Are you OK? Coping with the challenges of COVID-19 - rcoa.ac.uk - The Royal College of Anaesthetists
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
July 2020
Workforce update
On-call shifts: lessons for the
'new normal'
A shift in incident-reporting
culture
Are you OK?
Coping with the challenges
of COVID-19
Image © Nina Moore
rcoa.ac.uk
@RCoANews
Bulletin | Issue 122 | July 2020
RCoA Events
NOVEMBER
rcoa.ac.uk/events
events@rcoa.ac.uk
UK Training in Emergency Airway
Management (TEAM)
5–6 November 2020
EVENTS AND COVID-19
@RCoANews Edinburgh Due to the ongoing COVID-19 situation some of these
events may be postponed, cancelled or changed to an
RCoA and SSA Joint Winter online digital version.
Scientific Meeting
A career in anaesthesia 12–13 November 2020 Please keep up-to-date by visiting our webpage:
SEPTEMBER OCTOBER 8 October 2020 Glasgow
rcoa.ac.uk/events
%
RCoA, London
National Neuroanaesthesia and
UK Training in Emergency Ultrasound Workshop
UK Training in Emergency Airway Critical Care Society (NACCS)
Airway Management (TEAM) 5 October 2020
%
Management (TEAM) Neuroanaesthesia CPD conference
21–22 September 2020 RCoA, London
15–16 October 2020 12 November 2020
RCoA, London RCoA, London
Developing world anaesthesia Salford
Anaesthetic Updates 5 October 2020
%
Leadership and management: Clinical Directors Network Meeting
29 September to 1 October 2020 Malmaison, Manchester
%
Leading and managing change 16 November 2020
RCoA, London
Airway Workshop
Anaesthetists as Educators:
Introduction %
16 October 2020
RCoA, London
RCoA, London
DIGITAL EDUCATION AND
%
29 September 2020 6 October 2020
Leadership and management:
PROFESSIONAL DEVELOPMENT
%
Working well in teams and making
%
RCoA, London Anaesthetic Updates
RCoA, London an impact
19–21 October 2020
%
Introduction to leadership and Anaesthetists as Educators: The Studio, Birmingham 18 November 2020
management: the essentials Simulation unplugged RCoA, London
%
%
30 September to 1 October 2020 7 October 2020 GASAgain (Giving Anaesthesia
Anaesthetic Updates
WEBINARS
RCoA, London Safely Again)
The Studio, Leeds 19–20 November 2020
%
23 October 2020
RCoA, London Merseyside Maritime Museum, Liverpool
PODCASTS
Anaesthetists as Educators: non
technical skills (ANTS)
%
20 November 2020 VIDEOS
RCoA, London
Anaesthetists as Educators:
teaching and training in the
%
workplace
24–25 November 2020
RCoA, London
29 September – 1 October 2020
London To view our digital
19–21 October, 2020 offering please visit:
Birmingham bit.ly/RCoAEdProfDev
19–20 November 2020
Liverpool
Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training,
Foundation Year Doctors and Medical Students. See our website for details. Foundation Year Doctors and Medical Students. See our website for details.
%
%
Book your place at rcoa.ac.uk/events Book your place at rcoa.ac.uk/events | 1
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
Contents
The President’s View 4
News in brief 8
Guest Editorial 10
Revalidation for anaesthetists 12
From the editor
Faculty of Pain Medicine (FPM) 13
Faculty of Intensive Care Dr Helgi Johannsson
Medicine (FICM) 14
SAS and Specialty Doctors 16
Welcome to the summer edition of the Bulletin, and it is my sincere hope that by the time you read this I’ll
Patient perspective 18 be on my summer holiday, and that my flight booking won’t have been cancelled. Who knows? Maybe
Psychological consequences of we will be in our back gardens, or worse still back on our full shift systems dealing with a second peak of
COVID-19 20 the pandemic.
Perioperative care: the two
words that could unite our As I write this, the UK is slowly, gingerly, coming out of lockdown, and I’ve just finished my last night shift
health and care service after on the full-shift system we set up to deal with the pandemic. Anaesthetists and intensive care doctors have
COVID-19 22 been at the forefront of treating patients with COVID-19, while still keeping the NHS emergency service
A stroke of luck 24
going for non-COVID related cases. I am proud of my profession, and how we stepped up without fuss,
increased the capacity for intensive care nationwide by an order of magnitude, and delivered excellent
Guest editorial On-call shifts: lessons for the
‘new normal’ 26
care to some extremely unwell patients in very difficult circumstances.
Workforce update Tackling loneliness: the
'Stairs of Doom Challenge' 28
In this edition, Dr Chris Carey writes about the effect on consultants going back to full shift work: the
frustrations, increased uncertainty in our work, but also the improved supervision, teamwork, a flatter
How COVID-19 is shining a light on workforce Developing the next generation hierarchy, and the faster development of new pathways. From my own experience I would echo his
shortages in the NHS of simulation educators 30 comments, and add how antiquated a technology the bleep system most hospitals still use is.
Differential attainment
Page 10 I urge you all to read Daniel Barling’s account of how a 27-year-old healthy man suddenly develops
in anaesthesia – part two 34
symptoms of a stroke, and how as a doctor he instantly knew exactly what was going on, but still had to
When times are tough,
struggle to get the care he knew he needed.
think of chocolate… 36
The President’s View On-call shifts: lessons
A shift in incident-reporting culture 38 At a time when many of us have experienced some truly horrific things, it is incredibly important to focus
Celebrating the second for the 'new normal' Perioperative Journal Watch 41 on the wellbeing of our colleagues and ourselves – whether that be with chocolate (but not doughnuts, I’m
anniversary of Lifelong Learning A thought-provoking glimpse sure), walking up stairs, or improving our sleep hygiene, we have several articles for your perusal.
