas

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MTI How does it work?

• Joint approach between
• Postgraduate Deaneries
• Royal Colleges
• NHS Professionals
• Support from DoH
• Role of NHS Trusts

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Tier 2 appointments

• Appointments made solely or primarily to meet
  service needs
• Grants Work Permits to doctors appointed to
  service posts which cant be filled by EU
  nationals
• May still need GMC registration but because
  filling service posts, they will not be eligible
  to apply for PLAB exemption via ODTS, UNLESS the
  hospital can satisfy the BJA (O) the post meets
  the ODTS criteria

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Further information

• odts_at_rcoa.ac.uk
• NHS Professionals Medical Training Initiative
  Guide
• www.nhsprofessionals.nhs.uk
• mti_at_nhsprofessionals.nhs.uk
• http//www.ukba.homeoffice.gov.uk/

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• Thank you

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Launching the MTI guide Tim LundSkills for
Health
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Medical Training Initiative

• Moving on Post EWTD Implementation
• 8 October 2009
• Tim Lund
• Skills for Health Workforce Projects Team

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Policy Context for MTI

• NHS policy of self-sufficiency in our workforce.
  Doubled no. of graduates from UK medical schools.
  
• Consultation results on international medical
  graduates supported the policy of
  self-sufficiency and the MTI
• Self-sufficiency should not get in the way of
  supporting the international exchange of clinical
  expertise
• Cant rely on lots more doctors. Smarter
  solutions e.g. Working Time Directive pilots
  programme

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The MTI in Summary

• Designed for overseas doctors to undertake up to
  two years training in the UK
• Operates under Tier 5 of UK Borders Agencys
  Points Based System, Government Authorised
  Exchange
• Supported by stakeholders including a number of
  Royal Colleges, Deaneries, NHS Employers, NHS
  Professionals
• Up to two years of training at present. Academy
  leading efforts to extend maximum period
• Efforts to increase number of MTI doctors to 750

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MTI Roles/Sponsorship in Summary

• Employers identify spare training capacity with
  Deanery and employ doctors on agreed terms
  conditions
• Deanery ensure appropriate training capacity and
  quality is available (without detriment to UK
  medical graduates)
• Candidate doctors express an interest and seek to
  meet eligibility standards ensure immigration
  papers are in order
• Locate eligible candidates assess them against
  College criteria/standards work with deaneries
  to match MTI the doctors with placements or
  provide own sponsor scheme
• NHS Professionals are administrative sponsors for
  the MTI

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Do we need a guide? Recruitment myths

We said there would be a medical workforce
crisis
The MTI solution involves too much paperwork

• Tap hasnt been turned off to international
  recruitment
• Need to demonstrate how the MTI is working well
  in practice

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Benefits of Medical Training Initiative

• Win-Win increased NHS medical capacity and
  doctor returns to home country with better skills
  and experience
• David Grantham Head of Programmes at NHS
  Employers, says the MTI will support
  international development through the sharing of
  knowledge, experience and best practice and
  strengthen reciprocal links
• Robust QA involving Colleges, Deaneries and
  employers etc
• Training motivational for trainers as well as
  trainees
• Very flexible scheme compatible with
  self-sufficiency policy

131
Help Avoid Workforce Planning Feast or Famine
132
MTI Guide Content

• Articles and case studies feature MTI doctors,
  the Royal Colleges, NHS Employers and services
• Top tips and flowcharts help employers and
  candidate doctors through the MTI process
• Summaries of the MTI /international sponsorship
  schemes signpost readers to contact details for
  College leads
• Flyers and a MTI Calling Time article have been
  published
• See our portal www.healthcareworkforce.nhs.uk
  for MTI guide by end of the month

133
MTI Flyers and Calling Time
134
In Conclusion

• The MTI offers flexibility for employers and
  improved skills and experience for doctors to
  return home with
• The scheme is already working in many hospitals
  and there is plenty of scope for expansion
• Time to hear about practical and ethical examples
  from the Royal College of Physicians and Obs
  Gynae leads
• tim.lund_at_skillsforhealth.org.uk
• Tel  [phone]
• Mob [phone]

135
MTI RCP London Matt Foster Naa NoiRoyal
College of Physicians
136
International Medical Graduates and the MTI

• Matthew Foster
• Head of International Affairs

137

• Sponsoring doctors for GMC registration for over
  25 years
• Numbers increasing following introduction of the
  MTI visa
• MTI offers opportunity to strengthen
  international relationships

138

• Valuable training
• Sharing knowledge
• Promoting international collaboration and
  dialogue
• Supporting training in health systems overseas
• Promoting the NHS

