‘In the middle of the operation, my colleague said he had to go – it was his home time’
Senior doctor Tony Strong, 37, works an 80-hour week, despite a recent European ruling that it should be no more than 48. In this diary, he exposes why the rules are bad for doctors and patients alike
If I had to give one piece of advice to any patient worried about going under the knife in a UK hospital, I’d advise them to check when their surgeon started their specialist training.
Surgeons have to complete a five-year medical degree and work as junior doctors before they undertake this training. I qualified as a doctor in 1998 and began in 2004, and am now a senior registrar – so I am considered a senior trainee. But doctors who began training after 2007 do so under a new system which makes them less experienced than their predecessors.
This reduces exposure to the life-threatening complications which all consultant surgeons need to be confident in handling.
So my advice is to check who is doing your surgery, and whether they began their specialist training after 2007. I would want any doctor operating on me to have carried out the procedure 80 to 100 times. If they haven’t, ask for a surgeon who has. It could just save your life.
Three changes have undermined training for UK doctors. The first was a European ruling in 2003, which removed the opportunity to match working hours with training opportunities. The second was the introduction of a new scheme that shaved three years off the time it took to become a consultant (the most senior doctor). Under the old scheme – the one I’m on – the path from qualified doctor to consultant surgeon was typically 13 years. Now it is 10.
The third, most damaging, change was the implementation of the European Working Time Regulations (EWTR) last August, which reduced our working week to just 48 hours.
The new changes have resulted in a different work ethos among newer trainee surgeons. Many are becoming demoralised, with no clear sense of obligation to any particular surgical team.
I got my first feeling of this two years ago when I was operating on a patient’s abdomen and a newly appointed trainee was assisting. Suddenly, during the middle of the operation, he said he had to go – it was home time. I couldn’t insist that he stayed as he had exceeded his rostered hours.
I had to struggle to finish the operation on my own. Fortunately I was able to make a bigger cut to get more exposure and completed the operation safely. Had I run into difficulties, I would have been forced to wait for the consultant to come in from home to hold the abdomen open – this would not have gone down well.
So I have decided to publish my work diary to expose the potential consequences of cutting surgical training time:
8am: ward round. A colleague gives an update on all the patients in our team’s care, and any new ones admitted overnight – today there are 13. I review the notes of any patients booked for surgery that day, before heading to theatres to operate – today I have six patients.
Before leaving work, I check on all the patients I’ve operated on that day. But that’s not always the case for all surgeons. Under the new rules we are required to have at least 11 hours rest between shifts, which would mean today I’d be breaching them if I stayed beyond 9pm. After an hour’s drive I’m back home at 8.45pm. Time to look in on my kids who are asleep, then I shower, eat and iron a shirt for the next day, before bed and another 6am start.
As a senior registrar, one level below that of a consultant, I work every day during the week, plus additional rostered nights and weekends – typically this tots up to 80 hours. Some weeks are exceptional and I can work 100 hours. But in either case I’ll officially record just 48 and that’s all I’ll get paid for.
I work the extra hours voluntarily because I need to do as many procedures as possible if I’m going to be an accomplished surgeon. So it’s not just the very junior surgeons who are affected by the new working rules.
My trainers know that I work over my stated hours but are able to turn a blind eye because they want to offer me the best training they possibly can. But they also need to placate the managers who are under a legal obligation to declare the hospital “EWTR compliant”. So, even though my rota says I’m off tomorrow and the following day, that won’t be the case.
I’m on call throughout the night. As the most senior resident doctor on duty at night, I’m responsible for what happens to patients requiring emergency surgery. I’ve already operated on four patients, starting with an appendectomy on a child at 8pm. I finish the last case at 2am but am called back to theatre at 5am to operate on a young man who has been stabbed in his testicle. In between, I sleep in an on-call room, which is just a small room with a bed in it and a bathroom attached.
Our senior house officer (SHO) should have been able to deal with the last case – an exploration and repair – but he is not confident to operate alone, so I can’t take the risk. This is in contrast to my own training, prior to the introduction of the EWTR. At his stage, I would have been expected to operate on this patient without supervision.
9pm: I’m not on-call but I’ve come in for an emergency. The registrar on duty wants a specialist opinion on a patient and the on-call vascular surgeon is held up elsewhere. This is not unusual – each vascular surgeon covers four hospitals.