Why become a
Page 4 into the world of shift work in College FRCA Examiner? 42
the modern NHS We realise that in many hospitals the SAS grade doctors provide much of the day to day (and night to night)
Beyond sleep: exhaustion and care, and I want to highlight the excellent work that our SAS representatives on council Kirstin May and Lucy
Perioperative care Page 26 SAS doctors 44 Williams have done over the last few years, and hopefully for some time to come. Dr May’s article on the job
The two words that could unite Historical plague accounts 46 application process and getting shortlisted contains some excellent advice for doctors of all grades.
our health and care service after A shift in incident- As we were... 48
COVID-19 reporting culture Finally, the reason we do the job we do is for our patients and it is vital we see what we do from a different
Letters to the editor 50 perspective sometimes. Our lay representative Lynne Smith provides this perspective and although I’ve
Page 22 Learning from the positives, New to the College 52 always found the profuse expressions of gratitude uncomfortable, thinking of what we have been through
exploring the new systems in the last couple of months they are very welcome. As we take off our plague masks and try to get back
A stroke of luck focusing on what goes right as
Notices and adverts 56
to something vaguely approaching normal we accept the expressions of thanks, but they must never be
Becoming a patient – why getting well as wrong platitudes, and never divert attention from our goal of a fair, equitable, and excellent National Health Service.
ill changed a young doctor’s Page 38
perspective on healthcare
Page 24
2 | | 3
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
Professor Ravi Mahajan
President
president@rcoa.ac.uk
Before you read about your College’s work and
achievements in delivering an online Lifelong Learning
Platform, I’d again like to thank you all for your continuing
commitment, dedication and caring to your patients and
your colleagues during these challenging times.
As I’m writing this in May, there are signs of an easing to the global lockdown and work is
underway across the NHS to begin the resumption of ‘normal’ clinical services. Normal is a
description of our work some of us may think we’ll never see again. While the way we treat
and interact with patients will undoubtedly change, let us use this time also as an opportunity
to change elements of our professional lives we have control of for the better too. Change the
way we work across specialties, across hospital departments and the way we care for ourselves
and our colleagues.
Caring for our careers and our progression is important to ourselves, but caring for ourselves is
important to our families, our loved ones and our colleagues. An NHS Bereavement & Trauma
Line has been established to provide support seven days a week, between 8am and 8pm. All
calls are strictly confidential and no referral is needed. The number is 0300 303 4434.
Thank you again for your help in managing this global health crisis and please ask for help and
support if you need it.
This edition of the Bulletin marks the important development was one of the core deliverables
milestone of two years since the initial launch under the heading of ‘Harnessing the power of
of the College’s Lifelong Learning Platform technology to support our membership, staff
(LLP). This is the online hub which is designed and wider anaesthesia’ in our ambitious Strategic
to support members throughout all stages Plan. The LLP was launched with e-portfolio
of their careers. It features an e-portfolio for and logbook features in August 2018 followed
anaesthetists in training and a CPD online diary by CPD functionality in November 2019, and
The President’s View for non-trainees, plus a clinical logbook which
is available to both types of users.
we continue to make enhancements to better
support professional anaesthetic practice.
CELEBRATING THE SECOND As a College, we wanted to create a platform
that we own and could change as needed so
The LLP had its origins in the College’s
previous e-Portfolio system which had been
ANNIVERSARY OF LIFELONG LEARNING
that we can continue to meet the needs of in use since 2010. Over the years, a number
our members. The LLP is now celebrating its of suggestions were made as to how it could
second anniversary and its delivery as part of the be improved (particularly around the Annual
College’s Technology Strategy Programme. Its Review of Competence Progression process)
4 | | 5
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
which we incorporated into the design Figure 1 Logbook entries by month In November 2019, the LLP was live with all three
Bulletin
of the Royal College of Anaesthetists
of the new platform, and the LLP now functionalities operational and, after a brief transitional phase
contains 61 forms specifically designed for 2018 August 65,613
during which a new external supplier was sourced, the Churchill House, 35 Red Lion Square, London WC1R 4SG
professional development in our specialty 2018 September 77,453
project has now moved into the ‘business as usual’ phase. 020 7092 1500
2018 October 84,173
which can be fully edited and improved 2018 November 78,055
rcoa.ac.uk/bulletin | bulletin@rcoa.ac.uk
2018 December 69,130 The College’s Lifelong Learning team continuously
internally by the Lifelong Learning team. 2019 January 87,079
2019 February 84,719 monitors usage of the platform to ensure that the best user @RCoANews
The new platform offers users more
2019 March 95,789
experience possible is available, working with the suppliers /RoyalCollegeofAnaesthetists
Date created month
2019 April 101,155
permissions, thereby allowing them 2019 May 103,909 and users to remedy any bugs that might arise. While
2019 June 97,959 Registered Charity No 1013887
more control over their own records. 2019 July 86,446 the system has been future-proofed as far as possible,
2019 August 102,938 Registered Charity in Scotland No SC037737
We have also enabled SAS doctors, MTI 2019 September 113,562 there is a documented process in place to formally
VAT Registration No GB 927 2364 18
doctors and ACCS supervisors to use the
2019 October 122,118
evaluate and approve any members’ suggestions for
2019 November 116,158
platform, thereby catering for a broader 2019 December 111,793 further improvement. We have established a LLP Clinical President Hugo Hunton
2020 January 127,782
range of our membership. 2020 February 115,986 Reference Group to support us in making key decisions Ravi Mahajan Lead College Tutor
2020 March 89,207
on functionality and updates as well as to assist with our
2020 April 56,099 Vice-Presidents Emma Stiby
Similarly, the previous CPD Online stakeholder engagement and communications with users.
0 20K 40K 60K 80K 100K 120K 140K Fiona Donald and SAS Member
Diary, which launched in late 2011, Number of logbook entries
The success of a system designed to support members Mike Grocott Katie Samuel
received member feedback suggesting
improvements, including the ability to throughout all stages of their careers can be measured Editorial Board Anaesthetists in Training
from the data on its usage, and we now have the ability to Committee
map activities against the Good Medical Helgi Johannsson, Editor
functionality in-house and to incorporate This was a truly innovative project, and extract meaningful data from the LLP. To date more than
Practice domains and resolution of the Carol Pellowe
it as an integral part of the overall system. 100,000 people have participated via our MSF process, Jaideep Pandit
inflexibility of the activity report used no other medical royal college had Lay Committee
3,000 Milestones have been completed on the platform Council Member
to evidence participation in CPD for previously developed such a system.
