SPA days for all trainees?

Alexander Hall and Joanna Spence

The Issues

Supporting Professional Activities (SPA) time is a part of each consultant’s new contract. When the new consultant contract evolved in 2003, a suggested breakdown of the week was 7.5 sessions (1 session equates to 4 hours) for direct clinical care (DCC) and 2.5 sessions for SPAs.¹ This was driven by the need for consultants to continue their own professional development (CPD) as well as having the time for input into the development of trainees and medical students.

Examples of CPD work for consultants could include audit for improvement of service or patient care, teaching of patients, medical students or trainees, research, publications, aspects of hospital management and involvement in simulation courses e.g. Advanced Life Support (ALS)/Advanced Paediatric Life Support (APLS).

The General Medical Council (GMC) requires that during annual appraisals, doctors should use supporting information to demonstrate they continue to follow “Good Medical Practice”. This mandates that doctors should ‘take part in educational activities that maintain and further develop’ their competence and performance.¹ With regard to revalidation, the GMC states you will have to demonstrate that you regularly participate in these activities; at Annual Review of Competency Progression (ARCP) it is imperative that accurate records of these CPD activities are presented at the annual job plan review.²

It is clear, therefore, that the provision of allocated time during the working week to complete these aspects of work life are deemed necessary for consultants. The Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland both support the original view that a consultant should “typically” have 2.5 SPAs in their contract (though this would have to be subject to individual workload). With the demands of service provision it is clear that consultant SPAs are under threat, with around 40% of new consultants offered jobs with fewer SPA sessions than are thought necessary to allow sufficient non-DCC work.³

Since trainees are subject to similar appraisal and development requirements, we wonder if trainees should be allocated SPA time? For progression through training years and to pass the ARCP, it is necessary to provide evidence of trainee development within clinical practice in a similar way to consultants. This can involve a great deal of extra time. Once (notoriously difficult) exams have been passed, each trainee must go through the application process and prove what skills they have assimilated during their training to date. In fact, the ST3 anaesthesia application criteria states that the following are some of the ‘desirable’ criteria that require evidence:

• Relevant academic and research achievements
• Involvement in an audit project, or quality improvement project
• Interest and commitment to the specialty beyond the mandatory curriculum
• Evidence of interest in, and experience of, teaching
• Instructor status in an advanced life support course (ALS, APLS)
• Involvement in management…and understanding of management
• Effective multi-disciplinary team working and leadership
• Effective leadership in and outside medicine
• Achievement outside medicine
• Altruistic behaviour, e.g. voluntary work

The list is extensive and clearly requires a lot of time and input outside of the normal working week. With the expectation that trainees should be prepared to move straight from CT2 to ST3 (assuming their exams are completed), these desirable criteria must be addressed alongside completing other mandatory aspects of training such as, for anaesthesia: an Initial Assessment of Competency (IAC), an Intensive Care Unit (ICU) module, an Initial Assessment of Obstetric Competency (IAOC) and 15 Units of Training. With all these challenges between a core anaesthetic trainee and potential specialist anaesthetic training, there seems little time to complete an adequate number of the desirable criteria; this is a compelling reason to facilitate some time into the trainee contract to help produce more well rounded trainees.

However, therein lies the challenge - anaesthetic training is such a busy programme. Trainees are involved with multiple areas within a hospital such as ICU, theatre work or Obstetric Delivery Suite that they must learn and practice a wide range of skills to demonstrate the proficiency expected of a consultant anaesthetist. With experience of clinical work already at a premium due to European Working Time Directive hours, creating a good teaching environment whilst providing service provision is a hard enough task. It might seem difficult, therefore, to justify taking away yet more clinical time for trainees.

The proposed “7 day National Health Service (NHS)” contract could also pose more difficulties. Current example rotas released by NHS Employers demonstrate an increased likelihood of shift-work for a typical ICU rota.⁴ This shows trainees will be working more weekends and nights than at present, which could reduce the time spent directly with consultants. This would make introducing more non-DCC work difficult to justify as it would likely occur during daylight hours – when training could occur.

How it could be introduced:

Assuming SPA sessions for trainees were implemented, there would also be practical aspects to address. For example, how many SPA sessions to allocate for each level of trainee and how to monitor that this time was spent effectively and efficiently.

Monitoring:

Trainees could propose which aspects to focus on during their SPA sessions, such as management, teaching, quality improvement projects or more time in their sub-specialty interest. The goals could then be set at the initial educational supervisor meeting, much like a Personal Development Plan (PDP), and monitored throughout the year. This would give focus to any SPA time and ensure it is effectively used. If a trainee abuses their time or is not using it appropriately then removal of SPA time could be enforced. This would give the trainees more ability to improve the skills so often considered additional to trainees.

Funding:

In times of NHS austerity, funding would also need addressing. Potentially neither Deanery nor Trust might be willing to pay a doctor for days spent working outside the hospital workload – such as in educational roles or as a college tutor.⁵ A trial in one single deanery could assess the efficacy of such a scheme.

A possible solution would be to remove a few days of study leave allowance, as many trainees do not use their whole entitlement, and re-assign these to SPA time, allowing a trainee more flexibility. Trainees could initially start with fewer SPA sessions when more junior, to allow more clinical time, increasing SPAs to one per week for intermediate or higher trainees who may well be approaching their Certificate of Completion of Training (CCT).

Conclusion:

There are some practical difficulties in establishing trainee SPA sessions and no doubt many feel all contracted time should be spent practicing anaesthesia. However, given the changing way trainees are recruited via a ‘tick-box’ national application system, together with the variety of non-clinical skills expected by consultancy such as an ability to teach, conduct audit work, engage in managerial roles etc., a small change in the training set-up could produce more rounded trainees, benefitting anaesthesia in general and training programmes in the future.

References

1. General Medical Council. GMC/REV-SI/0114. Supporting information for appraisal and revalidation. Manchester. 2012. http://www.gmc-uk.org/revalidation (accessed October 12 2014)
2. Birks R, Nightingale P. The AAGBI and RCOA view of time for supporting professional activities (SPAs). Anaesthesia News. 2010; 271: 5
3. Barlow T, Barlow D, Edwards A. Consultant Contracts in England: how many SPAs do you have? BMJ careers. 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20007422 accessed Nov 13 2014)
4. NHS employers. Rotas. 2016. http://www.nhsemployers.org/your-workforce/need-to-know/junior-doctors-contract/pay-calculator/rotas#Rota15 (accessed April 5 2016)
5. McLaughlan C. Supporting Professional Activity – a cause of confusion. Bulletin. 2012; 74:41

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