Medical Royal Colleges Research Articles

WP4.9 - Audit on writing outpatient clinic letters in the general surgery department at a tertiary care hospital

Abstract Background Clinic letters are crucial medical notes for a patient’s medical history and medico-legal purposes. We assessed the quality of clinic letters with the guidelines from the Academy of Medical Royal College suggested for writing a clinic letter. Method A retrospective collection of data was done from January – May 2023 and a total of 166 clinic letters were collected by independent authors and then analysed to avoid any bias in the collection. Results Multiple parameters were poorly documented and are mentioned in increasing order of missing data – Plan for patient/carer (37.5%), Care planning arrangements (44.6%), Complications (67.5%), Anaesthesia issues (89.4%), Allergies (94%), Diagnosis (94%), Time (99.4%), Preferred name (100%) and Personal identifiers (100%). These findings were presented in the clinical governance meeting and to improve the quality of the clinic letters, we created a generic clinic letter including mandatory parameters suggested by the guidelines. Conclusion There were a few parameters missing from the analysed clinic letters. An adequate intervention after being discussed in the clinical governance meeting, in the form of a generic clinic letter has been introduced. A repeat cycle is planned in 3-5 months to assess the improvement in the quality. There was a lack of documentation, which improved after the intervention advised by QIP. A teaching session for new junior doctors is planned at the induction session, to strengthen the importance of frailty documentation.

Impact of the Proposed Closure of the NHS Practitioner Mental Health Programme for Doctors and Managers in Secondary Care

To reduce its financial deficit, NHS England decided to cull the funding of the Practitioner Health Programme (PHP), which has been providing confidential mental health services to 110,000 NHS doctors/ senior managers since 2011. This decision was announced when NHS doctors were in a dispute over pay and conditions, AND coincided with increasing prevalence of mental illness, stress and burnout. This decision raised concerns among doctors' unions, medical royal colleges, and doctors through social media. An open letter asked the Health Secretary to reconsider this decision. Access to primary care doctors was maintained. What appears not to have been considered is that around 50,000 junior doctors, including locally employed doctors and international medical graduates who are in short-term contracts or rotational attachments, are unlikely to meet the waiting time for such ‘secondary care OH services’. In addition, the elephant in the room of a massive challenge of the professional stigma that prevents doctors from accessing mental health support early seems to have been missed. This editorial briefly explores the causes of a high prevalence of stress and work-related mental illness amongst HCPs, the consequences on their overall health, employing organisations and their patients.

Mitigating the impact of blood shortages in England.

The supply of blood components and products in sufficient quantities is key to any effective health care system. This report describes the challenges faced by the English blood service, NHS Blood and Transplant (NHSBT), towards the end of the COVID-19 pandemic, which in October 2022 led to an Amber Alert being declared to hospitals indicating an impending blood shortage. The impact on the hospital transfusion services and clinical users is explained. The actions taken by NHSBT to mitigate the blood supply challenges and ensure equity of transfusion support for hospitals in England including revisions to the national blood shortage plans are described. This report focuses on the collaboration and communication between NHSBT, NHS England (NHSE), Department of Health and Social Care (DHSC), National Blood Transfusion Committee (NBTC), National Transfusion Laboratory Managers Advisory Group for NBTC (NTLM), National Transfusion Practitioners Network, the medical Royal Colleges and clinical colleagues across the NHS.

British Models of Person Centered Medicine

Background: The National Health Service (NHS) was established in 1948 as a publicly funded healthcare system in the UK providing universal health coverage that is comprehensive, equitable and free at the point of delivery. The British experience of person centered medicine (PCM) is enshrined in the NHS constitution. Objectives: The objective of this study was to highlight important developments in and evolution of PCM within the NHS in person-centered care (PCC), research and innovations in undergraduate and graduate health education. Methods: This is a narrative overview of the British experience of PCM. Results: It is evident that the British experience and practice of PCM have evolved naturistically over seven decades since the establishment of the NHS. Academic research groups in collaboration with the NHS have introduced person-centered models of care supported by pivotal research in practice. Importantly, person-centered nursing has been widely adopted following the early development of a framework for person-centered nursing and its extensive evaluation. There emerged many initiatives on PCM by National Voices, the Health Foundation, British medical schools and the Royal Medical Colleges. The landmark development was the production by the Royal College of Psychiatrists in the UK of the first blueprint for a postgraduate psychiatric curriculum that is in tune with person-centered psychiatry. Conclusions: It is envisaged that the NHS will evolve and increasingly promote, adopt, codesign and implement PCC approaches adapted to the local, regional and national contexts including services redesign, health education and applied health research. These innovations contribute to the universal development of person-centered healthcare and health education.