In addition, the fact that the College (automatically generating digital certificates for anaesthetists Krish Ramachandran Gavin Dallas
appraisal purposes. This presented some initial development
did not own the intellectual property in training), 25,000 ESSRs have been created, and two Council Member Head of Communications
challenges, although, on the other hand,
Both the e-Portfolio system and the CPD for these systems and was effectively million logbook cases (Figure 1) have been recorded. Mandie Kelly
starting with a blank canvas and with the Jonathan Thompson
Online Diary had served their purpose ‘leasing’ them was a further consideration Focusing on the CPD features, more than 1,500 personal Website & Publications Officer
ability to build into the LLP what had Council Member
for a number of years, but there were to be addressed. The move away from activities are being added and reflected upon each month
previously worked well while removing Duncan Parkhouse Anamika Trivedi
clearly opportunities for improving a charge per user (as had been the case (Figure 2), while the number of CPD-accredited events in
what didn’t and incorporating many of Lead Regional Advisor Website & Publications Officer
them, and this project of the Technology with the former e-Portfolio and CPD the LLP is already in excess of 900. We currently have more
the enhancements suggested by users, than 17,000 users. These include anaesthetists in training, Anaesthesia
Strategy Programme also presented Online Diary) meant that the LLP would
was a great opportunity. consultants, SAS doctors, MTI doctors and doctors on out-
an ideal opportunity to bring logbook be more cost-effective in the long term. Articles for submission, together with any declaration of interest,
of-programme professional activities.
should be sent to the Editor via email to bulletin@rcoa.ac.uk
Figure 2 CPD points and count of activities by deanery Earlier this year we submitted entries for two digital awards All contributions will receive an acknowledgement and
in recognition of the development of the LLP, and to the Editor reserves the right to edit articles for reasons of
1800
1,730 CPD points
Count of activities
celebrate the work that is making a real impact for our space or clarity.
1600 organisation and members. We were shortlisted, however,
the full awards events were cancelled as a result of the The views and opinions expressed in the Bulletin are solely
1400 those of the individual authors. Adverts imply no form of
CPD points and count of activities
1,290
coronavirus pandemic.
1200
1,129 endorsement and neither do they represent the view of
A huge amount has been achieved over these last the Royal College of Anaesthetists.
1000
874 868 880 884
two years, and, while the College remains focused on
817 841
© 2020 Bulletin of the Royal College of Anaesthetists
800
748 continuing to make future upgrades, members can be
690 All Rights Reserved. No part of this publication may be
590 confident that a comprehensive and responsive system has
600
524 540 553
reproduced, stored in a retrieval system, or transmitted in
502
been developed to support them throughout all stages of
405
any form or by any other means, electronic, mechanical,
400 312.5
336.5
their careers for many years to come.
photocopying, recording, or otherwise, without prior
263.5 292
254 257 227.5 244
208.5 200
168.5 164
200 103
51.5 81.5
109
72.5 If you have any comments or questions about any of the permission, in writing, of the Royal College of Anaesthetists.
issues discussed in this President’s View, or would like to
0
East East of Kent, No North North North North Northern Scotland South South Thames Wales Wessex West Yorkshire ISSN (print): 2040-8846
Midlands England Surrey & Deanery Central & East West West Ireland Deanery London West Valley Deanery Midlands & the express your views on any other subject, I would like to hear
Sussex East London London Humber ISSN (online): 2040-8854
Deanery from you. Please contact me via presidentnews@rcoa.ac.uk.
6 | | 7
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
NEWS IN BRIEF
News and information from around the College
RCoA patient New and updated patient Translations of
2019 Annual Review
information information resources patient information During 2019, we made significant advances in
resources Following feedback in the survey to preoperative leaflets many areas of work across the College, both with
assessment leads, we are pleased to announce two and on behalf of our membership. Introducing our
awarded quality new resources to join our main series of leaflets: first Sustainability Strategy, establishing the Centre
kitemark Anaesthesia and your weight (rcoa.ac.uk/media/13781)
and Your airway and breathing during anaesthesia (rcoa.ac.uk/media/13776). We are
of Perioperative Care and reaching a combined
membership of 23,000 are only a few of the
The College’s patient information also working on a new resource called Your anaesthetic for vascular surgery, which we College's 2019 highlights.
resources have been awarded the hope to publish shortly.
Read the full annual report including an introduction from your President and
Patient Information Forum Trusted Chief Executive Officer at: rcoa.ac.uk/annual-review-2019.
In February the full series of joint College/Association of Anaesthetists leaflets on
Information Creator Kitemark (PIF
anaesthesia were updated and can be found on our website at bit.ly/PILeaflets.
TICK). The RCoA is the first Medical
The College is working in partnership
Royal College to achieve this kitemark.
with the international translation
In order to achieve and maintain
the PIF TICK, organisations need
charity ‘Translators without Borders’ COVID-19 Weekly RCoA blogs
to demonstrate a consistent and
robust approach to the production
to provide translations of our most
popular patient information leaflets Updates The College blog page recently had
great input from various sources on
in the 20 most common languages For the time being, the College has put the
of patient information, based on topical issues and discussion points.
CPOC blog series – We may all
used in the UK, including Welsh. monthly President’s member newsletters
requirements such as user involvement, This includes a brand-new series
Patients whose main language is not on hold. During this challenging period,
language, evidence, user testing, called ‘Experiencing the COVID-19
design and much more. The kitemark become patients sooner than we think English can often find communication
with healthcare professionals to be a
we thought it would be best to provide Frontline’ – contributions to this series
demonstrates our commitment to you with succinct weekly updates on address difficult decisions, roles and
Lawrence Mudford, lay representative with the Centre for Perioperative Care, challenge, which can increase anxiety. COVID related news items as well as wider
providing patients, our members and personal anxieties to support frontline
(CPOC) shares his experience of being a cancer patient in a new three-part blog College news. New and revised clinical
the anaesthetic community with the anaesthetists.
series called ‘We may all become patients sooner than we think’ and identifies We hope that these translated guidance, information and support will be
highest quality patient information.
many similarities between preparing for cancer treatment and preparing our leaflets will help our members to top of this list. You can catch up on all College blogs
bodies and minds in the event of contracting COVID-19. communicate better with these at: rcoa.ac.uk/blog.
patients about procedures and risks All COVID Weekly Updates are saved
The three blogs will explore in turn three aspects of preparation – physical on the College website for everyone to If you would like to send us ideas and
and as a result have better informed
wellbeing, lifestyle choices and mental health strengthening. access at: bit.ly/RCoAWeeklyUpdate. contributions, please email
discussions around consent.
ddollinger@rcoa.ac.uk.
