SOCIETY FOR CARDIOTHORACIC SURGERY IN GREAT BRITAIN … · 2017-08-01 · 2 Meeting RCS Eng with Mr Chukwuemeka and RCS Professional Support Manager and Ass Director for Professional

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SOCIETY FOR CARDIOTHORACIC SURGERY

IN GREAT BRITAIN AND IRELAND

EXECUTIVE COMMITTEE PAPERS

Friday 9th October 2015

10:30hrs Moynihan Room, Royal College of Surgeons, London

1. STANDING REPORTS

i. STANDING REPORT FROM THE PRESIDENT

T Graham

A. MEETINGS ATTENDED / PARTICIPATED

MEETING DATE MINUTES

Meeting NHS Choices NHS Eng at RCS Ed Birmingham 04.06.15

SCTS Executive RCS Ed Birmingham

05.06.15

FSSA meeting Glasgow

Joint FSSA / RCPSG meeting

15 – 16.06.15

Malaysia review national CT surgery training

programme

20 – 27.06.15

Meeting Pres RCS Eng and Jackie Weller Director of

Internal Services RCS Eng Project 2020

01.07.15

HQIP data validation day London and subsequent

meeting with NICOR and HQIP

01.07.15

Meeting Scott Prenn re marketing strategy

01.07.15

NACSA database review meeting SCTS/ NICOR at RCS

Eng

03.07.15

Teleconferences WSSHC re CT surgery in Wales

10.07.15

Teleconference with Director of Planning WHSSC and

RCS Eng Wales advisor

10.07.15

Teleconference Jane Ingham CEO HQIP

17.07.15

Teleconference Chair SSG RCS Ed re joint working 27.07.15

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Meeting RCS Eng with Mr Chukwuemeka and RCS

Professional Support Manager and Ass Director for

Professional standards re SCTS/RCS approval

consultant jds / job plans and input of SCTS into AAC

process

07.08.15

Attended JSCFE General Surgery exam Kuala Lumpur

as JSCFE Chair and Examiner Assessor

17 – 21.08.15

KL – meeting with provisional Malaysia board of

cardiothoracic surgery / MACVTS at Acadamy of

Medicine Malaysia

21.08.15

Attended 3rd International Heart Care Conference

Bangkok Thailand

Spoke at Joint Global Harmonisation of Education

session

03 – 06.09.15

PLG NICOR meeting UCH London

16.09.15

Birmingham Review Course

17 – 20.09.15

EBCTS Examination Amsterdam

01 – 02.10.15

EACTS Amsterdam

03 – 07.10.15

Chaired Postgraduate Educational session

04.10.15

National Specialties Associations Meeting

06.10.15

Meeting with RCS England Mr Fountain Internal

Services re SCTS Legacy / Project 2020

08.10.15

Meeting with SCTS Meetings Team / Education team

at RCS Eng

08.10.15

SCTS Showcase event (Scott Prenn) at RCS Eng

08.10.15

B. MATTERS OF INFORMATION FOR THE EXECUTIVE COMMITTEE:

President meetings and commitments schedule as above

Most of these issues will be raised in the body of the Executive meeting – but I would like to

focus the Executive’s attention on the following:

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• National Clinical Audits

The SCTS / NICOR NACSA for 2011 – 14 has now completed and the information is available on

the SCTS website for units and individual surgeons and on the COP / NHS website for individual

surgeons. We have had a difficult summer with NICOR HQIP and COP/NHS E which has

required considerable effort from SCTS officers to maintain the position and interests of SCTS

and members.

A final list of individual surgeons’ positive and negative outliers was provided to SCTS on 5 June

following which calls were made to individuals, some of which needed to be reversed – causing

embarrassment

NICOR were committed to publishing positive outliers despite SCTS advice and initially a large

number were identified. Following a challenge and 3 different sets of statistical methodologies

there were no major positive outliers identified.

All the previous outcome data was taken down from the SCTS website at one point by an

external party without permission or knowledge of the SCTS.

There were several other issues as well which the clinical audit chair will describe including the

timeline and details of events in his report including the current situation with the COP outputs.

These events have undermined the relationship between SCTS and in particular NICOR. Before

the next NACSA phase SCTS have requested a meeting with NICOR HQIP COP/NHS E.

SCTS could consider supporting an analyst at NICOR to facilitate our research interests. There is

the proposal for an Adult Cardiac Surgical Outcomes in the Elderly project which SCTS should

support and facilitate with other stakeholders.

We are waiting for HQIP to respond to a further request to them for help with a complete audit

of Adult Thoracic Surgery including non cancer surgery.

• Relationship with Mr Ionescu (MI) / Educational issues

The education programme for the non NTNs supported by MI has commenced.

SCTS Education are proposing to organise a 2nd universities postgraduate training day in the

calendar year possibly aligned with the Birmingham Review Course in September with support

from MI and as part of the Ethicon portfolio of Postgraduate education with SCTS.

MI has recently sent 2 cheques – one his annual contribution to the AGM/Universities day and

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one to fund the first paper published edition of the Bulletin and the second one planned for the

next December / January edition.

SCTS will visit MI in December in Monaco and Graham Cooper and Rajesh Shah are scheduled to

go on 16 December.

• New Committees and Appointments

Gavin Murphy has been appointed as SCTS Research Committee Chair – he will outline his

committee and terms of reference – one of the first tasks will be to liaise with RCS Eng and their

research programme

Andrew Owens has been appointed SCTS Professional standards and Governance Committee

Chair. He will outline his committee and terms of reference – one of the first tasks that should

be considered are SCTS Guidelines for the introduction of new technologies and techniques into

NHS practice in view of difficulties being encountered by patients and members.

• External Agencies

We have met with the Professional Standards Group at the RCS Eng to improve how JDs for

posts are dealt with and how the SCTS input to the AAC process can be optimised (in England).

We continue to have meetings with RCS Eng regarding the potential for physical and owned

facilities/real estate within the RCS Project 2020 should SCTS receive a large legacy but this is

complex. We are watching the situation carefully with the 2020 project because of the

inevitable need to move the SCTS Admin team off site for some time and the requirement for all

our activities to continue (and potentially expand)

We are actively attending FSSA meetings and note and support their proposal for a British

Surgical Association (aka Surgical BMA)

The “Getting it Right first time “initiative funded and supported by DOH / NHS has commenced.

The communication with SCTS to date has been poor and further discussions are planned to

both engage with and advance the project in Cardiothoracic Surgery as appropriate.

• Scott Prenn showcase

A further showcase event is occurring at the RCS Eng the day before the Executive meeting.

This will focus on partnerships, education and on supporting advanced surgical techniques and

clinical audit.

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• Workforce document SAC / SCTS

The workforce document has been produced jointly between the SAC and SCTS and is an

excellent example of the potential for joint working. The President SCTS and Chair SAC are

distributing the document to appropriate agencies including JCST, GMC etc.

• ACCEA process

Submission of SCTS nominations for all awards and the required citations were submitted on

15/6/15.

• Mr Lincoln lifetime achievement award SCTS

Mr Lincoln has accepted the invitation to receive this award at the AGM in Birmingham in March

2016

Marjan Jahangiri will liaise with him regarding arrangements and she will present the citation at

the AGM.

C. MATTERS FOR CONSIDERATION BY THE EXECUTIVE COMMITTEE:

Working in the NHS

The environment in which we work within the NHS is becoming increasingly difficult and the

SCTS and members need to consider this .

Two consultant cardiac surgeons have been dismissed by trusts in the last 6 weeks and several

others are in difficulty with their employing trusts with restricted practice. None of these

instances are due to the direct effect of monitoring surgeons’ outcomes. The overarching theme

is that of professionalism and behaviour in the workplace.

Potential changes to newly appointed consultants’ contracts within the proposals for 7 day

working are of concern – the trainees require the consideration and support of the Executive at

this time.

The Professional Standards Committee will be asked to consider these issues and how SCTS

should move forward with professional support for members.

simonwhkendall

Sticky Note

PRESIDENTS REPORT: ACTIONS: 1. Workforce report: Need for update at 3 years and a complete revision at 5 years - 2020. Action chair of SAC and Secretary SCTS 2. TRG to contact / write to Bill Allum Chair JCST to get contribution to £3000 total cost of workforce report. KL to follow up 3. MJ to host Mr Chris Lincoln for his Lifetie achievement award and do citation 4. Agenda for BORS meeting to be professionalism: TRG / GC to prepare agenda

simonwhkendall

Sticky Note

Accepted set by simonwhkendall

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ii. STANDING REPORT FROM THE CHAIR OF THE CLINICAL AUDIT COMMITTEE

David Jenkins

David Jenkins (chair), David Barron (congenital), Doug West (thoracic)

(other members Rajesh Shah (see below), Andrew Mclean, Ben Bridgewater, Tim

Graham)

A. MEETINGS


Mon TC calls, weekly re adult cardiac data publication June-Aug 2015 Available,

notes on file,

secretary

Outliers NICOR PLG working group meeting, TC 25/06/15 Available PLG

Revision of NACSA risk factors working group meeting 3/7/15 Report tabled

here

NICOR PLG meeting 28/7/15 Available

NICOR

NACSA project group and research meeting 20/8/15 Awaited

NICOR

Telephone calls to outliers June and Aug

2015

Telephone and email correspondence with NHS

choices

June-Sept 2015 Available on

request


Thoracic (DW)

(1) LCCOP. This is the HQIP-sponsored Consultant Outcomes Project in Lung Cancer Surgery. It

applies to England. It first reported in 2014 (on 2012 data) and will produce a 2015 report

(2013 data) at the end of this year. It uses National Lung Cancer Audit (previously known as

LUCADA) data.

Due to recommissioning of the national lung cancer audit by HQIP there will be no change to

the LCCOP this year in terms of data collected or outcomes reported.

After concerns earlier in the year that the audit may be delayed, good progress has been made

in the last 6 weeks, with data going out to units for validation in August. The deadline for

submission is mid-October. Reporting is anticipated Q1 2016.

I now sit on the NLCA Executive Board to represent the SCTS and attend their regular Board

meetings. The relationship with the NLCA team (both during Richard Page's tenure and my

own) has been cooperative and productive.

I have been advocating within NLCA for an increase in perioperative data (specifically, name of

responsible surgeon, procedure performed, surgical access and use of regional anaesthesia) to

become part of the core dataset, and this has been accepted in principle by the NLCA Board.

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This would recognise that the NLCA is now acting as a surgical audit, and needs better data on

the process of care delivered to function effectively.

SCTS are working with the Roy Castle Lung Foundation on a project to understand what

information lung cancer patients would like to see reported in national audit. I believe this to be

a genuinely novel approach. Results are expected in late 2015.

(2) SCTS database. Una Lane the Director of Revalidation at the GMC has recently confirmed

that the GMC will co-fund the third and final year (2015-16) of the planned three year pilot of

this project.

This project faces major challenges. I do not think that it can or should continue in its current

form after GMC funding ends in March 2016. Over 7000 case have now been registered.

However, data upload has been declining. The problems are;

(a) excessive data requests to units from the three current projects

(b) the Dendrite database cannot be linked to NHS data (NLCA, COSD etc)

(c) To maintain the Dendrite database, SCTS will need to identify an

ongoing funding stream for database maintenance and reporting

We will report all three years of the SCTS database to date in a single "Blue Book" in Q3/Q4

2016. The project needs fundamental review if it is to continue beyond March 2016.

(3) The SCTS returns. This longstanding project is running well. There was strong support to

continue the project at SCTS Manchester 2015. We have complete data for all English Scottish

Welsh and Northern Irish units. Engagement in the Republic of Ireland has fallen off.

For the first year we have issued guidance notes for submission of the returns, which were

developed after discussion in the new thoracic audit group.

We have recently released a three year data summary (or "mini blue book).

Congenital (DB)

1. 2015 analysis complete and no concerns with overall performance across all centres

and two positive outliers. Three alerts on individual procedure funnels currently being

cross checked.

2. Some concern over level of analyst support and succession planning in NICOR. - we are

almost entirely dependent on David Cunningham, who is looking to retire.

3. The risk adjustment model may need re-calibrating - but there is already a funded

project underway to develop 'PRAiS 2' which will effectively achieve this.

4. There is no robust risk adjustment model for ACHD surgery which continues to be a

work in progress.

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Adult Cardiac (DJ)

1. Significant workload of discussion with NICOR, NHS choices, NHS Eng and external

statistical advisors over publication of 2011-14 data, including format of data

presentation, statistics of outlier identification, and false discovery rates. Contribution to

updating SCTS website. Timeline of events enclosed.