Undergraduate teaching of surgical skills in the UK: systematic review.

Students must be proficient in surgical skills according to General Medical Council and Royal College of Surgeons of England guidelines. If these skills are not appropriately taught, there is a risk of an incoming junior workforce with inadequate surgical skills. This paper aimed to review the literature relating to undergraduate teaching of surgical skills in the UK and summarize future suggested training methods. The databases MEDLINE, Embase and SCOPUS were searched, and the existing literature relating to methodology of undergraduate teaching of surgical skills in the UK over the past 10 years was summarized. The Medical Education Research Quality Instrument was used to assess research quality. A total of 19 papers were included. Cross-sectional evaluations and survey-based studies highlight a clear deficit in surgical skills teaching in the UK. Medical students are currently unable to fulfil their own learning needs and meet requirements set out by the General Medical Council. This lack of surgical teaching appears to negatively affect student desire to pursue a surgical career. The three main themes for improvement are extracurricular surgical skills days, near-peer teaching and simulation. Each method appeared to improve learning, although no studies utilized medium- to long-term follow-up to demonstrate efficacy and there lacks a clear consensus as to the 'standard' of undergraduate surgical skill education. There was also potential for selection bias and response shift bias in many of the studies assessing pre- and postintervention confidence and opinions. There is a concerning lack of surgical skills teaching that has resulted in medical students and junior doctors not having the necessary surgical skills as per General Medical Council guidance and students feel that their own learning needs are not met. This failure to address the learning deficit may be responsible for the fall in surgical competition ratios. While surgical skills teaching must be improved urgently, more robust evidence is required to evaluate the optimal ways of approaching this issue.

Medical royal colleges receive millions from drug and medical devices companies

Medical royal colleges receive millions from drug and medical devices companies

The Quality of Discharge Summaries at Al-Shaab Hospital, Sudan, in 2022: The First Cycle of a Clinical Audit.

Background The discharge summary is a vital component of the modern health system. It is defined as a synopsis of information regarding events occurring during the inpatient care of a patient, to allow for a safe, quick, and effective patient-centered discharge process. It contains important information about the patient's hospital stay, including the reason for admission, treatment received, and follow-up needed. Low-quality discharge summaries pose a great risk to patient healthcaresince the most frequent reason for error in clinical settings is poor communication.In the United Kingdom, the Professional Record Standards Body (PRSB) has adopted the Academy of Medical Royal Colleges (AoMRC) "Standards for the Clinical Structure and Content of Patient Records" and produced a standard discharge summary form. This study aimed to assess the quality of discharge summaries at Al-Shaab Hospital in Sudan in terms of information, filling adequacy, and adherence tointernational guidelines and evaluate the discharge interviews. Methods A cross-sectional institution-based study was conducted in the period of September to December 2022 at Al-Shaab Teaching Hospital in Khartoum, Sudan. Systematic random sampling was used to select the study participants from the discharged patients. A total of70patients were met in their wards over a period of two months, and the contents of their discharge cards were compared to items on an online checklist based on the Professional Record Standards Body (PRSB) and the Academy of Medical Royal Colleges (AoMRC) standard discharge summary. The patients were also interviewed to assess their knowledge regarding their discharge information. Results The hospital's discharge summary formcontained only four headings: date, patient name, age, and ID number. The assessed cards were found to be missing valuable information, including date of admission (missing in 83%), filling doctor's name (missing in 71%), and medication changes (missing in 70%). Only half of the summaries were clearly readable. The majority of patients had poor knowledge regarding their medication side effects (89%) and how to act in an emergency (86%), while knowledge of medication doses and follow-up details was good in 80% and 66%, respectively. Conclusion The patients are discharged with inadequately filled discharge forms. This may be due to the poor design of the form, so a newly designed form will be proposed, based on international standards. The discharge interview is also in need of improvement, to make sure patients are fully aware of their condition.