All three blogs can be found on the CPOC blog page: cpoc.org.uk/blog
CPOC FAQs for patients having an
New guidance for clinical leads on operation during COVID-19
preparing a job description CPOC has launched a new series of FAQs (bit.ly/2ZExsT1) following the
NHS’ announcement to restart normal surgical services as the COVID-19
The College manages the approval of job descriptions and person pandemic has moved past its peak.
specifications for consultant and SAS grade posts in anaesthesia, intensive
The FAQs aim to address concerns patients may have going to hospital
care medicine and pain medicine. New guidance has been published on
for their delayed operations and to offer advice on how you can best
our website at: bit.ly/AACGuidance2020 to provide advice to clinical
prepare for your surgery.
directors/leads on how to prepare a job description for advertisement.
8 | | 9
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
Guest Editorial of consultant anaesthetists in England
increased by 31%.5 The number of
WORKFORCE
600 556 569 549 542 528
intensivists, most of whom are drawn from
500 477
the anaesthetic pool, increased by 163%. 449
417
In the face of this increased demand, 394
400 357
Number of CCTs
UPDATE
during the period from 2013 to 2019 the
pipeline supply of anaesthetists gaining 300
their CCT dropped by 37% (Figure 1), 200
data provided by the College training
100
department. Unsurprisingly, clinical
directors report difficulties appointing new 0
colleagues. In the 2020 census, which 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
collected data from 96% of departments
in the UK and will be published later Figure 1 Number of CCTs per year – includes dual ICM CCTs data provided by the
Dr Hamish McLure Dr Phil Antill this year, 53% of departments reported College training department
Chair of Clinical Director Executive Advanced Trainee in Anaesthesia that they’d advertised a consultant post
and Member of the RCoA & Intensive Care Medicine, but had been unable to fill it. Of the posts in order to provide the service We’ve trained, re-trained, and moved out
Workforce and Strategy Committee; departments who hadn’t been able
York Teaching Hospital NHS Foundation Trust that was being asked of them. If we of our comfort zone in so many areas. As
Leeds Teaching Hospitals NHS Trust to fill a post, 79% reported a lack of include this ‘aspirational gap’, then the the crisis subsides and surgical services
applicants. The census revealed 676 workforce gap rises to 12%. If we use
workforce@rcoa.ac.uk start to re-emerge, perhaps this will be
Afsana Choudhury unfilled consultant posts, representing a additional data from the census, in which a time to re-assess what we do and
RCoA Workforce Planning & workforce gap (number of unfilled funded we asked about numbers of consultants find new ways of working. That might
Recruitment Coordinator consultants posts divided by total number on long-term sick leave, parental leave, be uncomfortable, but anaesthesia has
of funded posts including those unfilled) sabbaticals etc, then the real gap is shown that it’s good at that.
of 8%, a steady increase from 4.4% in around 15%. Rota writers need to find
At the time of writing, the UK has passed 35,000 fatalities in the COVID-19 2015, to 5.4% in 2017, and 6.9% in 2018. alternative cover for 1 in every 7 sessions. References
pandemic. Some hospitals are reporting that half of their medical staff are Some of the increase in the last year is a
consequence of new pension tax rules. Solutions to this problem are unclear.
1 Shortage of consultant paediatricians in the
UK. Report of RCPCH. (bit.ly/3bWFZEh).
at home, sick, or isolating due to illness in the family. Many recently retired The census showed that 1,114 consultant As part of the NHS Long Term Plan,
2 Royal College of Psychiatrists CENSUS 2019.
the number of medical school places
doctors have returned to work, and a substantial number of skilled workers are anaesthetists reduced their working
has expanded. This should increase
Workforce figures for consultant psychiatrists,
specialty doctor psychiatrists and Physician
hours. Despite a reversal of some of these
being sourced to staff new hospitals rapidly constructed in exhibition centres. changes, it’s unlikely that colleagues will the number of anaesthetists in training, Associates in Mental Health. (bit.ly/3aRfI93).
3 General Practice Workforce 31 December
The shortage of doctors is palpable. choose to increase their job plans back to but only if we find ways to inspire them
2019. NHS Digital (bit.ly/35ncvwQ).
their previous level, particularly if they are and present anaesthesia as a desirable
4 The NHS Long Term Plan. NHS
That a crisis has shed light on workforce GPs had dropped by 1% in the previous published the Interim NHS People Plan in the later stages of their career. career. However, that will take time, and (longtermplan.nhs.uk).
deficiencies shouldn’t surprise us. Many year as GPs left the profession or reduced which described the need to increase we need something sooner. The COVID 5 NHS Workforce Statistics, November 2019.
This gap is worrying, but is only part of crisis has shown that the specialty of NHS Digital (bit.ly/3bVrYa0).
medical specialties were reporting their working hours.3 numbers of GPs and psychiatrists, but
the picture. In the census, we also asked anaesthesia is able to adapt to new ways
workforce concerns before the pandemic. again, other hospital specialties weren’t
These concerns have been reported clinical directors how many posts they of working, supporting our colleagues in
As recently as November 2019, the Royal mentioned.5 It’s easy to believe that
in the media, generating a welcome required in addition to already funded intensive care medicine and other areas.
College of Paediatrics and Child Health anaesthesia isn’t considered to have a
published workforce modelling using best- political imperative. As a result, in January
significant workforce issue.
practice care to estimate that the specialty 2019, the UK government published the
had a workforce gap of 856 consultants NHS Long Term Plan, which recognised In order to monitor the anaesthetic
across the UK.1 A recent Royal College of that ‘over the past decade, workforce workforce the RCoA has carried out The census revealed 676 unfilled consultant posts,
Psychiatrists census of 86% of Psychiatry growth had not kept up with need’.4 The censuses (2007, 2010, 2015 and recently representing a workforce gap (number of unfilled funded
departments showed a gap of 708 plan has many laudable aims around in 2020) and recruitment surveys (2017
consultants posts divided by total number of funded
consultants (9.3%).2 General practice has a improving the working lives of staff and and 2018). The consistent message is that
long history of workforce shortages which increasing numbers of medical students, the specialty of anaesthesia is expanding posts including those unfilled) of 8%, a steady increase
doesn’t show any signs of improving. In nurses, midwives and GPs, but makes little at 2–3% per year. Online data from from 4.4% in 2015, 5.4% in 2017, and 6.9% in 2018.