2. Communication to members before the adult cardiac surgery COP release and SCTS data

refresh on 15/09/15.

3. Updated SCTS website member support information, Sept 2015.

4. Contributions to NICOR PLG outliers working group , SCTS represented by DJ and SK.

Final document nearly ready for publication.

5. Review and comment on HQIP COP outliers governance manual.

6. Negotiations with Dendrite and NICOR re new ‘Blue book’, ongoing.

7. Contribution to revision of NICOR PLG terms of reference and job descriptions for

appointed clinical audit leads.


1. Future publication of additional outcome measures, adult cardiac.

2. Decision on rationalisation of thoracic audits.

simonwhkendall

Sticky Note

CHAIR CLINICAL AUDITS. ACTION POINTS:THORACIC.1. TRG to seek reply from HQIP re non cancer thoracic surgery2. GC / DW Explore moving to HES data for non cancer surgery with clinical effectiveness unit in RCS Eng3. JK / RS / SB / DW to contact remaining units re returns4. Outlier guidance for thoracic surgery accepted5. DW to close SCTS / Dendrite database in April 20166. DW to brief BORS in December7. DW supported to continue with Blue Book for Thoracic surgery - includes Dendrite database AND returns. To be done in PDF form only and not printed.CONGENITAL1. TRG to raise succession planning for David Cunningham at NICOR wash up meeting2. DB supported to write Blue Book for congenital surgery3. DB / AO to do governance paper for congenitalADULT CARDIAC1. GC / IF WITH Light Media to make survival data available as PDF2. GC / IF with light media to change architecture of website to search by procedure3. DJ / GC to explore timeline and variation of outliers and prepare for BORS in December4. DJ / TRG / SK / GC to lobby NHSE to remove stigmatising labelling of outliers whilst assuring independant review / governanceGavin Murphy highlighted wide variation by county for surgery on thoracic aortaAndrew Owens raised importance of maintaining risk adjusted outcomes and establishing SOP for NHSE/HQIP/NICOR/SCTS5. There was support from EXECUTIVE to publish other outcome measures at UNIT levelGavin Murphy asked if we could measure equality of access for cardiac surgery2012 - 15 data to be released shortly

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Timeline of NACSA events 2015

1. Instruction from NHS Eng to report ‘positive’ outliers at surgeon level for NACSA

in 2015. Debated at SCTS executive Feb 2015, concerns about no patient benefit,

but accepted on HQIP advice after joint telephone conference and potential for

‘good news’ story. Concerns also expressed to NHS Eng and NHS choices March

2015, and the need for careful PR exercise agreed.

2. Discussion at NACSA steering group meeting 15/05/15. Confirmation from

NICOR audit lead that NACSA would have external statistical review prior to

publication in 2015.

3. Final validated NICOR data report returned to units in standard format with

positive and negative local outliers, document dated 29/05/15.

4. NICOR presented 2011-14 outliers to senior members of SCTS exec 04/06/15.

The question of external statistical sign off raised, but NICOR audit lead

explained a letter would be sent to HQIP confirming appropriate. The

spreadsheet of alert and alarm outliers at unit and surgeon level was entitled

‘NACSA 2011-14 outliers final’. It demonstrated 2 surgeon and 2 unit negative

outliers and 5 unit and 19 surgeon positive outliers. All members of SCTS exec

present understood from the NICOR audit lead that this was the confirmed final

list. The NICOR lead was questioned about the unexpected high number of

positive outliers at surgeon level, and confirmed the data were correct.

5. Standard SCTS policy involved contact of surgeon and unit outliers by telephone

in advance of data release, usually performed by the president. This year,

because of the increase in contacts due to reporting of positive outliers and the

potential perception of conflict of interest with the president, this task was

divided between the president (TG), president elect (GC), honorary secretary

(SK) and chair of the clinical audit committee (DJ). Calling commenced the week

of 8th June after NICOR had confirmed to HQIP (email BB to JI 01/06/15) that the

audit was ready for publication. Date of publication planned for end of June and

therefore timescale tight.

6. Senior members of SCTS executive contacted on 11/06/15 and told to suspend

further calls as data may be incorrect, and an external statistical review was now

taking place.

7. On going communication between SCTS president and NICOR CEO about the

situation. Publication date deferred.

8. No further official information from NICOR until 22/07/15 when a new set of

data was sent to units, in a new format without discussion with SCTS, causing

confusion for local audit leads and database managers. Superficial explanatory

email included.

9. Verbal information from NICOR audit lead 22/07/15, that when over dispersion

corrected for, all the positive outlying surgeons disappeared.

10. Current 2010-2013 outcome data removed form patient section of SCTS website

by NICOR on 27/07/15 without discussion with or authorisation by SCTS.

Confusion and anxiety for patients and increased workload for SCTS admin staff

and audit chair.

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11. DJ attends NICOR PLG on behalf of SCTS, 28/07/15. Informed of combined audits

meeting on 5/8/15 and need to discuss NACSA with the NICOR audit lead and

complete template in advance. NICOR audit lead contacted, who explained that

the meeting was an internal NICOR meeting and that SCTS opinions would only

be necessary after the meeting.

12. Alternative new formats for data display on public website circulated to SCTS on

29/07/15 with no public/patient field testing. SCTS found none satisfactory and

confirmed confusing by SCTS lay representative.

13. Letter from NICOR CEO to president elect of SCTS explaining NICOR account of

events on 31/07/15.

14. SCTS solicit independent statistical advice on the presentation of NACSA data as

sufficient worries about the understandibility of the NICOR options.

15. Information from external statistical advisor on 05/08/15 about the relative

merits of data presentation and the certainty of observed outliers being true

outliers.

16. NICOR audit lead circulates NACSA template proposal form on 06/08/15.

17. Data finally goes live on NHS choices website and SCTS website in acceptable

format on 15/09/15, with no adverse publicity. No press release made.

18. As of 30/09/15 continuing errors on NHS choices website with no data

displayed for many surgeons.

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iii. STANDING REPORT FROM THE TREASURER

Kulvinder Lall

A. MATTERS OF INFORMATION FOR THE EXECUTIVE COMMITTEE

FUNDS HELD AS OF 6.10.15 SCTS EDUCATION £131,653 SCTS £141,851 IONESCU ACCOUNT £185,297 CARDIAC & THORACIC SURGERY UK £144,850

SCTS MEETING MANCHESTER SURPLUS OF £74000

simonwhkendall

Sticky Note

No action points.Overall financial position is improving despite increased outgoings

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iv. STANDING REPORT FROM THE HONORARY SECRETARY

S Kendall

A. MEETINGS


Teleconference to Appoint Chair Research Committee 24.08.15 yes

Teleconference to Appoint Chair Governance

Committee

09.09.15 yes

Multiple Conference Calls SCTS x12 yes

Multiple Conference Calls Scott Prenn x 6 yes

WSCTS 25th AGM Edinburgh 22.09.15 no

NACSA meeting 20.08.15 yes

Thoracic Sub Comm teleconference 28.09.15 yes

British Cardiovascular Council 02.10.15 yes

Collaboration with BUPA Patient Website 08.10.15 film


Chair of SCTS Research Committee appointed Professor Gavin Murphy

Chair of SCTS Professional Standards and Governance Committee appointed Professor Andrew

Owens.

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v. STANDING REPORT FROM THE THORACIC SUB-COMMITTEE

S Kendall/J King

A. MEETINGS


Thoracic Committee Teleconference 28/9/2015 Y - below


Minutes of Thoracic Sub-committee Teleconference 28/9/2015.

Co-chairs: Simon Kendall, Juliet King.

Present: Tim Graham, Graham Cooper, Doug West, Henrietta Wilson, Richard Page,

Richard Steyn, Sri Rathinam, Kostas Papagiannopoulos, Mahmoud Loubani, Steve Woolley.

Apologies: David Baldwin, Rajesh Shah.

Agenda

1) Update from D West re future plans for thoracic surgery audit data collection, and

the lung cancer consultant outcomes project (LCCOP).

Currently there are three different national audit projects relating to thoracic surgery outcomes

being run. There are the national returns which continue in usual format to collect unit-level

data on all procedures by approach and diagnosis, with non risk-adjusted mortality. Second

project is the Dendrite-run thoracic surgery dataset. This has been beset by problems with poor

submission rates and inability to utilise NHS numbers for patients. Funding has been secured

for last of the 3-year proposed period (until end March 2016) and units are being encouraged to

submit as much data as possible for this year. Plan is to publish a new “Blue Book” for thoracic

surgery, sponsored in part by Ethicon next year. It is likely that after 2016 this the full dataset

will no longer continue and we need to think about how we best capture non-lung cancer

surgery activity in the future.

The submission deadline for validated LCCOP data is fast approaching and so far only 1 unit has

returned their data. Data submission is mandatory and units not complying likely to have non-

validated raw data published, with the potential for negative outcomes for units. DW should

have final version of letter detailing support for outliers by October and information regarding

which units are outliers before publication date in Jan 2016.

For next round of LCCOP it is hoped that risk stratification (based on Nottingham score) will be

introduced and that units will have opportunity to submit some surgical data-fields directly

rather than relying on MDM input. This will require IT support for trusts to get Infoflex onto

local computers. No feedback from HQIP and Ben B regarding future direction of lung cancer

audits so far.

Discussion: previously noted issues of missing and inaccurate data again flagged up (JK/SR).

Concerns raised re future of data collection for non-cancer work and how this fits into national

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audits. Validation of data very time intensive in format it is sent in, with little support at trust

level. Emphasis on need to have similar level of data quality assurance across all national

cardiothoracic surgery audits (TRG). GC raised possibility of improving data collection at MDM

level via peer review. DW congratulated by all in terms of progress made.

Actions:

a) Topic of LCCOP to be added to agendae for BORS, SCTS, BTOG and thoracic forum,

and written update in SCTS Bulletin (DW/JK/SK).

b) DW to update Executive at meeting on 9/10/15 as to which units have not yet

submitted data, giving a week to contact unit audit leads and try to ensure

submission before deadline (16/10).

c) TRG / GC to contact HQIP / Jane Ingham / Ben B.

2) CRG update (R Page).

Limited progression in terms of finalising and signing off service specification for lung cancer

for England since last discussed. Commissioning panel has asked for further information in

following areas: impact on interdependent services, evidence of likely effect on workforce

planning (particularly changes in number of surgeons undertaking mixed CT practice),

outcomes measurement and minimum unit surgical volumes, and trauma.

In view of delays, the recommended timeframe for cessation of mixed surgical practice has been

pushed back to 2020. In terms of workload there is some evidence that better outcomes seen in

units performing > 150 lung resections / year. Currently there are a few units in England below

this level, but relocation of a couple of smaller units and general increase in resection rates

means that most units will probably attain this level of activity in near future.

Role of trauma care within service specification unclear – impression is that a split into thoracic

and cardiac surgery rather than CT surgery may improve trauma care but other factors may

affect this adversely (see below, trauma update)

Discussion:

GC emphasised the importance of defining and balancing outcomes measurement with respect

to UK model of care. Reassured by RP that service spec indicates a direction of travel and

outcomes not currently “written in stone”. We will need to feedback to members re impact on

mixed practice posts and to inform trainee choices re specialisation. SR queried whether

minimum no of cases / surgeon likely to be enforced – currently unit volumes only, likely to

mean minimum 3 surgeon-units. KP raised potential impact of 7-day working – not specifically

covered in document. ML queried what would happen if unit activity < 150/LC cases – may not

be commissioned. Validity of some outcomes measures e.g. 30 and 90 day mortality not proven.

DW stated that outcomes would need to be aligned between CRG and lung cancer audits.

Actions: RP to circulate latest version of service specification.

3) Update on training and workforce planning (S Rathinam and R Page)

SAC / SCTS workforce report and Sri’s updated survey distributed and discussed. Sri’s survey

did not get update from any Irish units and one other unit so last years responses used.

Clarification re number of sessions vs days in theatre required and not all units submitted full

job plan information, but generally very good overview, and Sri congratulated on completion.

Discussion:

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ML queried minimum requirements for thoracic surgeon (1 all day list and 1 supported MDM /

week). Proposed by DW that document should be made available on SCTS website for reference.

GC suggested that document could be used as basis for publication in Thorax to provide

overview of current practice and speciality aspirations as aligned with CRG service specification

so that respiratory physicians and MDM’s can see direction of travel.

