The NHS and training in obstetrics and gynaecology

The NHS and training in obstetrics and gynaecology in the UK Dr Lisa Joels MD FRCOG July 2011 © Royal College of Obstetricians and Gynaecologists

Aims • To understand how the NHS is organised • To understand specialty training in the UK – What skills and competences are expected of an ST 5 registrar – The role of the ST 5 registrar in the multidisciplinary team

The NHS • Provides healthcare free at the point of need based on clinical need not ability to pay • England three devolved nations but all broadly similar to each other – Any exam question will avoid reference to specific country, default position is English system

Funding the NHS • Funded by taxation • Budget devolved to local bodies – Primary care trusts, local health boards etc. • Some treatments have restricted funding – IVF, cosmetic surgery, varicose vein surgery • Self referral – Accident & emergency – In O&G – early pregnancy clinic, labour ward

Structure of the NHS • Primary care – Diagnostics – Initial management – Gatekeeping of referrals • Secondary care – Hospital based specialties • Tertiary care – Region wide provision of specialist services • Quaternary care – UK wide subspecialties

Structure of the NHS: secondary care • University / teaching hospitals • Large district general hospitals (DGH’s) – Trauma centre • A&E, orthopaedics, burns and plastics & neurosurgery • Small DGH’s • Community hospitals – Visiting consultants

Structure of the NHS • National priorities – Targets, health improvement programmes – Waiting times • Care quality commission • Medical negligence schemes – E. g. CNST – Principles of clinical governance

Structure of O&G services • Neonatal network – Regional centres <25 weeks gestation – Neonatal intensive care – Special care – Transitional care • Hospital care – Consultant led unit – Midwifery led unit – stand alone/co-located • Home births

Gynae-oncology • Cancer networks – regional – Cancer centres - tertiary services: • Vulval cancer • Wertheims / laparoscopic radical hysterectomy • Multidisciplinary approach – Cancer units – DGH’s • Two week wait – 10 working days • Cervical screening programme

General gynaecology • Office gynaecology • General gynaecology – ? Major gynae surgery done by specialists only • Subspecialty gynaecology • Involvement of specialist nurses – Early pregnancy – Surgical assistants – Nurse practitioners

The clinical team Managers Consultant Midwives Registrar General practitioners Specialist nurses Senior house officer Supporting staff HCA’s, Porters etc

The clinical team • During office hours: – European working time directive – shifts – Handover is key element of team working – Indirect and direct supervision • The on call team: – Resident: minimum – 1 registrar or SHO – Usually I registrar and 1 SHO + 1 anaesthetist – Consultant on call from home (Obs +/- Gynae) – More recently consultant obstetrician resident

Specialty training in O&G • Specialty training programme – Overseen by Specialty Education Advisory Committee (SEAC) responsible to GMC • Core curriculum – Defines knowledge, skills, attitudes & competencies – Mapped to Good Medical Practice (GMC) – Defines evidence needed • Completion of training – CCT/CESR entry on to specialist register

Training structure

The membership exam • Not an exit examination • Certifies knowledge, skills and attitudes of core training • Entry to special interest training – ATSM’s – Subspecialty programmes

The skills of an ST 5 trainee • Indirect supervision: – Vaginal breech – Twins – Complex caesarean section – Laparoscopy – Laparotomy • Direct supervision

The skills of ST 5 trainee • Indirect supervision • Direct supervision – Maternal collpase – Eclampsia – Massive obstetric haemorrhage – Return to theatre • Don’t just answer “I would inform/call the consultant” – Real world vs knowledge expected for the exam

The core curriculum • 19 modules – Knowledge, skills attitudes and competencies – Blueprinting to ensure complete coverage of curriculum for each exam diet • E portfolio • Annual review of competence progression

Summary • In order to understand what is expected in answers – need to understand structure of NHS – AND – What is expected of an ST 5 trainee