139
3 Schemes

• International Sponsorship Scheme
• Clinical Placements Initiative
• Medical Training Initiative

140
ISS

• Facilitates GMC registration
• RCP not involved in placement
• Funding usually comes from outside of the NHS

141
Clinical Placements Initiative

• Facilitates GMC registration
• RCP identifies spare training capacity
• RCP works with partner organisations overseas on
  selection
• Overseas organisation funds scholarship

142
Medical Training Initiative

• Aims to match IMGs to paid NHS International
  Training Fellowships
• RCP has partners overseas who will assist in
  identifying suitable candidates
• Posts must be identified well in advance cannot
  be used to fill locums at short notice
• Posts must provide an appropriate educational and
  training experience

143
Selection

• Partner institution draws up short-list
• RCP representative sits on interview panel
• Selected candidates matched to posts
• Host/supervising consultant

144
Criteria for applicants

• Includes
• Appropriate postgraduate qualification
• 3 years minimum postgraduate experience
• IELTS
• References from Fellows of the RCP

145
Criteria for post

• Approved/supported by Deanery
• Educational approval/support from Regional
  Specialty Advisor or Specialty Advisory
  Committee
• ST3

146

• Cannot sponsor
• service only posts must have educational
  content
• Short term locums doctors should be coming for
  1 to 2 years
• Research elements of postgraduate degrees

147
Applications panel

• Assess applications against set of core
  competencies
• Clinical skills
• communication skills
• interpersonal skills
• Review references
• Assess the post (job description and timetable)
  to ensure
• Training is appropriate to the candidate
• Post contains appropriate educational content

148
Immigration

• UK now has Managed Migration System
• Tier 5 Short term training
• Overarching national visa sponsor NHS
  Professionals

149
Paperwork

• Posts need to be identified in advance
• There is some paperwork involved!
• Easier second time around, once process set up

150
In summary

• Been a difficult few years for IMGs in UK
• Situation improving
• Relationships take time to build
• The MTI can be of benefit to the NHS and IMGs,
  but lead in time needed.

151
Before end of 2009

• RCP will be visiting each region to meet
  stakeholders.
• Work through how the MTI can work for you
• Guidance on process.

152
Contact details international_at_rcplondon.ac.uk0
20 3075 1304www.rcplondon.ac.uk/international
153
MTI RCOG Dr Su ChariRCOG, Morcambe Bay
154
RCOG OVERSEAS TRAINING SCHEME

• INNOVATIVE SOLUTION OR
• The Lancaster experience
• SU CHARI
• RLI

155
Brief Background

• RCOG had run the IDTF scheme for many years with
  success
• IMGs come for 2 years
• GMC Limited registration
• Attachments - SHO for 6 months or SpR for 18
  months
• Rarely did not make the SpR grade
• 70 pass MRCOG approx
• Many IMGs have successfully applied for the
  training programme through NTNs and settled in
  the UK
• Others have returned to their own country or
  emigrated

156
Strengths of the scheme

• High calibre of doctors
• Usually from countries with historical
  connections with the UK
• Arranged via Overseas rep committee
• Access to selected Deanery training posts
• Planned programme of training
• Tailored to individual (sometime country) needs
• Appraisal at RITA and Sponsorship officer

157
2007 changes

• Concern about brain drain
• gt1000 increase in medical school places
• Expansion of EU membership states
• Introduction of Foundation programme and run
  through grade
• Sudden withdrawal of permit free training-after
  limited consultation
• EWTD, reducing working hours, increased
  feminisation of specialty

158
Subsequent Immigration changes

• 29/6/08- several former immigration categories
  closed
• HSMP- closed and changed to Tier 1 (currently
  closed temporarily)
• New Tier 2 for skilled workers in shortage posts
• Tier 5 for temporary workers
• TWES MTI remains

159
Leading to..

• Sudden reduction in available posts for IMGs
• Very few posts at ST12
• RCOG ODTF programme suspended for 1 year and
  restarted in August 2008
• Significant shortage of trainees in all
  specialties to fill in short term gaps bearing in
  mind EWTD etc

160
TWES/MTI Package.

• To enable individuals to gain skills and
  experience or obtain specialist qualifications
• Max 2 year stay in UK
• No extension allowed
• Leaves UK at the end of training
• Repeat applications are not considered within 2
  years
• Not counted toward CCT
• No scope for unpaid/self funded posts
• Cannot take up supplementary employment

161
RCOG Scheme

• ODTF Scheme relaunched from August 2008
• Trainees apply with
• Part 1 MRCOG 4 years of training in OG
• List of competencies
• 2 structured references
• Referees confirm competency checks
• Interview by Chair/member of overseas
  representative committees
• Appropriate IELTS score