Actions:

a) SR / RP / ML and ? Jon Anderson to finalise documents for submission to NHS England

and consider preparation of summary publication before end of year– to be discussed with

David Baldwin (? To be co-author), GC to be kept in loop re progress. R Page to lead this

publication.

b) Thoracic Survey and Workforce Report to be uploaded to SCTS website after next Exec

meeting (9th Oct) – SK/JK/IF to action.

4) Trauma Update (R Steyn and R Page)

RS tabled 2 documents on trauma delivery: “Audit standards for trauma” and “Required

standards for major trauma (with relation to cardiothoracic surgery)”. Take home messages of

the importance of high quality care for chest trauma, need for national guidelines and

importance of involving CT surgeons in any trauma audits. Fundamental problem is that not all

MTC’s are co-located with CT surgery units, and so attendance by CT surgeon within 30mins not

always achievable. Chris Moran has asked for formal guidelines to be drawn up.

Discussion: general consensus that trauma requiring urgent CTS input was rare but there was

increasing need for CT surgeons to be available for second line support, and in training of

trauma surgeons and in audit of trauma outcomes.

GC stated that it was vital to minimise impact of trauma management on elective cancer

workload, particularly management of trauma in elderly, and it was important that trauma skills

training not negatively impacted by “Shape of training” and focus on generalist rather than

specialist skills. RP – trauma provision also being considered within CRG service specification.

SK: SCTS need to make statement re vision of trauma delivery in UK as relates to our speciality.

Actions:

a) RS and PR to collate relevant docs from different sources into summary document to

clarify what support needed from CT surgery in trauma provision and national

guidelines?

b) To Liaise with David Jenkins chair of cardiac surgical committee to male an SCTS

“position statement”

5) Feasibility of formalising second opinion for high risk lung cancer resection patients

(JK)

Previously discussed whether a formalised process should be instituted to enable second

opinions on fitness for surgery in patients turned down for radical treatment by local MDM.

Discussion: all supported principle of second opinion if sought, and often this was already

possible from either second surgeon in same unit, or via centralised MDM. Vitally important that

second surgeon “protected” from taking on higher-risk cases by organising a formal discussion

in second MDM to validate decision. Impression was that few patients would pursue this option

if appropriately counselled as to why surgery not recommended in first place, but should be

available if desired.

Action:

JK to discuss with DB as to whether formal guidelines for MDM’s should be drawn up.

simonwhkendall

Sticky Note

Action Points THORACIC COMMITEE REPORT1. JK / DJ to prepare SCTS position statement on the role of the Specialty in Trauma. To be circulated at end of November.

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vi. STANDING REPORT FROM THE CONGENITAL SUB-COMMITTEE

D Barron/G Cooper

A. MEETINGS


Phone Conferencing May-June 2015

David Barron, Graham Cooper Co-Chairs

Conal Austin, Andrew McLean, Prem Venugopal, Andrew Parry Andreas Hoschtitsky, Mark Redmond B. MATTERS OF INFORMATION FOR THE EXECUTIVE:

1. Structure of the Congenital Sub-Committee

After discussion on the executive we had proposed that the Sub-Committee be expanded to

include a representative from each unit in the UK. Given the relatively small number of units

this created a ‘mini-BOR’ and was widely supported by the surgeons across the UK.

Most centres have now put forward a representative and the first meeting of this expanded sub-

committee will be at the Annual Meeting 2016.

The constitution has been duly changed for the definition of the sub-committee.

2. NICOR Reported Outcomes:

No major concerns with outcome monitoring and analysis. Anxiety that NICOR need more

personel/time-commitment for the analysis.

3. PICU Bed Availability:

Discussion with the PICU CRG has been helpful and they have agreed for there to be a

representative of the congential CRG now co-opted onto the PICU CRG to help raise the issue of

cardiac bed capacity

4. NHSE Congenital Heart Review

Standards are now agreed and implementation is to be April 2016. Standard will be for a

minimum of 4 surgeons per centre by 2021, but all must have a minimum of 3 surgeons by April

2016. Heated debate regarding concept of ‘super-networks’and of split-site appointments for

surgeons acorss more than one centre in a network. (see attached letter)

C. MATTERS FOR CONSIDERATION BY THE EXECUTIVE:

a) Confirm change in structure of the Sub-Committee

b) Consider support for the SCTS position on Split-Site Appointments.

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Counter-argument for the Proposal of Split-site Appointments in Congenital Cardiac

Surgery

The principles of the current review of congenital heart disease services are to design and

deliver the best model of care for our patients. To borrow the touchstone of the previous

review, clinical services must be both safe and sustainable for the patients and for the units and

their staff delivering these highly complex services.

Cardiac Surgery in babies and infants is one of the most high-risk, technically demanding and

clinically challenging area of modern surgery in the NHS. It requires extremely high level of

clinical expertise, decision making, technical skill, multi-faceted technology and close team

working between highly motivated teams of cardiac surgeons, cardiologists, anaesthetists,

perfusionists and intensive care specialists. Few other fields of modern surgery depend on this

level of coordinated multi-disciplinary input. This is amplified by the fact that the stakes are so

high, with the very nature of the conditions making each and every procedure literally a life-or-

death event. At the core of this whole process is the need for close and unambiguous

relationships between the teams and the individual key players involved. Unfamiliarity or

insufficient exposure to each other within these teams is a recipe for disaster.

The surgical procedure itself is only one part of a complex and time-consuming process that

requires total engagement from the key individuals (in this case, meaning the surgeon,

cardiologists and intensivists) from the point of diagnosis through decision making, MDT, pre-

op planning, consent and establishing trust and good relations with the family. The post-

operative phase can be the most critical of all and needs true multi-disciplinary care delivered

at the bedside. The surgeon and cardiologist are intimately involved with every step of the post-

op care, especially while in intensive care….often needing critical decisions on management

plans and need/timing of any investigations or re-interventions. The surgeon is ultimately

responsible for the outcome of the patient. It is the surgeon’s name that is published against

outcomes on the public portals and who has to face public scrutiny, media attention and GMC

referral if results do not match expectation. It is the surgeon who has to face the family if things

do not go well and it the surgeon who the family expect and want to see caring for their child in

those critical post-operative days.

Split site appointments have been very successful in other areas of medicine where the nature

of the clinical care is either in an outpatient setting or in performing investigations or in an

administrative role. However, as soon as on-going clinical in-patient care is required then this

model becomes dangerous and rapidly deviates from acceptable practice. It may work if the

procedures are low-risk, elective cases that do not require any sort of planned in-patient care

(generally day-case surgery) but even here this would not generally be accepted as ideal

practice. Furthermore, they have only ever been acceptable if the two sites in question are

geographically close (usually the same city or even within the same Trust) and the individual

can readily and safely travel between the two within the normal NHS requirements for

consultant practice (ie 30 min to bedside).

With these facts in mind, the concept of a split-site appointment for a paediatric cardiac surgeon

would raise the following issues:

1. On-Call: It is not possible to perform this type of surgery without being available out-of-hours

to attend the bedside. No matter how close-knit the surgical team might be, the operating

surgeon carries the ultimate responsibility and has the unique knowledge of that patient’s

18

anatomy and physiology. Should a patient deteriorate in ITU or need emergency re-intervention

then it is essential that the operating surgeon is involved and available. Anything less than this

would be unacceptable practice.

2. Travel and Availability: The split-site surgeon has to be within 30 min of bedside. The

geographical arrangement of the networks is such that paired surgical centres (except in

London possibly) are between 40 and 150 miles distant from eachother. For a split site

appointment to be viable then the surgeon would have to be resident on both sites when

operating. To do so one day at a time would require unacceptable daily commutes and the

requirement for a second home. An alternative would be to work for blocks of time at each site

(? a week at a time) requiring even greater logistics to support such a lifestyle. It still raises the

question of what happens if the surgeons’ cases from the end of the week are still providing

clinical concerns the following week and who will take responsibility for key decisions. You may

take the view that this could be devolved to the ‘in-house’ team. I am not sure that the patients’

associations would take the same view.

3. On-Call Rota: The standards are absolutely clear that surgeons cannot work more than a 1:4

on-call rota in any unit to ensure that teams are large enough and sufficiently robust to provide

safe cover in any eventuality. NHSE have clearly accepted this in their proposals for split-site

appointments. Thus, each site in a network would still need to have a minimum of four surgeons

in-house to satisfy the Standard regardless of whether or not any of the appointments were

split-site or not. Thus, each unit still has to achieve the minimum caseload of 500 cases with or

without split-site appointments. Furthermore, the split-site surgeon cannot be used to achieve a

1:4 on BOTH sites since this will mean that the individual in question will be required to provide

up to 1:2 cover – which is completely unacceptable. The maths simply don’t stand up.

4. Unsafe Practice: If split-site appointments are to be used then the surgeon cannot be present

at every MDT at both centres, nor can they be present for the entire ICU stay of all their patients.

Thus, they will not be part of the decision-making process and will either have to accept the

decisions of others or be prepared to over-ride the in-house team, leading to potential conflict.

The result is a clear deviation from everything the Standards describe as good practice. Not only

is this bad for the patients and bad for the clinical teams but it runs the risk of a deterioration in

outcomes and causing actual harm to patients. It is unthinkable to imagine what a coroner

might conclude should events lead to a mortality where the operating surgeon was absent or at

loggerheads with in-house management or trying to coordinate management remotely.

5. Risk to Team Performance: The importance of integrated and functional teams is at the

heart of this whole process. The very reason that minimum sizes were chosen was because

these are widely recognised as being the best model in which to generate the best quality of

care. They imply a critical mass of key team members that is necessary to provide the best

environment for

mentorship, teaching, good governance, sharing of ideas, research, innovation and training

while ensuring resilience to on-call work, succession planning and unforeseen absence. If one

team member is to be contracted to work only part-time in each of two centres then the result

will be a partial contribution to each team and a failure to be fully recognised as a full partner.

The individual will not be able to be present at all MDTs and professional development

meetings and so will not be seen as an equal on either site. There will inevitably be different

management styles and techniques used in each centre and so the split-site individual will

either have to adopt both sets of working practice simultaneously or impose one method on

both. The result is a weakened surgeon and potential conflict within both teams with lost

opportunities for all concerned.

19

6. Lessons Already Learnt: The only previous attempt for split-site appointment in this

specialty was between Alder Hey and Manchester. In theory this would have been an ideal

example as they are relatively close geographically (although still too distant to allow the same

consultant to cover both sites) and consist of the same paediatric and adult congenital services

of the same region. The arrangement lasted less than a year because the peripatetic surgeon

simply could not provide adequate input to the inpatients at Alder hey and his colleagues were

not able or prepared to manage the post-operative care and pre-operative decisions for a

remote surgeon.

7. Surgical Standards: The concept of surgeons in high-intensity specialist areas being

appointed to two remote centres with fixed commitments has never previously described in the

health service. It is most likely that the Royal College of Surgeons, the Society for Cardiothoracic

Surgery and the British Congenital Cardiac Association would regard this as unsafe practice and

an unacceptable risk to both patients and to the surgeon. Any such job-plan would not be

acceptable.

8. Lifestyle: This previously untried concept of appointment to two remote sites would entail

extraordinary hardship on the individual(s) concerned. A daily commitment to one site is

unworkable, so the presumed model would be to work for blocks of time in each centre. This

would require a lifetime committed to living in two homes and require repetitive and sustained

periods remote from spouse and children which, to most, would be an intolerable lifestyle and

introduce untold stresses into what is already a hugely stressful job. There is nothing that could

possibly be described as ‘good’ about such a job-plan and this is partly why the Professional

Societies would not accept such an arrangement.

9. Fundamental Principles of The Review: The very core of this process form the outset has

been to describe and then implement the best and safest model of care for patients with

congenital heart disease. Everything the standards describe has been about defining that model.

The concept of split-site surgeons working across distances of 150 miles with two separate

teams is so completely alien to this concept that it is difficult to put into words just what a

negative and detrimental decision this would be. The result would be a service that is actually

worse than the system it has set out to replace. The appointments would disrupt teams, invite

conflict and undermine trust; the quality of care would suffer on both sites and the strains on

the individuals involved would be unthinkable.

10. The Danger of Suggestion: It is inevitable that units feeling threatened by the standards

will be looking at every possible means to make themselves viable. Thus, the very suggestion by

NHSE that this could be a solution will inevitably be considered by such centres, regardless of

whether or not it is something that would otherwise have been welcomed. There is no

possibility of such appointments being sustainable, but they may considered be made as a

means to circumvent the necessary standards for entirely the wrong reasons.