The patient I’m called to see is an elderly man with an ischemic leg – his leg has gone blue due to an artery blockage caused by cardiovascular disease. It is vital to get his management right: whether to amputate the leg now or use drugs to try improve blood flow. Without surgery you have five hours before the leg muscle dies and the patient loses his leg. These patients are sick and an unnecessary operation could kill them.
When I was a junior registrar I was exposed to many similar cases and am therefore confident in making such a decision. But the newer trainees are not, so I need to see the patient myself. I make the decision to watch and wait – an emergency operation is just too risky and I think the leg will survive without any surgery tonight. Instead, I order X-ray tests to examine the blood flow through the legs. I’ll review the results tomorrow. (This turns out to be the right decision as the patient’s leg improves, returning to a normal colour.)
Much more HERE
Nobody disciplined after baby deaths
Nobody has been disciplined or even moved from their post at a children’s cardiac unit where four babies died within three months of each other, an NHS trust admitted last night. The babies died at the Oxford Cardiac Centre, part of the John Radcliffe Hospital, between December 2009 and February 2010 after the unit took on a second surgeon to increase the number of children treated there and save it from closure.
But despite a review finding serious organisational failings, no doctors or managers have been sanctioned.
The admission by Oxford Radcliffe Hospital NHS Trust comes as it prepares to face an investigation into the entire organisation by the healthcare regulator, the Care Quality Commission.
The four babies died after being operated on by Caner Salih, a relatively junior surgeon. He was left alone on his second day when the senior consultant, Prof Stephen Westaby, departed to take three weeks’ holiday.
After the fourth death Mr Salih blew the whistle on problems of ageing equipment and poor working practices at the unit, but his concerns were only raised with the board after journalists started asking questions.
A subsequent review of the deaths by Dr Bill Kirkup, the director of clinical standards at the South Central Strategic Health Authority, found that neither the two consultants could be found directly responsible for the deaths.
But the review, dislosed yesterday by the Telegraph, also highlighted entrenched management problems. These included “considerable” internal pressure to stop news of the deaths reaching the board, and a lack of appreciation that a business plan to increase capacity at the unit could put safety at risk.
In February Mr Salih wrote a letter to five clinical colleagues raising concerns and telling them he would not operate at the unit anymore. Surgery was consequently “paused” but it took 11 days to confirm that decision and launch a review.
Dr Kirkup’s wrote: “There seems to us to have been attempts to minimise the scale of the problem and to restrict knowledge of it.”
The Trust board and the strategic health authority were not even notified until television journalists enquired about the deaths, having received an anonymous tip-off.
Dr Kirkup concluded that “there was considerable pressure within the clinical directorate” – the Cardiac Directorate – “to handle concerns internally and to limit knowledge of the events externally”.
The Cardiac Directorate is still headed by the same two people who were responsible for it at the time of the babies’ deaths, Belinda Boulton, its manager, and Dr Adrian Banning, its chair. A Trust spokesman confirmed they were both involved in discussions during the 11 days between Mr Salih’s letter and the board being informed. However, she maintained they did pass on the surgeon’s concerns quickly enough. “As soon as Mr Salih’s letter was received it was raised with the Medical Director and the service was paused,” she said.
Explaining why no one had been disciplined or moved post, she quoted the review that “in no case did they [the review panel] find a clinical decision, untoward incident or other aspect of care that they regard as having led directly to death or to another adverse outcome.”
Dr Kirkup also found flaws with the business case for expanding the children’s cardiac unit, which was signed off by the board in April 2008. Clinicians and managers feared that if they did not raise the number of children treated – 100 patients a year – they would be recommended for closure in a forthcoming review.
While the business case highlighted “mainly financial risks” Dr Kirkup said “it did not, however, recognise that expansion itself, with new staff and techniques and in time more complex procedures, carried clinical risks that needed to be mitigated by careful planning.”
The spokesman said she could not say who had been responsible for drawing up the business case.
The review found the Trust’s clinical governance structure “complex and fragmented”, with responsibility for the Children’s Cardiac Unit split between the hospital’s three divisions.
The findings have prompted the Care Quality Commission (CQC) to instigate a review of the whole trust. Cynthia Bower, its chief executive, said: “While the report does not say that the failings caused any deaths, I am in no doubt that babies were not receiving care that was as safe as it should be.
“The trust did not handle the safety concerns raised by the surgeon in an effective or transparent way. The delay in notifying the board, strategic health authority and regulator was unacceptable. The clinical governance arrangements to identify and monitor safety risks were not up to scratch. Induction and supervision was clearly poor.