The Final Straw

The straw that broke the camel's back came from a most unexpected source. It was the sudden removal of all access to safe drinking water in an acute medical unit in one of the largest hospitals in the country. This action left a 58 bedded unit with over 100 members of staff without access to a vital ingredient of health and wellbeing. In a system which has come through unpredictable, unreliable and inadequate access to personal protection equipment throughout the various surges of the COVID-19 pandemic, this was something that all the mandatory training in resilience should have given strength to pull through. But sadly, it seemed to be the final straw. 
 So, I was going to suggest a different strategy, one that included arranging rotations with international partners and of inducting colleagues from allied health professions to share responsibilities of patient care much more than they are able to do at present. Both of these moves will require an open mind, a long-range vision from our leaders and flexibility from our regulators. We need sustainable models where junior doctors and nurses come on planned rotations from countries such as the Commonwealth where education and training are aligned but return to their countries enriched with their experience. The BAPIO Training Academy has similar schemes in place and all the Medical Royal colleges are keen to populate their medical training initiatives with international partner institutions. There needs to be a recognition and celebration of the diversity of the workforce and the contribution of migrants. An acceptance by the people of how the war was won and the country was rebuilt by the blood, sweat and tears of migrants working shoulder to shoulder with their UK peers. This change in mindset has to come from the top. Many had hoped that the first UK Prime Minister of colour may bring that change in mindset. Unfortunately, this is not what appears as Rt Hon Rishi Sunak MP moving swiftly from the diversity of Diwali celebrations in Downing Street to pushing the boats back rhetoric. A change is needed. We, in the health service need to be the change (in mindset of equality, diversity and inclusion) that we wish to see. The final straw must not break the camel’s back.

Assessing the Correct Documentation of Time and Physician Information on Medical Records in the Emergency Department of Queen's Hospital: An Audit and Re-audit.

Medical records are confidential medical and legal documents describing a patient's contact with a healthcare facility. Thequality of documentation has been found to be lower in settings of high patient volume and complex cases, such as the emergency department (ED). The variety and number of healthcare professionals involved in the care of the patient also negatively affect the quality of documentation. The aim of this paper is to present the results of an audit and re-audit conducted in the ED of Queen's Hospital, Romford, to assess ED record documentation against General Medical Council (GMC) and Royal College of Physicians (RCP) standards. For the audit, all records of patients who were discharged from the ED of Queen's Hospital in one day were reviewed and evaluated on whether they have a date, time, the full name of the physician, their GMC number, and signature documented, as per GMC and RCP official guidelines. No medical information or patient data were recorded. After the implementation of the change aiming to raise awareness of ED staff, a new sample was collected two months later, and the same parameters were assessed against the set standards. Results of the audit showed a low percentage of documentation of all parameters, especially of GMC number and signature. After the presentation of the results and implementation of change, the results of the re-audit demonstrated significant raise in all percentages, with a relative improvement of 40% regarding the recording of GMC number and 65% regarding signature. However, the documentation of these two parameters remained low and below acceptable levels. The re-audit results underline that the low compliance was significantly improved after the implementation of measures aiming to increase correct documentation awareness among ED staff. However, to maintain and even raise the level of current practice, additionalsystematic measures need to be put into action.

Discussing spiritual health in primary care and the HOPE tool—A mixed methods survey of GP views

In the UK, the General Medical Council (GMC) and Royal College of General Practitioners (RCGP) require doctors to consider spiritual health in their consultations. There are documented barriers to discussion of spiritual health, and suggested tools to help overcome them. To investigate how comfortable general practitioners (GPs) feel about discussing spiritual health in the consultation, and whether a structured tool (the HOPE tool) would be helpful. A mixed-methods online survey completed by GPs in England. A mixed methods online survey of practicing GPs in England asked about current comfort with the topic of spiritual health and use of spiritual history-taking tools. The acceptability of the HOPE tool was investigated using patient vignettes drawn from clinical practice. 177 GPs responded. 88 (49.71%) reported that they were comfortable asking patients about spiritual health. GPs felt most comfortable raising the topic after a patient cue (mean difference between pre and post cue 26%). The HOPE tool was viewed as acceptable to use with patients by 65% of participants, although its limitations were acknowledged. Qualitative data showed concerns about regulator (the GMC) and peer disapproval were major barriers to discussions, especially in the case of discordance between patient and doctor background. Only half of GPs are comfortable discussing spiritual health. Dedicated training, using a structured approach, with regulatory approval, may help overcome barriers to GPs discussing spiritual health. Further research into the benefits, and risks, of discussion of spiritual health in the GP consultation is recommended.