11. Patient and Parent Opinion: The concept of split-site appointments for surgeons is so

completely alien to every principle of Good Clinical Practice than the need to provide a counter-

argument seems superfluous. However, if NHSE are not prepared to listen to the advice of the

professionals then they should at least consult the parent and patient groups to seek whether or

not they feel this would be a good model of care for their children.

The Standards have been written after the most gargantuan and comprehensive process in the

history of the modern NHS. There is no other service specification within the entire NHS that

20

has come close to this amount of cogitation, review, public consultation and scrutiny. They are

an outstanding piece of work which has been roundly and universally supported by clinicians

and patients alike as the best thing to have come out of the whole Review. Nothing has received

more attention than this central issue of the numbers of surgeon per centre and minimum case

volume (or case-load per surgeon). The standards were not written so that they could be

circumnavigated, abused or ignored. They were written to be as unambiguous as possible –

particularly on these key issues – in order to describe what good practice should look like. If split-site appointments and peripatetic surgeons were thought to be a ‘good thing’ then do you not think the standards would have said so? This process was not a game where the first response to

a standard is to look for a loophole in the wording or to twist the meanings to undermine the

whole ethos of the process. Yet, before the ink had even dried on the document NHSE have quite

deliberately come up with this extraordinary and dangerous concept as a means of warping and

undermining the standards. If NHSE are not prepared to accept the Standards then why on

earth did they support them up to this stage? The option of 3 surgeons as a minimum was hotly

debated, foreseeing this dilemma that we are currently faced with – but there has been a clear

and strong decision for 4 surgeons as a minimum – strongly championed by NHSE themselves –

so it would be incomprehensible to then try and undermine this at the first opportunity.

It is my request that NHSE expunge this dangerous and ill-thought suggestion from the entire

process and that such action is taken immediately before any further damage is done.

Unfortunately, since the concept was introduced into the formal documentation by NHSE in its

presentation to the Executive then the wording will need to be formally and publically

withdrawn in order to remove any ambiguity.

David Barron September 2015

Consultant Cardiac Surgeon

Birmingham Children’s Hospital

simonwhkendall

Sticky Note

CONGENITAL COMMITTEE 1. Need for succession planning as DB ends term. AO / SM to advise 2. Executive supported letter with concerns re split site appointments. Also supported by whole of congenital committee3. Executive endorses document on Emergency Care for Children based on advice from congenital committee

21

vii. STANDING REPORT FROM THE CARDIAC SUB-COMMITTEE

T Graham/D Jenkins

A. MEETINGS


Mon TC calls, weekly re data publication June-Aug 2015 Available,

notes on file,

secretary

Risk factor meeting for NACSA 3 July 2015 Mins and

report

enclosed,

tabled for exec

today

Ethicon SCTS cardiac surgery symposium, supported

by members of ACSSC as speakers/chair.

19 June 2015 Feedback from

delegates

TC with PHE re Mycobacterial infection CPB

heater/coolers.

9 June 2015 Available,

secretary


1. Risk factor/NACSA review report forwarded for comment of ACSSC Sept 2015.

2. Heater/cooler infections, meetings with PHE and advice to membership, June 2015.

3. Letter to NICE to review guidelines on endocarditis prophylaxis, July 2015.

4. Letter to ICU CRG about implications of proposed standards for CT critical care to

support ACTA, June 2015.

5. The committee is responding to NICE requests for registration for consultation, latest

for trauma clinical guidelines review.

6. Continuing workload to review job descriptions for RCS(Eng).

7. Preliminary work on proposal for research into outcome of cardiac surgery in the

elderly, retrospective and prospective studies.

8. Advice to Welsh cardiac surgery collaborative model, ongoing.

9. Contribution, with Simon Kendal, to SCTS workforce document for adult cardiac

surgery.

10. Contribution to Safer Surgery research proposal.

11. Survey of ACSSC members about care of urgent pre op cardiac surgery patients on

behalf of unit request.

12. Update on cardiac ECMO, UK meeting including commissioners planned for January

2016, DJ will represent SCTS.

B. MATTERS FOR CONSIDERATION BY THE EXECUTIVE COMMITTEE:

Future chairmanship of this committee.

22

NACSA database review meeting Friday 3 July RCS(Eng)

Present: David Jenkins, Samer Nashef, Mark Jones, Tim Graham, surgeons Tracey Smailes, Sarah Powell, Philip Kimberley, database managers Robin Klinsman, database provider Anthony Bradley, Vlad Demian NICOR

Apologies: Uday Trivedi, Ben Bridgewater (Both provided input pre or post meeting)

1. Welcome and introductions. DJ welcomed all to the meeting and explained the importance of the group. There was representation from surgeons, SCTS, database managers, Dendrite, and NICOR. The main priority was to make the risk factor definitions fit for contemporary practice and offer guidance on interpretation. The order of discussion should follow 3 principles; clinicians to confirm as most correct, database managers to confirm practicality, database providers to confirm feasibility. In addition several questions posed by NICOR are to be debated. The notes from BB had been circulated in advance. Changes would be incorporated into the database from April 2016. SN was able to comment from his experience of EuroSCORE. TG agreed that the former task was most important and that consideration of morbidity outcome measures should be deferred to another meeting. TG thanked all for providing their time on behalf of the SCTS executive.

2. Revision of risk factor definitions. These were taken in order, debated in turn, and guidance decided.

1) Age. Continuous variable, in years. All satisfied, no changes suggested. 2) Sex. Male or female. No major issues. No changes suggested. 3) Chronic pulmonary disease. Some issues. EuroSCORE I and II were the same, but the

current NICOR/SCTS definition was different as the latter included FEV1 < 75% predicted. MJ commented that some colleagues in Belfast had a higher incidence of this factor. The potential problem of a risk factor definition precipitating increased patient investigations was debated, especially if an artificial threshold did not influence the surgical management. There was some concern that the FEV1 criterion may influence patient investigations and differed from EuroSCORE. SN explained that one of the principles of EuroSCORE was that the data should be easily available and non subjective. The EuroSCORE definition specified ‘long term use of

23

bronchodilators or steroids’. It was thought that to be future proof, a definition should be more inclusive as new therapies are used for chronic lung disease.

New definition: Current use of medication for lung disease. Guidance: Use of this medication up to admission for surgery. Change: Previous FEV1 criteria and ‘history’ of lung disease removed. NICOR action: To make dataset change to remove 3 options and change to N/Y as defined above. 4) Extracardiac arteriopathy. Again some concerns, especially as the current

NICOR/SCTS definition included clinical examination findings. It was commented that these would be very difficult to revalidate and were too subjective. It was noted that EuroSCORE II included amputation as a fourth factor in addition to those in EuroSCORE I. There was a discussion over‘claudication’, but it was concluded that this described a relatively precise clinical syndrome.

New definition: Anyone or more of, claudication, carotid occlusion or >50% stenosis, previous or planned surgical intervention, amputation for arterial disease. Guidance: Definition of claudication exertional calf or buttock muscle pain, not explained by arthritis and under investigation or previously investigated for vascular disease. Any of the 4 factors to score. Presence of atheroma found incidentally on CT scans should not score as difficult to quantify and classify. Change: Remove previous definition of reduced or absent foot pulses, angiographic stenosis of >50% and carotid or femoral bruits as evidence of PVD.

5) Neurological dysfunction. Noted change in EuroSCORE II as poor mobility included as a new field, independent of neurological disease. Discussion about difficulties of interpretation, as mobility subjective. Dendrite confirmed both field available in their dataset so that Euro I and II could be calculated. The original Euro I and NICOR/SCTS definitions were compatible and could be retained. All satisfied, no changes suggested.

Unchanged definition: Patient has neurological disease affecting ambulation or day-to-day functioning. Guidance: A neurological diagnosis and the need for mobility aids (eg walkers, wheelchair, stair lifts) or inability to self care.

Euro II mobility field, with Euro definition to be added as a separate field to the NICOR dataset (already present in Dendrite). 6) Serum creatinine. Few concerns. Actual level in micromol/L at the time of surgery.

Euro II and NICOR/SCTS fields compatible, with creat as a continuous variable. Previous scoring of > 200 micromol/L for Euro I also possible as actual number entered into field, as is criteria for new Euro II, because Dendrite confirmed a dialysis field of Y or N is already present.

24

Unchanged definition: Serum creatinine value. Guidance: Most recent result documented prior to start of operation. 7) Previous cardiac surgery. Accepted Euro I principle that a previous major cardiac

operation was necessary and opening of the pericardium was essential to score. Discussion that both were necessary to score, but that a complete sternotomy was not necessarily required eg previous closed mitral valvotomy or MIDCAB would count. It was felt that the current NICOR/SCTS variation that counted implantation of pacemaker leads should be changed, as this was not a major cardiac operation, the breach of the pericardium was very limited and the impact on future surgery was minor, unless performed via a full sternotomy. Hence, definition acceptable, but guidance to change.

Unchanged definition: Previous major cardiac operation requiring opening of the pericardium. Guidance: Cardiac procedure should be major eg CABG, valve, congenital correction, the pericardium must have been opened. Any previous full sternotomy, for whatever reason, and opening of the pericardium should also score. A minor cardiac procedure eg insertion of pacemaker leads without sternotomy should not score. 8) Active endocarditis. No major concerns, but thought that original Euro I definition

most objective – patient still on antibiotic treatment for endocarditis at the time of surgery. All agreed this was more objective than current NICOR/SCTS field of ‘active endocarditis’ from the native valve pathology field.

Guidance: Patient needs to be taking antibiotics specifically for treatment of the endocarditis at the time of surgery.

9) Critical preoperative state. Felt no need for formal definition as variables collected separately from other fields to allow subsequent calculation to score. However, guidance important. Dendrite confirmed Y or N fields for critical state already present in their dataset. Broad agreement between Euro definitions and NICOR/SCTS, but the latter specified some forms of mechanical circulatory support in addition to IABP (impellar) that therefore excluded others (ECMO). At the time of Euro I only IABP was available in most centres, and Euro II did not change. It was felt that the definition should be modernised to include contemporary forms of circulatory support to be fit for future practice, but not be too prescriptive. The dataset included provision for mechanical circulatory support, and ECMO, or new devices, could be included in ‘other’ box.

Guidance: The events to score should have occurred prior to arrival in the anaesthetic room, during the current in-patient treatment episode, not necessarily same hospital but without discharge to home, or precipitating the current admission (eg OOHCA). Mechanical circulatory support should include any form, IABP, “impellar” type device, temporary VAD, VA ECMO. 10) Unstable angina. It was recognised that practice had changed and the original Euro I,

25

and NICOR/SCTS definition were now both obsolete. TG confirmed that this was the problem field that resulted in the revalidation and changes last year. The definition was changed in retrospect after data had been submitted to NICOR because of abnormal distribution of the prevalence. This was an improvement, but not perfect. It was noted that for Euro II a simple definition of CCS class 4 angina was used. SN agreed that although useful to have backward and forward compatibility between risk score systems, it was justified to make the change as clinical practice had evolved. After much discussion it was agreed to make a further change. This would not need a specific field for ‘unstable angina’, but the condition would score if 3 fields were positive: non-elective CABG and CCS 4. NICOR were asked to check how many patients would score with this new definition compared with the latest NICOR/SCTS definition from 2014, which included heparin +/- iv nitrate.

New definition: Non-elective plus CABG plus CCS 4, derived from 3 fields. Dataset field change: Remove ‘iv nitrate’ field. Guidance: Unstable coronary syndromes will be determined from other fields, CCS 4, non-elective surgery and CABG. The CCS grading should be the most symptomatic for the current hospitalisation episode (usually symptoms on admission). This also applies to NYHA grading.

11) LV dysfunction. The Euro I definition was clear, and did not change substantially in Euro II, although a separate category for very poor function has been included (< 21%

EF). The EuroSCORE definitions did not include any guidance about the means of measurement. The current NICOR/SCTS definition does include examples of imaging techniques, but also states an “eyeball” value could be used if no objective measurement was available. The latter was thought to be no longer acceptable as it could not be validated and all patients should have a formal pre or intra operative assessment in 2015. It is also technically different from Euro as “Fair” is described as LVEF 30-50%, rather than moderate at 31-50%.