December 2019, NHS Digital recorded mention of addressing the shortages of NHS Digital corroborates this, showing
that the number of full-time equivalent hospital specialists. Later in June, NHSE that from 2009 to 2019, the number
10 | | 11
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
Chris Kennedy
RCoA CPD and Revalidation
Coordinator
cpd@rcoa.ac.uk
Revalidation for anaesthetists
CPD accreditation applications:
2019 and 2020 compared
Previous editions of the Bulletin have featured the annual data from the College
service for the CPD accreditation of events run by NHS trusts and hospital
boards, registered charities, specialist societies, and associations. This service
has been available for a number of years, with the application form becoming
Dr Barry Miller
online in 2012, followed by a much more streamlined and user-friendly version contact@fpm.ac.uk
getting incorporated into the Lifelong Learning Platform in November 2019.
Data was first collected from 2012, at so as to assist with meaningful reflection, 19 and the subsequent cancellation of Faculty of Pain Medicine (FPM)
The Medicines Advisory Group
the end of which year a total of 599 or for ‘mini biographies’ to be provided face-to-face events meant that only 40
applications had been received for about the event faculty. applications were received during March
accreditation. In subsequent years the 2020 (compared with 108 applications
volume has increased significantly and A total of 112 applications last year were in the previous year) with an even smaller
the number of applications received not accredited, with the main reasons number in April 2020.
for this decision including the fact that ‘The saddest aspect of life…is that science gathers knowledge faster than society
during 2019 was 1,200.
the requests had been made less than Since then numbers have started to pick gathers wisdom.’ Isaac Asimov
To provide a brief snapshot from last two weeks before the event date (which up, and we would particularly like to
year, 951 of the applications received did not not allow sufficient time for the reassure providers who postponed events
As I write this, like many others, I am in self-isolation. The pain service is
were accredited unconditionally, while two-stage College review process to be that these can be easily ‘reactivated’ for
137 were only approved after additional followed), and that the events were more your new dates without the need for you partially suspended at my hospital, with telephone support for existing patients
information had been supplied by the appropriate for internal/local audiences to complete a new online application
only. The timescale for its restart is uncertain, but it will restart. Long-term pain
applicant. For example, in some of the only or for anaesthetists in training. form. Please contact cpd@rcoa.ac.uk for
applications it was necessary for the assistance with this. problems are not going away, and they need managing with expert support.
learning outcomes to get strengthened Full information is included in the quality
assurance report, which is available In anticipation of the second half of Pain management is rightly a brought hopes of benefit to some, and material, and the development of new
on the College website at bit.ly/ 2020 seeing an increased volume of multidisciplinary field with various options side effects and risks to others, with the resources.
RCoACPDAccred. applications, there remains a need for used in series, parallel, or not at all, as balance shifting over time – usually more
new CPD assessors, and for further The vice-chair will be Dr Baranidharan,
an individual’s condition guides. The towards the latter.
2020 started in a similarly busy way to information about this important role who has worked extensively within the
appropriate use of medication remains
last year, and by the end of February please visit rcoa.ac.uk/membership/get- Prior to recent world events, the Faculty Professional Standards Committee and
a total of 215 applications had been an important aspect of this – when?,
involved/cpd-assessor. had decided to bring the various strands the Faculty board and recently with the
received. However, the impact of Covid- how much?, what variations?, and, British Pain Society in the creation of the
of work relating to medication under one
importantly, IF AT ALL. Outcomes Criteria guidance.
group – the Medicines Advisory Group,
Prescribing trends have changed which will focus on all areas of the The current national, and international
considerably over the course of my Faculty’s work where medications are the focus, and the workload of many of
career. The introduction and popularity principle issue, and will provide support our fellows, is elsewhere, with many
of the gabapentinoids, the increased to internal and external activities where co-opted to frontline anaesthesia and
For further information about becoming a CPD Assesor please visit the
use of opioids, the changes in the medications are a significant component. intensive care duties. But normal service,
Get involved section of our website: bit.ly/RCoA-Involved
law around cannabinoids – all have This work will include the Opioid Aware and its challenges, will resume.
12 | | 13
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
Dr Alison Pittard Dr Peter Hersey
Dean, Faculty of Intensive Care Medicine Consultant in Critical Care Medicine and Anaesthesia,
contact@ficm.ac.uk South Tyneside and Sunderland NHS Foundation Trust
contact@ficm.ac.uk
Faculty of Intensive Care Medicine (FICM) Faculty of Intensive Care Medicine (FICM)
COVID update from FICMLearning: the new
the Dean learning platform for the FICM
First of all I would like to thank all anaesthetists for assisting us during the On behalf of the FICM education subcommittee, I’m delighted to be able to
pandemic. Without you we would not be able to care for our critically ill report that FICMLearning launched in early February. The site is the new hub
patients and we are extremely grateful. for the educational output of the Faculty.
Despite the current situation, we have engagement with NHS England and relatives, and advice for use of alternative The functions of the site are: project fits into that space, so it ■ To provide a central registry of
been extremely busy at the Faculty. Our Public Health England has allowed us drugs and techniques while demand is seems very appropriate to highlight national educational events. We
■ To provide a home for our new
enhanced-care guidance, co-produced to influence specialty-specific standard high – developed in conjunction with other providers. We also signpost are asking for anyone organising an
podcast (also available on Spotify
with the three Royal Colleges of operating procedures and PPE guidance. the UK Clinical Pharmacy Association useful books and other resources for
and Apple music), blog and educational event to tell us so that
Physicians, was due for publication on and the Chief Pharmaceutical Officer. those preparing for the final FFICM
In collaboration with RCS England, ‘cases of the month’ series. The we can advertise it on FICMLearning.