Charter for Locally Employed Doctors in the UK Health Service

Locally employed doctors have been described along with their compatriots as 'the lost tribe' compared to their peers who are either in formal training, consultant, or general practitioner posts. Over the lastdecade, considerable progress has been made in improving the recognition, value, and respect given to doctors in Specialty, Staff Grade or Associate Specialist (SAS) roles with harmonised contracts, working conditions and support available. The vast majority of the cohort of over 127,000 doctors in the SAS-LED category as per the UK medical register (GMC 2022 dataset) continue to be lumped with their SAS historicalcounterparts yet have a very different experience. These LEDs are unsung and unheard and remain voiceless in the UK NHS medical staff, yet continue to provide service in delivering high-quality healthcareto the nation.
 This Charter is ambitious in its aspiration and aims to deliver the 'Gold Standard' for all LEDs. It was developed following a prolonged exercise of listening to the experiences of many LEDs within themembership of BAPIO across its affiliated organisations and social networks. It is unique in being developed and written by LEDs and IMGs early in their careers or by those transitioning to more establishedsenior and autonomous roles. So it is grounded in the reality of lived experiences and ambitious in setting the bar at an equal level with other doctors in the UK NHS.
 The LED Charter offers ten practical recommendations for implementation by all NHS employing organisations. Most of the principles of equality and inclusion described in this Charter should be embraced by the medical royal colleges, education and training agencies (i.e. Health Education England) in their committees and processes to provide a voice to this 'lost tribe'.

Could BMPs Therapy Be Improved if BMPs Were Used in Composition Acting during Bone Formation in Endochondral Ossification?

The discovery of bone morphogenetic proteins (BMPs) inspired hope for the successful treatment of bone disorders, but side effects worsening the clinical effects were eventually observed. BMPs exert a synergistic effect, stimulating osteogenesis; however, predicting the best composition of growth factors for use in humans is difficult. Chondrocytes present within the growth plate produce growth factors stored in calcified cartilage adhering to metaphysis. These factors stimulate initial bone formation in metaphysis. We have previously determined the growth factors present in bovine calcified cartilage and produced by rat epiphyseal chondrocytes. The results suggest that growth factors stimulating physiological ossification are species dependent. The collection of human calcified cartilage for growth factors determination does not appear feasible, but chondrocytes for mRNA determination could be obtained. Their collection from young recipients, in view of the Academy of Medical Royal Colleges Recommendation, would be ethical. The authors of this review do not have facilities to conduct such a study and can only appeal to competent institutions to undertake the task. The results could help to formulate a better recipe for the stimulation of bone formation and improve clinical results.

Implementing the HEART score in an NHS emergency department: can identity leadership combined with quality improvement promote racial equality?