New definitions: LVEF Good, EF>50%, Mod 31-50%, Poor 21-30%, Very poor <21%. Dataset change: Include very poor (EF <21%) category for compatibility with Euro II. Guidance: Subjective determinations not acceptable. Category should be supported by an objective measurement documented in case notes. Clinicians should be careful to note the boundaries of EF between categories. If more than measurement or different modalities, then the most contemporary should count most, acceptable to count the lowest measurement if different modalities at a similar time were either side of a boundary. 12) Recent MI. Within 90 days of surgery, concordance between Euro definitions and

NICOR/SCTS. No changes suggested. Unchanged definition: MI < 90 days before surgery. Guidance: MI defined by ECG, CKMB enzyme rise, Troponin rise. For biochemical markers the local reference lab range should be used.

26

13) Pulmonary hypertension. Actual systolic PA pressure recorded, continuous variable. No need to change field. The original Euro I and NICOR/SCTS concurred, with SPAP > 60 mmHg to score. Noted that Euro II had complicated the issue with a new category, moderate PH SPAP 31-55 mmHg and severe PH SPAP > 55 mmHg. As the figure entered was a continuous variable, the field could be unchanged and both scores could be calculated.

Unchanged definition and field: as above. Guidance: Recognised as important. Accepted pre operative right heart catheter best evidence, but that pre CPB PA catheter readings would also count (if anything underestimated under GA). Echocardiography estimates of SPAP are acceptable records (including intraoperative TOE), but clinicians are reminded that CVP should be added (and this could be assumed as 10 mmHg, unless documented higher value). 14) Operative urgency. The original definition of emergency in Euro I was noted, on

referral, before the beginning of the next working day. Four classes in Euro II, (elective, urgent, emergency, salvage) with good concordance with the current NICOR/SCTS definitions. There was an important discussion that emphasised that some of these classes were defined by the admission status and others by the decision to operate or working day. The newest Euro II descriptions were felt to be most helpful.

Unchanged definitions: elective, urgent, emergency, salvage, as in Euro II, see guidance. Guidance: Critically important to be correct as salvage and emergency cases would not be included under individual surgeons data. The published operation list was a useful arbitrator, as emergency or salvage cases would never be listed in advance. Elective, routine admission for operation. Urgent, patients not admitted electively for an operation, but who require surgery on the current admission for medical reasons and cannot be sent home without a definitive procedure. Emergency, operation indicated before the beginning of the next working day. Salvage, patients requiring CPR en route to the operating theatre or prior to induction of anaesthesia. The highest urgency category should always prevail, as should the decision to operate over admission status eg a patient admitted electively for surgery the following day, who arrests on the ward at 5am and is massaged into theatre becomes a salvage. 15) Other than isolated CABG. No significant concerns, over field (Y/N) or definition,

but felt that guidance was essential. The Euro definition stated that it had to be a ‘major cardiac procedure’ other than or in addition to CABG.

Unchanged definition: as above. Guidance: Only major cardiac procedures count eg valve surgery. Major procedures under ‘other’ in the Dendrite system include: VSD, ASD, myxoma excision, pericardectomy, pulmonary embolectomy, LV aneurysmectomy, myomectomy, should all also score, as should MAZE procedure and complex pacing lead extraction. Exclusion of the LA appendage or insertion of pacing leads should not count. 16) Surgery on the thoracic aorta. No major issues, but there was a problem with the

27

Dendrite field with respect to root replacement – MJ to send information direct to Dendrite.

Guidance: Includes surgery on the ascending (including root), arch and descending thoracic aorta. 17) Post infarct ventricular septal rupture. No concerns with definition or field. Noted that

this condition no longer scores in Euro II as frequency of occurrence now lower. Overall, recommended that all Euro II fields should be included to make the dataset future proof. Definitions and guidance should appear as a box with a hover/prompt. 1. Guidance on interpretation.

Performed as above 2. Consideration of morbidity outcome measures for units/COP.

The chairman had circulated a draft list in advance. However, due to time pressure this item was deferred for a separate meeting. There was concern that data would have been collected retrospectively and used for purposes unknown at the time of data entry. TG thought this issue merited a meeting in its own right, but that this same group would be appropriate to perform the task. Action SCTS to organise a further meeting after September, pending NICOR progress and agreement on the presentation of survival data.

3. Compatibility with other international systems eg STS.

The STS database was reviewed. It was recognised that this was a more complex database with > 160 fields, with paid subscription in the USA, but did not incorporate all cardiothoracic hospitals. It did include more demographic data and all agreed a race/ethnicity field would be beneficial in NACSA, as included in BCIS already. Decision – NICOR to add for NACSA. NICOR explained that fields not contributing to the EuroSCORE were less well completed, and therefore felt increasing fields to approach the STS comprehensiveness would not be helpful. It was recognised that some illnesses eg liver disease, did impact on survival, but were not included in EuroSCORE – to discuss further with SN.

Research information from Ben Bridgewater’s work also indicated the social deprivation impacted survival. Hence, calculation of the deprivation score may be helpful if easily performed?

4. Preparing for EuroSCORE II, adding fields.

All agreed essential for future proofing, and discussed, as above. All database providers will need to update, already incorporated in the latest Dendrite version. Action –database providers.

28

5. Other data to collect

eg incisions/robotics for minimal invasive surgery. Agree that operative approach increasingly important since last revision. Five years ago the majority of cardiac surgery was performed via median sternotomy, but this was changing. There was much discussion. Conclusions for operative approach fields: full conventional sternotomy, partial sternotomy, thoracotomy, mini-thoracotomy (one choice only). CPB Y or N, if Y, central or peripheral cannulation for arterial and venous. This would also allow successful exclusion of inappropriately entered TAVI cases, ie AVR with no CPB.

6. Other database issues to resolve (NICOR).

The database issues from Ben Bridgewater’s comprehensive preparation paper were reviewed. Field for destination/discharge, where no data assumed death. However, also field for status at discharge alive or dead, so potential conflict. Agreed best to remove latter field. Action – notice to database managers. Previous cardiac surgery. There is a box for number previous cardiac operations 0-123 etc, and also previous cardiac surgery Y or N. Fields present in different areas of the database. To remove latter and keep number previous operations, with guidance note hover box as above. Operator grade. Acknowledged that titles changed and will need up dating. Consultant unchanged, NTM middle grades now ST1-8 and SA now SCP. Agreed NICOR to check for commonality of definitions in the BCIS and MINAP databases. Conduit harvest for CABG. Agreed needs update. Expanded fields under each graft for type of vein harvest: conventional open, bridged, endoscopic. Include ethnicity, but not MDT discussions. Post operative variable, blood loss and products etc. Agreed important, but to discuss at subsequent meeting on other outcome measures.

7. Review of this working group report by ACSSC of SCTS?

TG felt that this was unnecessary as current group appropriately configured and could inform NACSA steering group and main SCTS executive.

8. Conclusions and next steps.

All to review this draft Report to next NACSA steering group meeting 20 August 2015

simonwhkendall

Sticky Note

CARDIAC COMMITTEE ACTION POINTS1. Paper of definitions of datapoints accepted by Executive2. Succession Planning in March 2016 for co-chair to be considered by AO / SM3. ML volunteered to be part of review of ECMO support for cardiothoracic units

simonwhkendall

Sticky Note

Accepted set by simonwhkendall

29

viii. STANDING REPORT FROM THE PRESIDENT-ELECT

G Cooper

A. MEETINGS


Conference Calls 8/6/15. 9/6/15,

18/6/15,

22/6/15,

29/6/15,

6/7/15,

31/7/15,

3/8/15, 4/8/15,

10/8/15,

14/8/15,

18/8/15,

24/8/15,

7/9/15,

28/9/15,

29/9/15

RCS Eng Council 11/6/15,

9/7/15,

10/9/15,

8/10/15

Yes

FSSA 9/7/15,

10/9/15,

Yes


i. British Surgical Association

ii. FSSA initiative based on premise that BMA does not adequately represent surgeons.

Survey results, attached, strongly supported and establishment of BSA being pursued.

simonwhkendall

Sticky Note

PRESIDENT ELECT ACTION POINTS:1. GC pursue Blue Book for 2016 with Dendrite and NICOR2.Governance Document completed3. Professionalism book on hold until after BORS meeting

simonwhkendall

Sticky Note

JOHN BUTLER PRESENTATION ON WEBSITE DEVELOPMENT1. Excellent Demonstration of developed Education website2. Fraction of the cost of employing independent contractor3. AO - need strategy as well as creativity4. DJ - hospitals often block video content - can be overcome5. GC - would it be possible to register for CPD. Potential for committees to update their areas6. TRG - invited JB to continue dialogue with SCTS about creativity.7. SK - to organise teleconference to discuss strategy

30

British Surgical Association: survey of interest

FSSA/090715/DocD

Surgeons, like many clinicians in today’s NHS, are unhappy. Morale is at an all time low. There are many reasons for this: a

perceived loss of professionalism, a culture of fear and intimidation in the work place and perhaps most importantly, a

perception that surgeons are no longer in control of their own destinies. These are often determined by non clinical staff

and politicians for whom cost containment is the absolute priority.

Whilst surgeons frequently point the finger of blame for their altered circumstances to our political and managerial masters

and mistresses, much opprobrium also falls upon Colleges and Specialist Associations. How often does one hear the

accusation “what do the Colleges or the Associations do for me?”.

The problem here is defining what surgeons expect from Colleges and Associations. If it is certification, examination,

maintenance of standards, development of crafts skills or encouragement of research, then really surgeons have no reason

to gripe. The Colleges and Associations throughout the UK and Ireland actually perform these tasks with considerable

aplomb and have done so for many years. The perception that they are glorified dining clubs for an aging elite is simply

wrong!

If, however, surgeons are disgruntled because they feel no-one is looking to their professional interests as defined by their

terms and conditions of work, or their salaries and pensions, or job contracts, or disciplinary procedures then they may

have a point. Colleges and Associations are largely Charities and as such their actions are determined by the Charity

Commission which specifically states that their activities must be for the benefit of the public and not exclusively for their

surgeon members. Of course, there is inevitably some fudging of the boundaries and Colleges and Associations frequently

justify activities on the basis that some benefit will accrue to patients as a secondary benefit to helping surgeons. But the

inescapable fact is, and is often not appreciated by surgeons, that the Colleges and Associations are effectively powerless to

intervene on surgeons’ behalf with respect to terms and conditions of service. This latter is the role of the BMA which is the

recognised trade union for medically qualified individuals. And, as is well known, surgeons are not particularly well

represented in this organisation which is largely comprised

of general practitioners.

31

For these reasons, I and others* suggested some years ago that consideration should be given to the creation of a “British

Surgical Association (BSA)”. We recognise that surgeons are traditionally conservative with a small “c” and are usually

reticent to become involved in matters appertaining to trade unions. Also, we recognise that there are already arguably too

many surgical Colleges and Associations and speciality groups. Nonetheless, numerous discussions have occurred and we

were advised that no progress could be made on this suggestion without some verification that there was support for this

idea in the surgical community. Hence, this survey.

A letter inviting surgeons to complete the survey was sent out on behalf of the FSSA from all 10 Specialty Associations. It

read as follows:

Re: British Surgical Association: survey of interest

As many of you will be well aware, there has been discussion in recent months about the suggestion that the UK would benefit from the creation of what has been called “a British Surgical Association”.

The aim of such a Professional Association would be to act as a ‘Trade Union’ for surgeons and to look after their interests irrespective of Surgical Royal College or Surgical Specialty Association affiliation. As such, it would be able to involve itself in matters relating to terms and conditions of service, contracts of employment, litigation, insurance and other matters which the majority of Surgical Colleges and the Associations are effectively excluded from on the basis of their charitable status.

A BSA would emphatically and specifically not be in competition with the Surgical Colleges or Associations, as these have remits relating to professional standards, education and membership activities and are not permitted to act, in any way, as a trade union. Indeed, it is apparent that any potential success from a BSA would only occur if it existed in harmony with the Surgical Colleges and Associations.

We have been informed that there is no theoretical impediment to Surgery as a defined craft Profession establishing its’ own trade union.

For your information, the subject of BSA has been informally discussed with Presidents of all four Surgical Royal Colleges as well as informally with members of government and ACAS.

We are advised that an important preliminary step in establishing a BSA would be to substantiate the fact that there is popular support within the Profession for such a move. Hence the need for a survey.

This proposal (to sample surgical opinion using a survey distributed to members of all 10 speciality associations and facilitated by FSSA) has been discussed by the executives of all speciality associations.