25 March, but we put the launch on examination.
we produced cross-skilling guidance To ensure appropriate communication successful blog written by the If we can capture most events,
hold. We have worked with the GMC
#BetterTogether, available via during this rapidly evolving time we Women in Intensive Care Medicine ■ To give e-ICM a stronger Faculty planning CPD activity should be
and HEE on alternative plans for national
icmanaesthesiacovid-19 – the covid commenced regular COVID digests for (WICM) group has also moved to identity. The partnership between the made that little bit easier.
recruitment and for ARCPs, and also
hub we co-founded with the College, FICM members, launched the ViRUS: FICMLearning. Faculty and eLearning for Healthcare
released statements to support trained We are releasing content every week, so
the Association of Anaesthetists and Safety Bulletin project, and have been To signpost other useful resources. is a strong and productive one, but the
and trainee ACCPs. ■
the Intensive Care Society. Please visit involved in a huge number of media programme wasn’t obvious within the the site will grow and evolve. Please let
The meteoric rise of free and
The FICM was involved in the production ficmlearning.org for related open- appearances. We have supported two open-access medical education Faculty structure. By including e-ICM us know if you’d like to get involved or
of NICE guidance NG159 (nice.org. access releases. The hub also has our initiatives – Life Lines iPad and People (FOAMEd) has led to the production within FICMLearning, it should increase have any feedback, but most importantly
uk/guidance/ng159) and led the RCP templates for critical care transfer, Powered two-way radios. of an incredible array of quality the accessibility of the programme and we hope you will find it a useful and
London project for the supporting toolkit, admission and daily review, guidance resources. The FICMLearning highlight Faculty ownership. engaging resource.
And finally, if all that wasn’t enough, we
criticalcarenice.org.uk. Stakeholder for communication with patients’
were asked to submit written evidence
to the Health and Social Care Select
Committee prior to my later virtual
appearance before the Committee.
For further information,
Supporting implementation Find out more
please visit theat
Get invo
of NICE Critical Care ficmlearning.org
section of our website:
Guidelines bit.ly/RCoA-Involved
criticalcarenice.org.uk
14 | | 15
Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
Dr Kirstin May Dr Robbie Kerry
RCoA SAS Member of Council, Consultant Anaesthetist
Banbury and Clinical Lead,
sas@rcoa.ac.uk Horton Hospital Banbury
ne important key to success is confidence.
O
An important key to self-confidence is preparation.
Arthur Ashe
SAS and Specialty Doctors
Winning the battle for
shortlisting
It is a truth universally acknowledged that specialty doctors are a much needed
but difficult to recruit commodity in today’s NHS. Many posts are unfilled.
Our two most recent recruitment The process we employed is fairly typical
for the UK. Candidates are invited to fill
will save you, and the potential employer,
to make the process as fair as possible. Manager’s
rounds have shown that a standard time and effort.
NHS job advertisement can result in a in a comprehensive application form,
If you attend for interview in person it
is customary to dress smartly. You may
■ Read the instructions in the advert – if we want a CV,
we’ll ask for it, otherwise it’s entirely down to the quality
TOP TIPS
high number of applications. We have which provides the basis for standardised As most applicants for specialty doctor
have the option to conduct a Skype of your application form. Your personal statement is
recently advertised four specialty doctor scoring to shortlist for interview. Several posts come from overseas and many will
interview. If you have no experience of your opportunity to give a succinct summary.
posts in our small and friendly district individuals assess the applications not have worked in the UK before, it is
UK job interviews, you may wish to take Make sure you understand what we’re asking of successful post holders –
general hospital anaesthetic department, independently against a set of criteria, important to describe your experience ■
advice from senior colleagues or have a check that this is the job for you, then use the application to show us why you
located in a pleasant market town with usually with the personal details of in detail. Communication skills are
mock interview. are the right fit for this job.
beautiful surrounding countryside. We the applicant redacted. The scoring is highly valued in the UK, as is cross-
probably benefit from being part of a generally based on a list of essential and cultural experience. Unfilled sections References from previous employers ■ Read the person specification – this is the standard by which we will judge
prestigious tertiary referral centre, but the desirable person specifications which on an application form will damage the are usually requested as part of the pre- the applications. If it’s in the person specification, we will be looking to see if
breadth of clinical experience locally is applicants should find within the job score. Honesty is a must, embellishment employment checks after a job offer has your application form shows that you have this skill, qualification, experience
limited and the on-call commitment we advert. Your application should make is unacceptable. Facts trump flowery been made. It is generally expected that or attribute.
are looking for is significant. direct reference to these, and you will not language here! If you have knowledge references are provided by the current ■ Make it easy for us – we don’t want to be searching through your application
make the shortlist if you don’t possess the of UK postgraduate training and medical and most recent employers, and you form with a fine-toothed comb to find that key information.
At first glance it is surprising that we essentials. It may be worth considering practice, aim to relate your personal therefore need to include full details of ■ If I publish contact details, it means I’m very happy to be contacted. Please do!
quickly received 66 applications, mostly seeking a less senior role than you are experience to what a UK doctor the referees, their professional role and full At the very least it gives an opportunity for you to ask questions, learn more
via the NHS jobs portal. Despite these used to when first coming to the UK, but might have. Correct grammar and a details of the institution. References only about the job than can fit in an advert, and is a chance to gain insight that might
numbers, it is not easy to appoint it is also possible to be overqualified for a spell check will create the required from private individuals without having a help your application.
candidates that fit well. We hope that role. There is no value in taking a ‘scatter professional first impression. professional connection to the applicant
■ Ultimately, I want a colleague who, firstly, can do the job effectively and
describing the process – and its pitfalls – gun' approach, applying for a multitude are not acceptable and will almost certainly
safely, and then also make a positive wider contribution to the department
will help job applicants, particularly those of jobs you are not suitably qualified for. A similarly standardised process will take prevent you from being shortlisted.
and trust, particularly if this is a permanent role.
coming from abroad, find the right post If in doubt, use the contacts provided in place at interview. Candidates will be
after fewer applications. the job advert to ask questions, which asked the same questions in an attempt
16 | | 17Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
Patient perspective
Reflections on COVID-19:
a lay perspective
Lynne Smith
RCoA Lay Committee
laycomm@rcoa.ac.uk
When our redoubtable Chair, Carol Pellowe, was not in a position to write about the most striking things to hear about. I When I first exchanged WhatsApp may be left traumatised and stressed by
was reminded of this by the careful way comments with my fellow lay members, the exhausting experience of working
COVID-19 from the lay perspective (thankfully not for medical reasons), I offered in which a Council member stressed I remarked on my admiration for all for many hours using all their skills and
to try to comment on behalf of the Lay Committee. I sought the views of my the importance of senior staff providing those of you at the front of the front line. resourcefulness, as well as managing
support for trainees, as people watch out Subsequently, I modified such martial their own perfectly legitimate fears for
friends and colleagues, and my phone pinged relentlessly for several hours with for their colleagues. language. I can understand why it has themselves and their families and the
expressions of admiration for the clinicians who are the main readership. been so powerful, as illustrated in the fears and distress of their patients and
Reflecting on telecoms chats with friends, families.