PurposeThe purpose of this paper is to report on the dynamics of “identity leadership” with a quality improvement project undertaken by an International Medical Graduate (IMG) from Sri Lanka, on a two year Medical Training Initiative (MTI) placement in the National Health Service (NHS) [Academy of Medical Royal Colleges (AoMRC), 2017]. A combined MTI rotation with an integrated Fellowship in Quality Improvement (Subedi et al., 2019) provided the driver to implement the HEART score (HS) in an NHS Emergency Department (ED) in the UK. The project was undertaken across ED, Acute Medicine and Cardiology at the hospital, with stakeholders emphasizing different and conflicting priorities to improve the pathway for chest pain patients.Design/methodology/approachA social identity approach to leadership provided a framework to understand the insider/outsider approach to leadership which helped RH to negotiate and navigate the conflicting priorities from each departments’ perspective. A staff survey tool was undertaken to identify reasons for the lack of implementation of a clinical protocol for chest pain patients, specifically with reference to the use of the HS. A consensus was reached to develop and implement the pathway for multi-disciplinary use of the HS and a quality improvement methodology (with the use of plan do study act (PDSA) cycles) was used over a period of nine months.FindingsThe results demonstrated significant improvements in the reduction (60%) of waiting time by chronic chest pain patients in the ED. The use of the HS as a stratified risk assessment tool resulted in a more efficient and safe way to manage patients. There are specific leadership challenges faced by an MTI doctor when they arrive in the NHS, as the MTI doctor is considered an outsider to the NHS, with reduced influence. Drawing upon the Social Identity Theory of Leadership, NHS Trusts can introduce inclusion strategies to enable greater alignment in social identity with doctors from overseas.Research limitations/implicationsMore than one third of doctors (40%) in the English NHS are IMGs and identify as black and minority ethnic (GMC, 2019a) a trend that sees no sign of abating as the NHS continues its international medical workforce recruitment strategy for its survival (NHS England, 2019; Beech et al., 2019). IMGs can provide significant value to improving the NHS using skills developed from their own health-care system. This paper recommends a need for reciprocal learning from low to medium income countries by UK doctors to encourage the development of an inclusive global medical social identity.Originality/valueThis quality improvement research combined with identity leadership provides new insights into how overseas doctors can successfully lead sustainable improvement across different departments within one hospital in the NHS.

Expanding the Scope of Mentoring for Psychiatry Trainees in Northern Ireland

AimsThe Northern Ireland psychiatry mentoring scheme, in which higher trainees mentor core trainee year 1 (CT1) doctors, has been running for four years. In this year's scheme, implemented in August 2021, we have expanded the scope of the scheme and implemented an online platform to match and connect mentors and mentees. Our aim was to gather baseline data regarding the experiences of mentors and mentees and to capture information regarding the content of mentoring meetings and attitudes towards format of meetings.MethodsHigher psychiatry trainees were invited to sign up as mentors through the Northern Ireland Medical and Dental Training Agency (NIMDTA) and Royal College of Psychiatry Northern Ireland (RCPsych NI) mailing lists. Mentors were obliged to complete a theoretical module on training before meeting their mentees. Core trainees in the first and second year of training were asked to opt-out of the scheme if they preferred not to be involved. CT3 trainees were offered the opportunity to opt-in to the scheme. There were a total of 16 mentors and 22 mentees at the outset. The NIMDTA Professional Support Unit provided an online platform, Mentornet, which allowed mentors and mentees to complete a profile, for mentees to rank their preferences for mentor, and to facilitate meetings. One of the authors (M.M.) presented the developments in the scheme to a nationwide audience in the RCPsych webinar on mentoring.ResultsSix mentors and two mentees responded to the call to complete a baseline online questionnaire. 83% of mentors responded that they had found their role enjoyable and rewarding, whilst 67% of mentors indicated that their role had helped them develop in other skill areas. Both mentees responded that they had found the scheme beneficial and would recommend participation to other trainees.ConclusionMentorship is a valuable opportunity for senior psychiatry trainees to facilitate the professional development of junior trainees and to pass on their experience. This is the first year that all core trainees have been invited to participate and that a new web platform has been used to facilitate meetings. Baseline feedback response numbers have been limited although the responses were universally positive. We intend to obtain further feedback at the end of this year in order to devise quality improvement measures for the 2022/2023 cohort.

How Readable Are Consultant Psychiatrist Letters From the Mental Health Liaison Team?