We are grateful to you for your cooperation and would welcome any comments.

The questions were as follows:

1. Please state grade (Consultant / NCCG / trainee) 2. Number of years in present appointment (<1 , <5, <10, <15, <20 years) 3. Do you agree that terms and conditions of service for surgeons should be considered separately to those

of other specialities 4. Do you consider that terms and conditions of service are adequately dealt with at present 5. Would you support, in principle, the establishment of a “British Surgical Association” 6. If ‘yes’ would you agree that such an Association should be independent of Colleges and Specialty

32

Associations but work closely with them

33

Results

Over 1500 responses were received.

A total of 82% were consultants. As regards years in practice approximately 10% were within 1 year of

appointment and then there was an even distribution of about 20% each for the bands up to 5, 10, 15 and 20 years

respectively.

When asked the question “do you agree that terms and conditions of service for surgeons should be considered

separately to other specialities?” 78% said yes and 22% no.

In answer to the question “do you feel terms and conditions of service are dealt with adequately at present?” 85%

said no and 15% yes.

Question 5 asked “would you support, in principle, the creation of a British Surgical Association?”, 82% said yes

and 18 %, no.

The final question asked: “ if yes, would you agree that such an Association should be independent of Colleges and

Speciality Associations but work closely with them?” No less than 95% said yes and 5% no.

A total of 496 responses included free text. These are shown in full on the FSSA website (http://fssa.org.uk/BSA

survey/responses). The majority were in support of the suggestion that a BSA should be established. The most

commonly recurring theme was that surgeons were poorly represented and that the BMA was not fit for purpose

from a surgical perspective.

There was a vocal minority who argued that we already have an ample sufficiency of representative associations

and do not need anymore.

Discussion

Notwithstanding “survey fatigue” which afflicts most of us, this survey generated over 1500 responses in less than a

month. There is absolutely no doubt that surgeons are disgruntled about their terms and conditions of service and

a majority of respondents were very supportive of the concept of a British Surgical Association.

These results were discussed at a recent meeting of the FSSA. Three important points were raised:

34

1. The fact that a survey shows a professional group are unhappy with terms and

conditions of service may simply be a reflection of low morale throughout the NHS

2. The results might have been different if we had included a question asking whether or

not surgeons would be prepared to pay a fee to join a British Surgical Association

3. It was pointed out that a notable feature of the free text responses was that very many

were critical of the BMA. Perhaps therefore these results are a manifestation of

discontent with the BMA rather than an appeal to create another association. In this

regard I emphasised that reference to the BMA was deliberately omitted from the

questions as I felt this would have inappropriately detracted from the main issue.

The FSSA have agreed that the next step should be to meet with the BMA in an attempt to determine

whether or not they are prepared to specifically consider surgeons concerns. In the absence of any

progress, then further enquiries would be made about other options; these include affiliation to another

existing union, the formation of a voluntary union which can negotiate on members’ behalf without

using legal procedures and usually in liaison with ACAS or formation of an independent statutory union.

Recognition as a statutory union necessitates application to a Central Arbitration Committee and needs

as a basis proof it would be likely to attract a majority in favour in a ballot. This survey achieves that!

Comments received with interest.

Professor John MacFie, President of the Federation of Surgical Specialty

Associations, June 2015 Mr Paul Blair President, Vascular Society

Mr David Burge President, BAPS

Mr Michael Davidson President, BAOMS

Mr Tim Graham President, SCTS

Mr Richard Kerr President, SBNS

Mr Nigel Mercer President, BAPRAS

Mr John Moorehead President, ASGBI

Professor Tony Narula President, BAO-HNS

Mr Mark Speakman President, BAUS

Mr Ian Winson President-elect, BOA

*acknowledgements

In particular to Professor Nick Gair, CEO of ASGBI who made informal enquiries of regulatory

authorities to determine if there was any legal impediment to the proposed BSA and who was informed

that the concept was perfectly feasible.

35

ix. NURSING & ALLIED HEALTH PROFESSIONALS REPRESENTATIVE

C Bannister

A. MEETINGS


SCTS Organisers Site Visit, Belfast & Dublin Centres 09-10/06/15 N/A

6th Cardiac SSI Surveillance Meeting, London 19/06/15 Available

CTSNet Allied Health Committee Conference Call 07/07/15 Available

SCTS Organisers Meeting RCS, London 15/07/15 N/A



Scott Prenn / BUPA Conference Call re Website 26/08/15 Available

SCTS Education Sub-Committee Meeting RCS, London 04/09/15 Available


NCBC Steering Group Meeting, BCS London 22/09/15 Available

SCTS Developing an Advanced Allied Health

Professional Practitioner Service Course, St. Thomas’

Hospital, London

02/10/15 N/A

EACTS Postgraduate Nurses Day @ EACTS Annual

Meeting, Amsterdam

03-07/10/15 N/A



• The Nursing and Allied Health Professional Cardiothoracic Forum at the Annual

Meeting. The CT Forum is planned to be held at International Conference Centre in Birmingham

in March 2016 and will once again run a nursing and allied health professional stream at the

SCTS Ionescu University. This will be planned along the lines of the Heartlands Advanced

Cardiothoracic Course, and will consist of a half day cardiac and a half day thoracic course.

Feedback from last year’s University stream was excellent and hopefully through advertising

throughout this year we will have a larger number of participants at the meeting in

Birmingham. We would like to thank the entire surgical faculty for their participation in

Manchester and also the companies that took time to teach the participants, and we look

forward to their participation once again.

Plenary speakers planned to be invited:

Ms Andrea Spyropoulos & Ms Cecelia Anim – past & current RCN President’s who gave the

‘Opening Remarks with a topical Nursing UK perspective’, and the Closing comments. As the

NMC are bringing in nurse revalidation starting in April 2016, we are planning to invite a

leading member of the RCN to discuss the issues surrounding this topic.

On a clinical perspective we are also planning to re-invite Jill Ley, Nurse Specialist in Cardiac

Surgery at the California Pacific Medical Centre, San Francisco, USA & Fellow of the

American Association of Nursing, Scott Balderson, Lead Cardiovascular & Thoracic

Surgical Physician Assistant, from Duke University Medical Centre, and David Lizotte, the

President of the Association of Physician Assistants in Cardiovascular Surgery (APACVS).

All have attended the CT Forum before and their perspectives from an international level are

invaluable, they also are planned to teach at the CT Forum University stream.

36

Following a successful session at the EACTS Postgraduate Nurses Day on clinical guidelines we

are also planning on inviting Philippe Kolh from the University Hospital of Liege and Joel

Dunning to share their knowledge with the UK nurses and AHP’s. Both are also planning to

participate in the CT Forum University Stream.

Abstract submission is now open and hopefully we will have a large amount of abstracts

submitted for next years’ meeting. We again encourage everyone to support as many nurses &

AHP’s to attend that meeting. We are planning this year to film the CT Forum Ionescu Nursing &

AHP stream and then also the entire 2 day CT Forum meeting. Once edited this will create an

advertising opportunity for all nurses and AHP’s to see the impact of the CT Forum and the

benefits they will gain from attending.

• Ionescu Nursing and Allied Health Practitioner Fellowship

This year SCTS Education has advertised the opportunity for two Ionescu Nursing and Allied

Health Practitioner Fellowships worth £2,500. We had a number of excellent applications

from across the UK and Ireland and shortlisted 4 applicants to be interviewed at the annual

meeting in Manchester. I am extremely happy to say we offered two nurses the Ionescu

fellowships and we look forward to the feedback from both Emma Hope and Daisy Sandeman’s

experiences.

Emma plans to gain insight into the Aortic Aneurysm pathway and create an Aortic Nurse

Specialist role for the service at Southampton General, through her planned visits to Liverpool

Heart and Chest Hospital and the Queen Elizabeth II Hospital in Birmingham. Daisy currently is

in her 2nd year of her PhD focussing on delirium in cardiac surgery, she plans to visit John

Hopkins Institute in Washington, USA where they have specialist teams and units dealing with

post-operative delirium. Daisy plans to create a risk assessment model which could be used in

all centres in the UK and Ireland based on the knowledge she gains.

Both Fellows have started their fellowship visits and will present their experiences at the next

annual meeting in Birmingham, and will also create a paper each for the SCTS website and

Bulletin.

• Bupa/SCTS Patient Information Website Portal.

Currently there is a nursing project running to create patient information pages for the SCTS

and Bupa Websites. The aim is to create a central repository of Quality Assured information

which will provide accurate information regarding cardiac surgery for both patients and their

relatives; and to provide a resource for nurses and allied health practitioners working with

cardiac patients. A group of nurses met during the annual meeting in Manchester with

researchers from Bupa for an insight meeting and discussed the patient journey and pathway

around Aortic Valve Surgery. A patient survey has been given to a group of patients with

regards to the information they receive. The written information has been created and is

currently being edited and referenced. Plans are underway for nurses, surgeons and patients to

film videos for the websites, detailing their experiences.

• Consultations with the Surgical Care Practitioners remain ongoing, currently there are

many streams of work progressing.

Following consultations with the Royal College of Surgeons of Edinburgh, the SCP exit exam is

planned to be held on the 10th December at the RCS, Edinburgh in Birmingham. This exam is

open to those that have successfully completed a recognised SCP training programme as

37

described in the National curriculum framework, with the content of the cardiothoracic

pathway as a basis for the exam. Closing date for applications will be 30th October 2015. There

was a revision course held prior to the exam on the 1st and 2nd September 2015 in the CTCCU

seminar room, Wythenshawe Hospital, Manchester, details again on both the SCTS and ACSA

websites. This year’s exam will be based upon the current SCP exam structure and questions.

Work is ongoing to update the SCP course for next years’ exam, with a rigorous QA process

being developed. Thanks go to the RCS, Edinburgh for all their help, support and backing for this

process. A ‘silver scalpel’ award for the best candidate will once again be awarded at the

annual meeting with support from Swann Morton.

Throughout 2015 there are a number of Master Classes planned at the Manchester Surgical

Simulation Centre, Manchester in collaboration with SCTS Education and Ethicon. In April 2015

there was a SCP Master Class in Thoracic Surgery, the Master Class in Cardiothoracic

Surgery was held on the 23rd June, and the Master Class in Cardiac Surgery ran on the 8th

September 2015. The courses were well attended and feedback was excellent. We would like to

thank the surgical faculty and all the clinical international trainers from Maquet, Sorin, Terumo,

Sonasite and Karl Storz for their participation in these courses, and we also thank Ethicon for

sponsoring the courses

Discussions are continuing for increased involvement of ACSA with the SCTS, especially with

regards to formal recognition of the Cardiothoracic Surgical Care Practitioners.

• This year’s Advanced Cardiothoracic Course is planned for the 24th and 25th October

2015 at the education centre, Solihull Hospital, Lode Lane, Solihull. Cost is £30 for one day and

£50 for two days. Details are on the SCTS website. Please see the SCTS website for a link to a

film of the course.

• SCTS Education and Covidien have also supported the Nursing & AHP group in

sponsoring a course, a how to guide on ‘Setting up an Allied Health Practitioner

Programme’. The course is aimed at managers and clinicians who do not have such a

programme and will give tips and hints on how to set up a successful service. The 2nd course was

held at St Thomas’ Hospital in London on the 2nd October 2015; Advanced Nurse Specialists

across the UK presented their experiences of setting up their services. The course was well

attended and feedback was positive.

• Work towards creating SCTS Band 5 & 6 nursing training course and competencies

is progressing. This initiative has been brought about by a call from nurses on the

cardiothoracic wards, asking for guidance and support in basic cardiothoracic training. A

Cardiothoracic Nursing Clinical Development Course ‘Core Principles of Cardiothoracic

Surgery and Care of the Patient following Surgery’ is currently being created. This course

will be aimed at Band 5/6 nurses and we plan to create a framework of core competencies for

ward based nurses that will underpin a 1-4 day programme. The course will compose of

lectures and scenario simulation with an aim to identify local trainers that will be able to

replace the core SCTS faculty and teach the course at a local level, utilising the resources of

written lectures and content provided by the SCTS. The aim is to create a national workforce of

nurses with appropriate knowledge to care for the cardiothoracic patient and to act as a

benchmarking assessment tool across the UK and Ireland. Currently the lectures are being

written by advanced nurse specialists and SCP’s in cardiothoracics across the UK. The plan will

be to run the first course in Spring 2016.