highly effective BBC feature on the
I’ll do my best to reflect their wishes been discussions about the strange fact to me after watching a group of doctors I noted that the most frequent comments
work of critical care, with its frequent
related to an appreciation of the There is a word limit to any article for
while presenting my own thoughts on that anaesthetists are such a big clinical in a feature on intensive care and said references to battles, which had such an
professional expertise and calmness they the Bulletin. Having consulted my Lay
this extraordinary time – when events specialty yet many of the public are simply ‘well, you know they would do impact on the public. I appreciate that
observed. Personally I have responded Committee colleagues and canvassed
are so dramatic they seem beyond unaware of their role. I rather suspect everything possible’: I googled them and it has helped illustrate the gravity of the
most to the mixture of professional friends and family, I realise the most
belief, and yet are all too horribly real. that this could change in the light of most were College members. situation, but that situation has seemed
dedication and simple humanity on important message is only two words:
It has been unsettling and frustrating COVID-19, as anaesthetists and critical bad enough to me without needing
However, although this is written for display. One critical care consultant ‘THANK YOU!’
to realise that, while others are doing care specialists have played such a comparison with anything else. I also
prominent role in providing information the College Bulletin, I must stress that found time to reflect on the benefits of
remarkable things, your best contribution noted that clinical staff did not talk in that
and advice. Some leading figures have the thoughts and gratitude expressed having a job and purpose while others
is… to do nothing. This strangeness is way, but rather talked about using their
become familiar faces, as I realised are equally relevant to all the members are worried about their financial futures,
reflected in the media, with content skills and training.
when my very elderly mum told me of the clinical team, who have simply even though most of us would be very
swinging between reflections on the
how impressed she was listening to the identified a need and worked tirelessly daunted by that job of his. I confess that However, one aspect of the crisis in
bravery of those working all hours under
RCoA’s vice-president on the news. The to meet it. That remarkable teamwork, as my bottom lip wobbled a little when I which the language of combat might be
horrendous conditions and advising on
impact was further illustrated when my anaesthetists moved across to intensive read the comments of a young trainee, very relevant, will be in managing what
the best box-sets for others.
son, an earnest young social scientist, care, surgeons trained to use ventilators, redeployed to critical care, on how she happens afterwards, whenever that might
Ever since I joined the Committee, more who cannot normally watch any news and physios pitched in to help roll simply wished this terrible thing hadn’t be. I trust that the College, NHS and
than four years ago, there seem to have without a sociological analysis, turned patients at crucial times, has been one of happened to her patients. other agencies will recognise that staff
18 | | 19Bulletin | Issue 122 | July 2020
Dr Sue Walwyn
Consultant Anaesthetist, Mid-Yorkshire
Hospitals NHS Trust
president@seauk.org
Society for Education in Anaesthesia (UK)
Psychological
consequences of
COVID-19
As the pandemic surge wanes and the public return to a pre-COVID-19 with individuals appearing overly anxious ■ Support: do they need immediate also the team that defines our specialty,
and suffering severe insomnia, panic physical/expert psychological help? anaesthesia, and enhancing our ability to
lifestyle, it will be ourselves as healthcare professionals who are left reflecting reactions and inability to function with ■ Supply: information re resources, rise to the challenge in the future.
on our recent experiences in healthcare. normal daily activity. Up to 50 per coping strategies – time with family,
cent of these individuals then go on to Reference
rest, exercise, mindfulness and
Although anaesthetists have been shown regarding ability to provide excellent care, up work starts and acute stress reactions develop PTSD. 1 Maunder R, Lancee W. Long-term
wellbeing apps; there is currently free
Psychological and Occupational Effects of
to be more resilient than other healthcare working in unfamiliar environments and become evident. Moral injury (related to NHS access to self-help apps.
Individuals suffering from PTSD present Providing Hospital Healthcare during SARS
workers in the past (SARS, Toronto 2003),1 roles, personal safety, health, implications the inability of clinicians to adhere to their Outbreak. Journal of Human Behavior in the
later with a spectrum of symptoms,
a significant number of our colleagues or for loved ones and, if prolonged, a moral and ethical codes in the care of
including intrusive memory disturbances
How do we avoid Social Environment 12(12): 1924–1932;2006.
team members may feel overwhelmed degree of preparation fatigue. patients) resulting from the disequilibrium psychological consequences
of resource demand and allocation, can
(flashbacks and disturbing dreams), Resources available
during or after this pandemic. There
The peri-pandemic phase is physically mood disorders (negative thoughts of Covid? 1 Intensive Care Society:
will be much research on the subject of be associated with guilt and may precede
and emotionally exhausting. But it such as blame, guilt and anger), and The response to COVID-19 will (icmanaesthesiacovid-19.org/staff-wellbeing-
psychological consequences, but what can post-traumatic stress disorder. resources).
is made easier by the provision of disturbance in cognitive function and involve many new adaptations in how
we do now? In part, the answer to how 2 Psychological first aid: WHO guide for
appropriate equipment and staff, open behaviour patterns. Although diagnostic we work and how we interact with
we come out best will be about learning – Reactions fieldworkers: (bit.ly/2yxamTl).
and honest communication, transparent criteria and management strategies our environment, and the majority
learning how we approach the challenge, In the acute stage, a small number of 3 The British Psychological Society guide to the
decision-making, and appropriate are beyond the scope of this article, of clinicians will feel that they have psychological needs of HCW:
developing new initiatives, recognising our individuals demonstrate maladaptive
involvement in process. From a personal recognition that a colleague needs help contributed in a positive way. However, (bps.org.uk/responding-coronavirus).
limitations and using our skills to enhance coping strategies and behaviours
perspective, awareness of one’s own and appropriate referral is important. we need to recognise the need 4 Covid trauma response group:
our resilience as a specialty. such as substance abuse, withdrawal,
limitations and those of your colleagues (www.traumagroup.org).
communication difficulties, and strained to support those who suffer from
Although not a formal intervention, 5 American Psychiatric Association – DSM and
is important, for example, the need for
Approach to pandemics interpersonal relations, displaying both immediate use of psychological first psychological sequelae. We need to PTSD: (www.psychiatry.org/patients-families/
‘time out’, for food, or for reassurance.