AimsTo assess whether consultant discharge letters from the mental health liaison team are: 1. Written to patients as advised by NICE shared decision making guidance. 2. Easy to read using the Flesch Reading Ease Test as advised by the Academy of Medical Royal Colleges, which equates to a score of 60 to 70.Methods50 consultant discharge letters were collated from April to November 2021. Each letter was assessed whether they were written directly to a patient and scored according to their Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) via Microsoft Word.FRE scores a text from 0 to 100 from the average length of sentences and the number of syllables in words to indicate its difficulty to read. The higher the score achieved, the easier it is to read the text. It is a recommended tool by The Academy of Medical Royal Colleges’ guidance on outpatient clinic letters, however, does not specify a target level of readability. A score of 60 to 70 equates to plain English easily understood by students aged 13 to 15 years and was concluded to be the equivocal score expressed in the guidance.4The FKGL presents a score as a U.S. grade level to indicate the level of education generally required to understand a text. Words per sentence and syllables per word are factored in to calculate the grade.5ResultsThe median FRE was 50.9 (n = 50, IQR 8.9). Only one letter met the desired standard. The mean score was 50.6 (SD 6.4). This mean was significantly different from a hypothetical ideal mean of 65 (t(df) = 15.9(49), p < 0.0001) so could not, unfortunately, be explained by chance. The median FKGL was 10.1.ConclusionOverall, the letters were of greater difficulty than the desired score of both FRE and FKGL. Lay language and patient-directed writing will aid in improving scores.

177 Outpatient letter writing in the neurology department

ObjectiveAs a predominantly outpatient-based specialty, neurology clinic letters are a vital, yet often overlooked, communication tool. This study aims to evaluate whether current Neurology outpatient letters in University Hospital of Wales meet the standards suggested by the Academy of Medical Royal Colleges and the Professional Records Standards Body.MethodsAn assessment proforma was created based on the standards. A retrospective sample of consult- ant letters from General Neurology, Epilepsy and Multiple Sclerosis outpatient clinics throughout January 2019 were assessed. 2–4 letters were randomly selected from each clinic, aiming for equal numbers of follow-up and new cases.Results187 clinic letters were assessed, from 12 different anonymised consultants. Letters universally achieved ‘mandatory’ PRSB headings, fewer meeting non-mandatory headings. There was a wide variety in style and content, with consultants’ mean word counts ranging from 89 to 537. Turnaround delay between clinic and typing ranged from 0 to 79 days, with 79.7% of letters copied to the patient.ConclusionThough mandatory content was achieved, consistency and clarity often lacked. Present- ing the results at audit meeting prompted much interest and discussion. Many supported implementing a departmental letter structure and exploring reducing turnaround delay to improve the quality and efficiency of outpatient letters.LockFJ@cardiff.ac.uk

390 Assessing the Standard of Operative Notes Within a Vascular Surgery Department: An Audit Cycle

Abstract Aim Both the General Medical Council and Royal College of Surgeons of England’s (RCSEng) ‘Good Surgical Practice’ state that all clinical documentation must be recorded clearly, accurately, and legibly. The operative note is not just a means of communicating post-operative plans but can also be used for medico-legal purposes. The aim of this audit cycle was to ascertain how well the operative notes within a Vascular Surgery department adhered to the guidelines devised by RCSEng. Method 40 operative notes were analysed prospectively against the criteria stated in the ‘Good Surgical Practice'. The surgeons were made aware of the initial results via a departmental meeting. Using the Plan-Study-Do-Act (PDSA) model, we studied the pre-existing operative note template and created an aide-memoire highlighting the criteria with poor compliance. This was placed in all the vascular theatres. A re-audit was then undertaken 2 months after. Results In the first audit, we noted good compliance in areas that were included in the pre-existing template such as date (97.5%), name of operator (97.5%), name of anaesthetist (100%), operative procedure (100%), and closure technique (95%). Areas in need for improvement included time (0%), anticipated blood loss (2.5%) and elective/emergency procedure (10%). The second cycle demonstrated improvements (100% compliance) in most parameters. Documentation of time, elective/emergency procedure, and legibility showed minimal improvement. Conclusions This audit highlighted the importance of greater awareness of the expected standard of note documentation. Implementation of proformas and electronic documentation can effectively circumvent issues related to variability and legibility, and ultimately improve patient safety.