38

• The postgraduate nurses’ & AHP day at EACTS was once again run by nurses and

allied health professionals from the UK, the Netherlands, Denmark and Germany. This was held

at the Amsterdam RAI Conference Centre, Amsterdam on Sunday 4th October 2015, and had a

focus on patient frailty and creating safe environments for patients. The SCTS CT Forum top

marking presentations were invited to present at this meeting, and plenary talks from Specialist

Nurses from across Europe were also presented. The meeting was extremely well attended this

year, we had a total of 117 delegates for the pre-lunch session, and around 50-60 for the

morning and afternoon sessions. This year EACTS presented an award for the best presentation

at the Nurses & AHP day which was peer marked based on the system used within the CT Forum

at the SCTS annual meeting. I am extremely pleased to say this was won by Brenda Andrews, a

thoracic Nurse Case Manager from Southampton. Brenda received a certificate from Jose Luis

Pomar. Congratulations go to Brenda and thanks to EACTS for the opportunity.

• The SCTS Nursing & AHP Website Pages have been amalgamated into one page with a

subpage for course, with a link to the CT Forum at the Annual Meeting; and a subpage for

contacts and useful Nursing & AHP websites and links. All the information on these pages has

been recently updated and the most recent Bulletin article is attached there for all nurses &

AHP’s to read. Please encourage all your nurses & AHP’s to look at the page and see the benefits

of membership, especially in relation to SCTS Education courses.


• Support for Nurses and AHP’s to attend the courses planned throughout the year and

also to attend the CT Forum University & Programme at the SCTS Annual Meeting.

• The nursing bursary, previously was £500 and the recipient needed to provide a report

for the bulletin. There had been an application. Where will the money come from

now? Is it an education issue?

• Discussions with Atricure with regards to creating some development and training for

theatre nurses. Cardiosolutions keen to be involved with nurse and AHP training also

simonwhkendall

Sticky Note

AHPS:1. Executive reminded to support their AHPs to attend forum and courses2. CB thanked for her continued hard work

39

x. STANDING REPORT FROM THE MEETING SECRETARY

C Barlow

A. MATTERS OF INFORMATION FOR THE EXECUTIVE COMMITTEE:

The Meeting Secretary will update the Executive on the current status of arrangements for

Birmingham 2016, Progress with the Action Points (included) and a Succession Plan (included).

There is a meeting of the Meeting Secretariat with Senior Executive Officers on Thursday 8

September. The outcome of this Meeting, including all updates, will formally be presented on

Friday 9 October.

simonwhkendall

Sticky Note

AGM Meeting Secretary. ACTION POINTS:1. CB / TRG to write to members re new abstract system and registration fees2. Co-operation with GM and research committee3. 2017 Belfast 2018 Joint meeting with ACTA. CB to liaise with ACTA4. BORS and ABM merged for AGM in 20165. Meetings team congratulated on surplus from AGM 2015 of £34,000

40

xi. STANDING REPORT FROM THE CHAIR OF THE SAC

S Barnard

A. MATTERS FOR CONSIDERATION BY THE EXECUTIVE COMMITTEE:

SAC Report September 2015

ST1 Pilot progress

This has been running for 3 years (2013-2015 intakes) and early indications at the selection day

and subsequent clinical progress have been encouraging. A more formal assessment has been

agreed to be made and this will take place next year, to allow feedback from the 2015 cohort to

take place. Dr Plint will write to Tara Willmott at the GMC to enquire what they would look for

in the report for the ST1 pilot, to be submitted in summer 2016.

National Selection 2015

The 2015process was reviewed, a significant spreadsheet issue was addressed. Applications and

bids were discussed in the September 11th SAC meeting. The whole process had been moved

forward 3 months to fit into LETB/Wessex Deanery timelines: the outcome is summarised

below.

Training Programme

ST1 ST3 Congenital

East Midlands 1

East of England 2 1

London 1 3

Northern 1 (ACF) 1 ⃰

Northern Ireland 1

North Western 1

South West 1

Wales 1

West Midlands 1 1

Yorkshire and Humber 1 1

Total numbers 8 8 2

National Selection 2016

National selection will be held in Botley Park Hotel on 1st & 2nd February 2016. There is to be a

meeting in the Wessex Deanery on the 13th November, where the possibility of running the

process in a single day will be explored (given the relatively low number ST3 posts).

SAC/TPD Joint meeting

It had been agreed in the last joint meeting in June 2015, that the joint meeting in 2016 would

be held on one day (SAC meeting in the morning, and meeting with the TPDs in the afternoon).

The date is Thursday, 9 June 2016.

GMC E&D

There is a 60 page document from the GMC (available on their website) regarding curriculum

change with respect to Equality and Diversity requirements. There is a lack of clarity as to how

41

the requirements would affect NTNs (as opposed to non-NTNs) and it was agreed to raise a

query with the ISCP Team, in the first instance, so clarification could be sought from the GMC.

GMC Standards

New GMC standards for medical education and training will come into effect from January 2016

and will cover both undergraduate and postgraduate training. There were 10 standards in total

and a series of requirements for each, which organisations would need to evidence that they

were complying with in order to demonstrate they were meeting the standards. The LETBs are

supportive of the new standards.

Workforce Planning Report SAC/SCTS 2015

The final workforce planning document has been circulated to the SAC by email; paper copies

were distributed to members at the meeting and we will be sending copies to other

stakeholders (eg JCST, DoH, GMC) in early October.

Transplantation:

A third periCCT post is to be created and competitively bid for by end of 2015. It is hoped that

the applications/interview will follow soon thereafter and the successful applicant be in post in

April 2016. This (coupled with the other two periCCT posts in Transplant) would mean, in

theory at least, that one new Transplant proficient CCT holder is produced every 6 months.

OOPT:

Once the trainee is back from their OOPT, it will be left to the ARCP panels to make the decision

as to whether that time should count towards certification. It will be the role of the liaison

member to comment on that OOPT at the ARCP meeting and agree about time towards

certification.

Curriculum Change

This meeting with the GMC o discuss curriculum change (streamlining cardiac and thoracic

surgical training) was put back at the GMC request from August to October 19th.

S P Barnard

Chairman SAC

simonwhkendall

Sticky Note

SAC Action points:1. Instigate review of training rates - ie number of supervised training cases (scrubbed and unscrubbed)2. SK to chase definition of training case from Ms Clare Burdett

42

xii. STANDING REPORT FROM THE EDUCATION SECRETARIES

M Lewis/R Shah

A. Meetings


SAC 12th Jun/11th

Sept

JCSFE board 15th July

Education Subcommittee Meeting Friday 4 Sept

Ethicon update Thursday 17th

Sept

SCTS University /Birmingham review Course

development

Friday 18th Sept

Ethicon Telecon Monday 5th Oct


1. AHP Stream

Courses 2015-2017 • Surgical Care Practitioner (SCP) master courses

• The SCP exam Revision Course

• The SCTS Advanced Cardiothoracic nursing course

• How to set up an AHP service

• The Core Principles in Cardiothoracic course portfolio

2. NTN Stream

• Introduce new courses - ST4B (Core Thoracic), ST5B (NOTSS), ST8A (Pre-

Consultant) and ST8B (Professional Development), ST1

• Continue to evolve current courses - ST3B, ST3A, ST2, ST4A, ST5A, ST6AB and ST7A

• Operative video prizes and operative video database

• Quality assurance of courses from RCS Ed / SCTS (Mahmoud)

• Measures of success / outcomes. Develop robust formative assessments criteria for

the courses

Assessment of Outcomes • DOPS (type) assessments pre and post courses

• Tracking of procedure numbers over the 12 months

• Clinical supervisor evaluation of trainee response to courses

• Self-evaluation of trainee

• Development of assessment group in partnership with RCS Ed

• Improve attendance through encouraging ARCP oversight

3. Consultant stream

• Non clinical learning. Aim is for every consultant to have access to a prof devel

course in a revalidation cycle. Delivered through Academyst.

4. Non NTN Stream

43

• Still working on non-NTN database. Engagement remains an issue.

• 2 courses to be run: 1 workshop on professional development, 1 on clinical issues

5. Medical Student Stream

• Bristol student engagement event success

• making 6th formers aware of the speciality

• 50 students at 2015 Annual Meeting; 50% female

• Request for 3 national events a year

• Scholarship scheme for elective

6. Accreditation & CPD

• Aims: o Develop a robust process of quality assurance of courses and awards of CPD

points

o Ensure Trainee SCTS Education courses are mapped to ISCP

o Ensure that the educational content, the teaching methods and the learning aims,

and learning outcomes are appropriate for the target audience

o Encourage appropriate evaluation of educational activities

o All cardiothoracic course providers to aspire for SCTS Education Accreditation

• Challenges: o Credibility (Link with RCSEd could be useful?)

o Manpower

o Publicity

7. VATS lobectomy Project

• Programme to improve VATS lobectomy outcomes

• Piloting in Manchester and Wolverhampton

• Ongoing mentorship and site visits from trainers

• Similar ideas around TAVI and mitrial repair in the works

8. Fellowships

• Advertising and application dates to be brought forward

• Aim to advertise 1 December; close 15 January; 4 week for assessment (Ethicon will

be later)

9. SCTSed.org.uk

• Developed by John Butler and Kasra Shaikhreza

• Platform for delivering and hosting SCTS education material

10. SCTS University

• Proposal for development of second University day. Industry support.

• Most likely linked to Birmingham Review Course

11. JCSFE

44

• Likely first clinical in Bangalore Sept 2016


Both Ed secretaries likely to demit in next 12months. Succession planning.

simonwhkendall

Sticky Note

simonwhkendall

Sticky Note

Education Committee: ACTION POINTS1. Announcement of Consultant Courses2. So far poor take up of non NTN opportunities - database to be updated3. Birmingham review course - to host a day of Ionescu SCTS University4. AO / SM to consider succession planning for ML and RS

45

xiii. REPORT FROM THE CHAIRMAN OF THE INTERCOLLEGIATE EXAMINATION BOARD

J Anderson

A. MEETINGS


Intercollegiate Specialty Board 20th Jan 2015 Available

Intercollegiate Specialty Board 1st Sept 2015 Unconfirmed


No change in format for CT exam. Awaiting SHOT review before SAC decides on curriculum

change. E and D training now embedded into examiner training and exam briefings.


Entry criteria unchanged but only 4 attempts at section 1 and 4 attempts at section 2. No

exceptional attempts after Jan 2016

46

Unconfirmed

Present: In attendance:

MINUTES of the MEETING of the INTERCOLLEGIATE SPECIALTY BOARD in Cardiothoracic Surgery held on Tuesday 20 January 2015 in the Reception Room at the Royal College of Surgeons in Edinburgh. Mr J R Anderson – Chair Mr S Barnard (SAC Chair) - Honorary Secretary Mr C Barlow (RCPSGlas) Mr J Hinchion (RCSI) via Teleconference Mr Rana Sayeed (Leader, Panel of Question Writers S1) Mr Rajesh Shah SCTS Ed via Teleconference Mr A Sepehripour (SCTS Trainee Representative) Mrs C R Digance-Fisher – Specialty Manager Mrs L Sheen – Specialty Manager

1. Welcome and apologies for absence

Apologies were received from Mr M E Lewis (SCTS), Mr M T Jones (RCSEng), Mr J McGuigan (RCSEd) and Mr J A J Hyde (SCTS).

The Chair welcomed Mr Amir Sepehripour (SCTS Trainee Representative) to his first meeting.

2. Minutes of Meeting held on 20th September 2014 at the Intercollegiate Office, Edinburgh.

The minutes were accepted as a true and accurate record and signed by the Chair.

Mr Anderson gave an update on the Equality and Diversity profile of the Examiners. These were overwhelmingly male however Mr Sayeed highlighted that a large proportion of the Question Writing Group were female.

3. Matters arising not covered elsewhere on the agenda.

The Chair confirmed that there is a new JCIE approved Equality & Diversity training presentation which would be circulated to examiners before each examination. Action: Secretariat The Board agreed that Mr T Graham would be retained as an assessor for a three year term.