In the pre-pandemic phase, collaborative elements of excessive resentment or aid may be appropriate. The process show inclusivity, understanding, kindness ptsd/what-is-ptsd).
Informal debriefing is a recognised
planning and preparation gives a rumination. The individuals may be involves the following – and empathy, and to build cohesive 6 Royal College of Psychiatry – mental health
means of reducing immediate and during Covid: (www.rcpsych.ac.uk).
common sense of purpose and a degree anxious, depressed and fatigued. More departments in which there is clear
prolonged stress reactions. Prioritise: is the patient safe, is the 7 NHS employers wellbeing apps:
of control. Constructional motivation sustained responses to health epidemics ■ honest communication, and recognition
(bit.ly/2WwABBl).
has positive effects on staff wellbeing. Reflection and learning in the post- include acute stress disorder (ASD) and clinician safe and able to work? and support of humility, humanity and
8 COVID-19. What is the BMA doing.
In addition to the fear of managing pandemic phase is an important part of post-traumatic stress disorder (PTSD). ■ Assess and validate: area of calm, the infrequent wobble. In doing this, we (bma.org.uk/advice-and-support/covid-19).
an unknown entity, there will be fear recovery. This is also the time when catch- ASD occurs within the first few months, active listening; reassure. are helping not only the individuals but
20 | | 21Bulletin | Issue 122 | July 2020 Bulletin | Issue 122 | July 2020
No one really knows what the future 4 reductions in the overall length of critical care capacity, all rooted in an
of our health and care system will look stay (including stay in critical care) underlying principle of equity of access
like on the other side of the COVID-19 5 better integration between primary to treatment. And, it outlines a set
pandemic. In this unprecedented period and secondary healthcare and social of criteria that should be met before
of uncertainty, it would, however, be a care services elective activity is resumed, including
huge mistake to assume that the rapid (but not excluding others):
6 reductions in the number of
progress we have made in improving
unnecessary surgical procedures ■ sufficient numbers of staff should be
the way in which care is delivered during
7 improved overall value, cost- available to return to routine work
COVID-19 cannot be undone, or that
continued progress is guaranteed. We effectiveness, and capacity for ■ sufficient anaesthetic and critical care
must grasp this once-in-a-generation demand management. drug stock levels should be secured
opportunity to work together, across ■ sufficient supply of personal
Each of these will align with existing
specialties; across the divide between protective equipment (and access to
national priorities around preventing illness
primary, secondary, and social care; it) should be ensured
and improving long-term outcomes,
and with public health. We can heal the ■ all standard operating procedures
tackling health inequalities, digital
divisions and make a truly unified health should be reviewed and, if necessary,
transformation, and facilitating the move
and care sector a reality. adjusted
to a population-health management
Mark Weiss Doing this will require bold solutions approach – all of particular relevance in ■ there should be an acceptance and
and strongly collaborative working with the COVID-19 health and care landscape. remediation of the sustained toll of
RCoA Head of Policy and Public Affairs
government, the NHS, and wider health And, each will support a movement away COVID-19 on the welfare and morale
mweiss@rcoa.ac.uk
and care sectors. As I write, in late May from system incentives which have skewed of our members.
2020, that collaborative working is already investment towards services showing
With more than one-third (34%) of
underway. The cross-specialty Centre for short-term returns, particularly to the NHS,
anaesthetists reporting low confidence
Perioperative Care is actively considering instead of those demonstrating wider
Perioperative care:
in their hospitals’ preparedness for the
what an effective model of post- social or economic value.
restoration of non-COVID-19 NHS
COVID-19 service transformation could
The door is open. In the wake of services (according to the College’s
look like. Over the coming months we’ll be
COVID-19 all sides of the political May COVID-19 membership survey),
making the case for dedicated investment
the two words that could unite our
divide recognise, now more than the strategy is particularly timely.2 Our
and transformation funding to deliver a
ever, the importance of integration members’ input is vital in helping us to
number of perioperative pilot schemes,
understand where the pressure points
health and care service after COVID-19
revolutionising the services surgical patients and system change, preventative-care
models, reducing transaction costs, are, and how best the College can act
receive and how they receive them.
and redesigning care. Over the past as an advocate for a post-COVID-19
Our aim is to deliver substantial and few weeks, the College has engaged in transformation – a transformation, rooted
When you ask the public to name what they will remember most about measurable improvements in outcomes, regular discussions with the Secretary in perioperative care, that can unite our
health and social care services.
satisfaction, and financial sustainability. of State for Health and Social Care, the
COVID-19, towards the top of their list will be when, across the UK, millions Perioperative transformation has innovation Shadow Health Secretary, and senior
and spread at its core. Each pilot will References
joined together every Thursday evening to applaud all those who care for aim to facilitate the personalised and
teams across the NHS to make the case
1 View from the frontline of anaesthesia during
for perioperative care as a cornerstone
us with selfless dedication – an applause that makes no distinction between multidisciplinary optimisation of patients of primary, secondary, and social care.
COVID-19, May 2020 survey results. RCoA
2020 (bit.ly/2ZzomXE).
prior to surgery, and improved prevention
doctor, nurse, or wider health and care worker. Yet, that applause has belied of future disease, to demonstrate: At the same time, the College has
2 Restarting planned surgery in the context of
the COVID-19 pandemic, May 2020. RCoA
the divisions characterising for so many years the relationship between health 1 improved patient outcomes, patient
been working with its partners to 2020 (bit.ly/36n1HiG).
develop a medium-term strategy for the
and care – divisions leading to confusion and frustration for patients and satisfaction and quality of care
management of the COVID-19 demand
carers, and wasted resources. 2 improved shared decision-making and and resumption of activity.1 The joint
patient-centred, individualised care strategy, which complements national
3 enhanced postoperative recovery, guidance, makes the case for additional
outcomes and care investment in staffing, resources, and
22 | | 23You can also read