162
Selection process.

• Runs exactly like UK Deanery NTN SELECTION
  PROCESS
• Varied and experienced selection panel- STC
  Chairs, TPDs, College tutors, Large/small DGH
  reps
• Each part of application scored by 2 panel
  members and then scores agreed jointly
• All marks added up and top candidates selected
• Agreed cut off points
• Process supervised by senior vice president

163
List of competencies.

• LSCS
• ERPC
• Hysteroscopy
• Diagnostic laparoscopy
• Ventouse and forceps delivery
• (LSCS for prematurity and at full dilatation)
• (Laparoscopy for ectopic)
• No mention of CTG interpretation or FBS

164
Checks..

• Rigorous checks of competency list
• Matched with Referee/Chairpersons assessment
• Cut off point below which applicants are not
  selected
• But applicants are not interviewed by UK
  Consultants
• Potential for interviews during overseas trips
  but not all countries are visited and may be
  regarded as unfair/biased
• May not really solve the problem

165
Latest changes in Feb 2009

• New sub-category of Tier 5 titled- Govt
  Authorised Exchange (GAE) to cover MTI
• NHS Professional National Tier 5 sponsor to
  provide certificate of sponsorship to help with
  visa application and work permit
• MTI extended to include ST5-7 grade to include
  ATSM
• Duration of posts range from 3 months to 2 years
• Provision for posts where salary paid by
  overseas govt suitable for ATSM posts

166
Potential problems.

• Selection process
• Competency checks
• Patient Safety Issues
• Salary/funding of posts

167
Other issues

• With the acute locum shortage, some urgency to
  continue with selection process
• Anticipated high demand for and from IMGs- but
  quality of applicants and competency levels must
  be maintained together with a rigorous selection
  process
• Salary package- imaginative
• Quality of training offered- needs periodic check
• Early identification of ATSM slots
• Competency issue even more profound at ST6-7

168
Patient safety

• Biggest concern!!!
• Limited scope for more than 6 months experience
  at SHO level
• Few suggestions
• Acclimatisation for a min of 2 weeks
• Shadowing programme similar to that for F1s
• Mandatory structured induction programme
• Competency assessment similar to ST3
• ALSO/BSS courses within 2 months
• Communication skills/ consent taking course
• Practical skills training e.g. CTG/FBS
• College based courses before the start of
  attachments

169
Lancaster experience.

• Offered a post on the scheme or unfilled LAT
• Spoke to colleagues and managers
• Biggest challenge was to convince medical
  staffing that they had to apply for the Tier 5
  Visa and not Pennine Acute Trust
• CRB clearance required
• Hospital accommodation
• Post has been filled since the 20th of August

170
Strengths

• Speciality training post filled by a trainee
• Good quality of trainees likely
• Well motivated
• Preliminary assessments done with regards to
  competence levels
• By and large in view of language test
  requirement, language not a problem

171
Weaknesses.

• UNKNOWN QUANTITY..
• Needs to go though SHO job and then Registrar
  training
• Variable quality of assessors
• Variable competency levels
• Needs time to settle into a new home and work
  place environment
• Variable rates of learning

172
Opportunities

• Learning opportunity for both parties
• Can acquire new skills through ATSM
• Can acquire a new qualification
• Building relationships
• Positive effect on the unit and institution long
  term
• Agreed in region if required paperwork can be
  given to appointees

173
Threats..

• Funding
• MONEY!!!!!
• Being paid as a Registrar when they are
  supernumerary
• Need locums at additional costs as the registrar
  slot has to be covered
• Possibly a stipendiary period with free
  accommodation
• Close watch to identify gaps- gap management at
  deanery level with RCOG liaison or the slot may
  be lost for this kind of opportunity

174
Overall..

• Usually College backed schemes are good
• Teething problems
• We will get better at putting things together
  quickly
• Hopefully the applicants will achieve their
  training objectives in the time given
• Rewarding for the trainee and the unit as in this
  Deanery it has been agreed that they stay in the
  same unit
• Long term benefit to the country of origin

175
Acknowledgements.

• Mani DAS
• Andy Watson
• RCOG Overseas Office and personnel

176
Thinking Hats with Mona Stokes
177
Thinking Hats

• The main difficulty in thinking is confusion!

• We try to do too much at once. Emotions,
  information, logic, hope and creativity all crowd
  in on us.
• De Bono

178
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179
Key Questions

• 3 key questions..
• What do you need to know?
• How do you take this forward?
• Where do we go from here?