159 The Role of Proformas in Improving the Documentation of Surgical Ward Rounds

Abstract Introduction Several NHS trusts rely on handwritten notes, including ward round (WR) reviews. These are essential in-patient care and must be completed/documented thoroughly. The General Medical Council and Royal College of Surgeons have both published guidance on WR documentation. Method This was a prospective study aiming to review WR documentation within general surgery at Frimley Park Hospital. 17 WR entries were reviewed using an 18-point checklist. A proforma was created based on published guidance and gaps in reviewed documentation. This was introduced for two months before a repeat review was conducted. A third review was conducted after an additional month to monitor for sustained improvement. Results Strengths in the baseline included documentation of WR leads (100%) and plans (100%), legible handwriting (95%), and NEWS score (88%). Common weaknesses were documentation of full observations, anticoagulation (both 6%), and relevant bloods and imaging (both 12%). The two months post-proforma review found improvement in all 18 areas of documentation, with five elements scoring 100%. Documentation of anticoagulation improved from 6% to 94%, relevant bloods from 12% to 82%, and full observations from 6% to 76%. Higher scoring WRs were linked to pre-prepared proformas, with lower scores linked to post-take WRs. The review was repeated after an additional month, showing consistently improved results in all areas. Conclusions This project has shown significant and sustainable improvement in WR documentation with the proforma. This project would therefore recommend the continued use of the proforma, and an additional review after the junior doctor change over to show continued sustainability.

EP.TU.740Implementing a departmental handbook to improve induction for FY1s during COVID-19 pandemic

Abstract Aims The 2020 cohort of FY1s qualified during the COVID-19 pandemic; most prequalification placements were cancelled. Induction provides crucial information for new FY1s. We assessed the impact of redesigning the General Surgery induction handbook at Hereford County Hospital. Methods A 40-question survey, designed against standards in ’Recommendations for safe trainee changeover’ published by the Academy of Medical Royal Colleges, was sent to all FY1s commencing General Surgery in August 2020 two weeks following induction. The survey contained 5 sections: introduction; testing your knowledge parts A and B; team atmosphere; and demographics. Answer modalities included: binary answer; multiple choice; Net Promoter Scores (NPS); and free text. Submissions were made electronically via Microsoft Forms. Feedback guided redesign of the induction handbook which was sent to FY1s rotating December 2020. Information included: how to contact seniors; requesting investigations; referring to specialties and expected duties. A repeat survey was sent to FY1s 4 weeks following induction. Results 10/11 FY1s responded during the first rotation; 9/11 during the second. FY1s felt more confident requesting bloods (NPS +50 to + 90), requesting imaging (NPS –20 to + 70), completing discharge summaries (NPS +30 to + 80) and referring to specialties (NPS –40 to + 60). There was a better understanding of different shift types (NPS –40 to + 30). More FY1s correctly recalled on call bleeps for the medical registrar (from 56% to 75%) and the anaesthetic registrar (from 50% to 78%). Most (78%, NPS +78) felt they had enough support from other FY1s which remained the same (NPS +78) through the second rotation. As a result of the COVID-19 pandemic, prequalification experience varied greatly between individual FY1s. Conclusion Overall, FY1s were more confident requesting investigations, referring to other specialties and completing discharge summaries after redesign of the induction handbook. Considering disruptions in pre-qualification training as a result of the COVID-19 pandemic, a thorough departmental induction handbook can be an invaluable resource tool to aid rotation into a new specialty.

EP.FRI.992 Milking the COW: A pilot study of seven-day consultant working

Abstract Aims The Five Year Forward View, predicts a funding gap of nearly £30 billion per year by 2020/21, with continued disparity in resources and healthcare demand. Further, the view describes ever widening gaps in three main domains of healthcare; prevention, quality and efficiency. Those domains raised are echoed in the efficient operative working of a general surgical service with an aged, co-morbid population and inefficient theatre utilisation with increasing case cancellation due to lack of bed space. In 2012, the Academy of Medical Royal Colleges recommended patients have the same standard of care seven days a week, with consultant review ‘at least once every twenty-four hours’. In general surgery, will a seven-day consultant led working model with a ‘consultant of the week’ (COW) enable more rapid and appropriate decisions to be made for patients enabling their efficient treatment and reducing length of stay. Method A retrospective analysis of hospital length of stay and mortality before and after the implementation of a consultant led weekday and weekend service in general surgery was carried out looking at data in October 2017 and 2018. Results The introduction of enhanced seven-day working is associated with reductions of one fifth in length of stay but no difference in mortality. Conclusions Whilst statistically significant associations with the COW and reduced length of stay have been made, the clinical significance of one fifth of a day may be negligible. Continued data collection over a longer time period, prospectively will increase the power of the study.