“We will conduct a full review of quality and safety standards across the hospital. This will involve inspections, interviews with patients and staff, and a review of all available data. We won’t hesitate to take action if we find similar problems exist elsewhere in the hospital.”
Sir Jonathan Michael, chief executive of the Oxford Radcliffe Hospitals NHS Trust, which runs the hospital, said: “Both personally as chief executive, and the trust as a whole, very much regrets when the outcome of treatment we provide for patients is unsuccessful, and we give our condolences to the families of the babies who died.”
This is not the first time that cardiac services at the John Radcliffe Hospital have come under the spotlight. In 2007 the Healthcare Commission said improvements were needed, after looking at the number of deaths linked to adult heart surgery in adults between 2002 and 2005.
The report highlighted issues over data collection, saying: “Bearing in mind the history of the cardiac unit at Oxford, and the number of questions about the trust’s rates of mortality, there had been a surprising lack of robust processes to validate and cross check the completeness and quality of its data.”
Israel president claims English are ‘anti-semitic’
Israel’s president has accused the English of being anti-semitic and claimed that MPs pander to Muslim voters. Shimon Peres said England was “deeply pro-Arab … and anti-Israeli”, adding: “They always worked against us.” He added: “There is in England a saying that an anti-Semite is someone who hates the Jews more than is necessary.”
His remarks, made in an interview on a Jewish website, provoked anger from senior MPs and Jewish leaders who said the 87-year-old president had “got it wrong”. But other groups backed the former Israeli prime minister and said the number of anti-semitic incidents had risen dramatically in the UK in recent years.
The controversy follows the furore last week over David Cameron’s remark that Gaza was a “prison camp”, as he urged Israel to allow aid and people to move freely in and out of the Palestinian territory.
Mr Peres, a Nobel Peace Prize winner who is three years into his seven-year term as president and was awarded an honorary knighthood by the Queen in 2008, said that England’s attitude towards Jews was Israel’s “next big problem”. “There are several million Muslim voters, and for many members of parliament, that’s the difference between getting elected and not getting elected,” he said.
“And in England there has always been something deeply pro-Arab, of course, not among all Englishmen, and anti-Israeli, in the establishment. “They abstained in the [pro-Zionist] 1947 UN partition resolution … They maintained an arms embargo against us in the 1950s … They always worked against us. They think the Arabs are the underdogs.”
By contrast, relations with Germany, France and Italy were “pretty good”, he added.
He made the comments in an interview with the historian Professor Benny Morris of Ben-Gurion University of the Negev published last week in Tablet, a Jewish news website.
The wide-ranging interview covered Mr Peres’ role as one of Israel’s longest-serving political leaders – an MP for 48 years, twice prime minister, and holder of other ministerial posts over the decades. He is firmly on the Israeli Left. He was awarded Nobel Peace Prize in 1994 jointly with Yitzhak Rabin and Yasser Arafat for his part as foreign minister in the peace talks which produced the landmark Oslo Accords.
But following his comments, James Clappison, the Conservative MP for Hertsmere and vice-chairman of Conservative Friends of Israel, said: “Mr Peres has got this wrong. “There are pro- and anti-Israel views in all European countries. Things are certainly no worse, as far as Israel is concerned, in this country than other European countries.”
The MP added that he could “understand the frustration” that people in Israel felt with “certain elements of the British broadcast media” which present an unbalanced view of Israel. He said: “I can understand Mr Peres’ concerns, but I don’t recognise what he is saying about England.”
Yet in Israel, Mr Peres is far from alone in holding such views, which have gained a wider following, particularly on the Right, since the expulsion of an Israeli diplomat over accusations that Mossad sent agents using British passports to assassinate a Hamas commander in Dubai.
Aryeh Eldad, a right-wing member of the Israeli parliament, the Knesset, accused Britain of working against Israeli interests for decades – ever since it “betrayed” its promises to build a Jewish homeland when it governed Palestine under a League of Nations mandate. “Both governments from the right and the left prefer Arab interests over Israeli interests,” said Mr Eldad, whose father Israel was a leading figure in the Stern Gang, the most radical of the Jewish terror groups that fought British mandatory rule.
“The other layer is an ongoing, subtle form of anti-semitism. It is not as overt as it was in Germany, it is a quiet, polite form.”
Some leading Jewish commentators in Britain disagreed. Rabbi Dr Jonathan Romain, minister of Maidenhead synagogue and a writer and broadcaster, said: “I am surprised at Peres. It is a sweeping statement that is far too one-sided. “Britain has supported both Israel and Arab causes at different periods over the last 50 years. There are elements of anti-semitism but it is not endemic to British society. “The tolerance and pluralism here make Britain one of the best countries in the world in which to live.”
Mr Peres found support, however, from other pro-Israeli groups. Jacob Vince, the director of Christian Friends of Israel, said there was anti-semitism in the UK although many people had a positive view of Israel but were unwilling to express it publicly.
Mr Vince said it was “difficult to see how many MPs would not be influenced by the number of Muslim voters in their constituencies”. The Government was not treating Arabs as the underdogs but rather was trying to appease them, he said. “The question is how well they understand those with whom they are seeking conciliation.”
Mr Peres is “measured and moderate,” he added. He said: “His comments have serious connotations and I am sure would not be said lightly.”
One Israeli politician expressed disbelief that the doveish Mr Peres had launched such a broadside against the British. Benny Begin, a cabinet minister whose father Menachem was prime minister and before that leader of Irgun, the group that killed 91 people in an attack on Jerusalem’s King David Hotel in 1946, said: “Peres? I simply can’t believe he said that.”
The latest figures show that the number of anti-semitic incidents in Britain is rising, according to the Community Security Trust (CST), a charity set up in 1984 to monitor such incidents. The situation in Britain had worsened “significantly” in the past decade, a spokesman said.
In 2009 there were 924 anti-semitic incidents, the highest figure since CST began keeping records in 1984, and 55 per cent higher than the previous record in 2006. The figures include reports, accepted only when backed by evidence, of physical assaults, verbal abuse and racist graffiti. The monthly figure has soared from 10-20 incidents in the 1990s to 40-50 now.
Last year nearly half of the 924 anti-semitic race attacks recorded by the CST showed a political motivation, with 66 per cent of those including some reference to Israel and the Middle East.
A 2009 report by the US-based Anti-Defamation League found one in five Britons admitted Israel influences their opinion of British Jews, and the majority of those said that they felt “worse” about Jews than they used to. It found, however, that Britain was less anti-semitic than other European countries.
360,000 troublemakers suspended from British schools last year
The sheer number of such suspensions shows what a futile disciplinary measure it is
More than 360,000 children were suspended from school last year amid Government warnings that classroom behaviour remains a “significant problem”. Pupils were temporarily barred from lessons 86,000 times for attacking teachers and classmates, while 3,440 suspensions were meted out for sexual misconduct.
Official figures show that large numbers of very young children were also excluded from state schools in England. Some 4,000 pupils aged just five or under were suspended in 2008/9, with a further 70 expelled altogether.
But data from the Department for Education showed an overall drop in the number of children kicked out of lessons compared with a year earlier.
The disclosure will fuel claims that schools are reducing the number of suspensions following the introduction of rules by Labour requiring them to educate pupils excluded for more than a week.
Ofsted has already warned that many secondary schools are giving children “managed moves” to other comprehensives to get around the policy.
The Coalition has pledged to crackdown on bad behaviour by introducing new powers to allow teachers to retain “control of the classroom”.
Nick Gibb, the Schools Minister, said: “Despite the fall in exclusions, poor behaviour remains a significant problem in our schools. “Tackling poor behaviour and raising academic standards are key priorities for the Coalition Government,
“We trust teachers and that’s why we have already announced a series of measures to put head teachers and teachers back in control of the classroom – including ending the rule requiring schools to give 24 hours written notice for detentions and increased search powers. “We will introduce further measures to strengthen teacher authority and support schools in maintaining good behaviour.”
According to figures, children were suspended 363,280 times last year – representing almost 4.9 per cent of the school population. In primary schools, 39,510 children were suspended. The average length of a suspension was two-and-a-half days and boys were three times more likely than girls to be punished. In all, 6,550 pupils were also permanently expelled from schools in England, compared with 8,130 a year earlier.
Physical assaults on fellow pupils were named as the main reason for fixed-period exclusions. Children were suspended 69,090 times for attacking peers, while a further 17,200 suspensions were made for assaulting staff. Pupils were barred on 93,000 occasions for threatening pupils and staff, while 3,440 suspensions were made for sexual misconduct, 8,580 for drug and alcohol use and 3,930 for racism.