Action: Secretariat Members discussed the criteria for applicants and that trainees must have an ARCP Outcome 1 at ST6 to be granted eligibility and discussed whether this could be part way through the year. This would be discussed at next SAC meeting and Mr Barnard agreed to update the Training Programme Directors. Action: Mr Barnard

47

4. To receive Unconfirmed Minutes of the JCIE Meeting held on 8 October 2014 in Edinburgh

The Board noted that the examination fees would be reviewed at the next JCIE Meeting. The Board noted that the Joint Surgical Colleges Fellowship Examination in Cardiothoracic Surgery has been established. The Board noted that Mr Richard Hedges would extend his term as Chair – Oral Question Writing Groups until April 2016. The Board noted that candidates who have been unsuccessful in Section 2 twice may receive more detailed feedback. This would be discussed at next JCIE meeting. The Board noted that JCIE is keen to recruit more diversity for the Panel of Examiners.

5. To receive Unconfirmed Minutes of the JCIE Internal Quality Assurance (IQA) Committee

Meeting held on 30 October 2014. The following points relevant to Cardiothoracic Surgery were noted:

The Board noted Dr Featherstone’s Psychometrician report. It was agreed to implement the automation of feedback to examiners after each diet of an examination, to provide analysis of their marking patterns and feedback from assessors. The May diet of the Cardiothoracic Surgery examination will see the introduction of this examiners’ feedback. The Board noted that Equality and Diversity training will be a component at the examiner induction course. Yearly monitoring (5 years in Cardiothoracic) with gender, ethnicity, religion, disability etc. would also be done. Mr Anderson suggested that all the banked Oral questions be reviewed. Two or three Writing Group Meetings would be required for the Oral questions and many more for the Section 1 Questions.

Mr Barlow expanded on the feedback to unsuccessful candidates confirming that the Training Programme Directors receive a copy of the final performance reports The Board noted that there remain gaps in the Section 1 questions mapped to the Curriculum and some of these are significant. The gaps would be actively looked at and it is hoped that they would be plugged by the end of this year. Members agreed that there should be a move to create higher order thinking questions rather than recall questions. Action: MCQ Mr Barlow summarised the numbers of questions in the various banks and the Board noted the low number for Cardiothoracic Surgery

6. To receive a report from the SCTS Trainee Representative

Mr Anderson welcomed Mr Sepehripour to the meeting and explained the Board structure.

7. Section 1 and Section 2 Reports

i. Section 1 – 8 July 2014 – CBT

a. The Board noted the report from Mr Rana Sayeed, Leader of the Section 1 Panel

of Question Writers

48

The Board noted that eight new members have been appointed to the Writing Group and that most of these are recent Consultant appointments.

b. The Examination report was noted.

The cut score for the examination was: 58.03

SEM for the examination was: 2.92

The eligibility to proceed mark was set at 603.95%

12 out of 23 (52%) candidates had been granted eligibility to proceed to Section

2.

The results by candidate type were noted as follows:

Type 1 (3a-2012 Regs) – 5 out of 6 (83%) passed

Type 2 (3b-2012 Regs) – 0 presented

Out of Training (O-2012 Regs) – 7 out of 17 (41%) passed

c. The Board noted the Survey Monkey Feedback and agreed that the majority of

questions are relevant to clinical practice and this proportion may further

improve with the question review.

ii. Section 2 – 15/16 October 2014 – Bristol

a. Members noted the Examination Report. 10 out of 14 candidates (71%) passed the examination Type 1 (3a-2012 Regs) – 5 presented and passed (100%) passed Type 2 (3b-2012 Regs) – 0 presented Out of Training (O-2012 Regs) – 5 out of 9 (56%) passed

The winner of the McCormack Medal was Mr Neil Cartwight (MRCSEd) with a total mark of 518.

b. The Examiner Assessor Report was Noted

The principle of an image bank was discussed, Mr Tsui had suggested this and it was felt this was a good idea but needed further work. It especially lent itself to Thoracic, but good cardiac echoes with representative views of common conditions would also be appropriate. The discussion expanded into using the imaging from an Examination centre to reuse into the Imaging section or the Oral questions in subsequent Examinations.

c. The Psychometrician’s Report was noted and the Board noted the low Thoracic

Oral intermarker reliability. Members discussed the differences in marks and

how this can be addressed. Debate between Examiners to establish facts with

respect to any uncertainty regarding performance before marks are given.

8. To note the 2015 Board Members and the Panels of Examiners, Assessors and Question Writers [S1]

i. The Board noted the 2015 list of Board Members

ii. The Board noted that the following Members of the Panel of Examiners are due to

retire from the Panel of Examiners on 31 December 2015:

Mr A J Bryan – 2nd term

Mr S Hunter – 2nd term

Mr S W H Kendall

49

Mr S K Ohri – 2nd term

Mr R D Page – 2nd term

The Board agreed that Mr Kendall would be asked to extend his term for a further 5

years. Action:

Secretariat

iii. The Board noted that Panel of Assessors and noted that Mr Kay and Mr MacArthur

will complete their term in December 2015.

iv. The Board noted the Panel of Question Writers for Section 1.

v. Two applications had been received for the Panel of Examiners and there was

agreement to appoint the following:

Mr John Dunning FRCSEd and Professor Mark Redmond FRCSI Action:

Secretariat

9. Dates, Venues and Local Organisers for Future Section 1 and Section 2 Examinations

i) Mr Jim McGuigan will host the examination in Belfast on 21st/22nd October 2015. ii) Mr Suku Nair will host the examination in Newcastle on18th/19th May 2016. iii) Mr Jonathan Unsworth-White will host the examination in Plymouth on 2016 in Plymouth.

10. To note the arrangements for Section 2: 19/20/21st May 2015

The proposed schedule for the Section 2 examination in May 2015 being hosted by Mr Mark Pullan in Liverpool was noted. The examination would be held at the Liverpool Heart Centre. The Examiners would stay at the Radisson Blu Hotel. Mr Page would organise the Thoracic component. A total of 27 candidates are entered.

11. On-going development of the Intercollegiate Specialty Examination in Cardiothoracic

Surgery Mr Barnard updated the Board about progress with Curriculum development. The Chair of the JCIE favours a 4:2 split, whereas the SAC had favoured a 5:1 split. It was agreed the sequence needs to be deciding the nature of the split, change the curriculum to reflect that and then change the Examination to suit. It was felt that the Examination may not change until 2019. Mr Barnard to write to the GMC to get written confirmation of proposed change.

Action: Mr Barnard

12. Any other business

There was no other business.

13. Date and time of next meeting

i) Late 2015

Date: Tuesday 1st September 2015 Time: 10.30am Venue: RCS Edinburgh ii) January 2016

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Date: Tuesday 19th January 2016 Time: 10.30am Venue: Edinburgh

Signature of Chair: ……………………………..……….…………………..………..

Date of Signature: …………1 September 2015……………………………

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xiv. REPORT FROM THE TRAINEE REPRESENTATIVES

A Sepehripour/J Afoke

A. MEETINGS


Teleconference with AsiT Director of Education 17.9.15 Yes


1. Databases-The NTN database has now reached a critical phase with movement from the

initial establishment to the practicality of tracking trainees due to LATs, OOPEs, research

etc. All NTNs were emailed to ask which ST level they are; there has only been a 40%

response rate. A non-NTN database has been created and will evolve over time as it is

used.

2. Curriculum issues-Following discussion at last SAC meeting, agreement to begin work

on a trainee manual mapping out progression through training in terms of case numbers

and competencies.

3. Work experience projects-The application to Mercers was declined; the feedback

obtained by Scott Prenn was that the application and the philanthropic aims of Mercers

didn’t fully align. Nevertheless the work experience project in Plymouth run by Mr

Unsworth-White was extremely successful and oversubscribed with excellent feedback,

reflecting the strong set up. We are awaiting the feedback from Leeds who have set up a

de novo project.

4. Medical student engagement/foundation taster weeks- we have received feedback from

most Foundation schools about official policy on taster weeks. It should be noted that

for practical reasons, taster weeks are encouraged and generally allowed in the latter

part of F1 since that would precede applications in the early part of their F2 year for ST1

applications. Plans to link with Mr Coonar and build a central list of elective/taster week

opportunities.

5. Accepted invitations to meetings: ASiT Preparing for a career in surgery London October

2015, Medical student engagement day Cambridge November 2015, ASiT pre-

conference course March 2016.

6. Discussion about current junior doctors contract negotiations. Following an online

enquiry on the social medium Facebook from Mr McCormack, there has been a request

from several trainees whether the Society will respond to the latest contract

negotiations and take an official position.


1. Database/curriculum issues already considered by education sub-committee and SAC

2. Further plans to continue work on building central list of elective/taster week

opportunities with Mr Coonar.

3. Forum for continuing work experience projects.

4. The issue about the junior doctors’ contract negotiations is extremely complex. The

major issue highlighted is about pay and social/non-sociable hours; it is reasonable to

52

say that exact facts and figures are currently lacking. We will be presenting limited data

on this and results of a trainee survey. There is also keenness amongst trainees for the

Society to take an official position, not only regarding cardiothoracic trainees, but junior

doctors as a whole.

xv. PERFUSION REPRESENTATIVE REPORT

T Pillay & H Luckraz



Council Meeting for The College of Clinical Perfusion 9/6/15

Council Meeting for The College of Clinical Perfusion 10/9/15


Disciplinary Policy and procedure for Perfusionists – see attached document

simonwhkendall

Sticky Note

Trainees Report - Action Points:1. Trainees response rate is only 40%2. Need strategy from SAC / SCTS to ensure trainees to attend SCTS curriculum courses3. Reminder from AO that these are SCTS courses and not industry courses4. Junior Doctor Negotiations - the information is currently confused . Full reply from Sec of State today. Not all facts are known. President / Executive urged caution re any industrial action.

53

THE COLLEGE OF CLINICAL PERFUSION SCIENTISTS

OF GREAT BRITAIN AND IRELAND

DISCIPLINARY POLICY AND PROCEDURES AND FITNESS TO PRACTISE HEARINGS

PART 1 – INTRODUCTION

1. There are three committees that deal with allegation, complaints and fitness to practise:

the Investigating Committee, the Conduct and Competence / Fitness to Practise

Committee and the Appeals Committee. Together they are known as the Professional

Practice Committee.

2. Each Professional Practice Committee is made up from at least three people who may be

registered Clinical Perfusion Scientists, Cardiac Surgeons or Cardiac Anaesthetists and Lay

Person. If a lay person cannot be found, then an alternative medical professional may sit

which can be a Clinical Perfusion Scientist, (who may be recently retired if appropriate).

One member of the panel will be appointed as Chair. The Professional Practice

Committees are held in public with the parties concerned. Private meetings may be held

leading up to this. These panels can be supported by a Legal Assessor (appointed to

provide the Committee with legal advice) and / or a Medical Assessor, and by a clerk or

panel secretary (to assist in the administration of the meeting or hearing).

3. A legally trained Case Presenter or Prosecutor may be appointed to present the case on

behalf of the College.

4. All complaints and allegations against a Clinical Perfusion Scientist working in Great

Britain or Ireland are considered including allegations that fitness to practise is impaired

by reason of:

i) Misconduct

ii) Lack of competence / seriously deficient performance

iii) A conviction or caution in the UK for a criminal offence, or a conviction

elsewhere for an offence which, if committed in England and Wales, would

constitute a criminal offence

iv) Physical or mental health

v) A level of proficiency in the knowledge and use of the English language that is

insufficient for the safe and competent practise of the perfusion profession

vi) An entry in the Register that has been fraudulently procured or incorrectly made

5. Any allegation or suspicion that an entry on the Register relating to the Registrant has

been fraudulently obtained or incorrectly made will be investigated.

6. Allegations can be received from any persons including employers, work colleagues,

patients, the police, NHS Protect or equivalent, other regulatory bodies and members of

the public. The College can also initiate its own investigation.

7. Refusal of annual re-registration or removal from the Register will be considered if a

Registrant is convicted of a criminal offence or accepts a police caution that involves one

of the following types of behaviour:

• Violence

• Abuse

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• Sexual misconduct

• Supplying drugs illegally

• Child pornography

• Offences involving dishonesty

• Offences for which a prison sentence is received

PART 2 – FUNCTION AND CONSTITUTION OF PRACTICE COMMITTEES

Investigating Committee

8. The Investigating Committee will consider in respect of each formal allegation referred to

it whether there is a case to answer.

9. In considering whether there is a case to answer, the Committee will consider the

evidence before it and decide whether there is a realistic prospect that the College will be

able to demonstrate that the registrant’s fitness to practise is impaired.

10. Hearings will be held in public.

11. When an allegation has been received, the Clinical Perfusion Scientist will be notified and

a request for information about their employment status will be made. In appropriate

cases, the allegation will be notified to the Clinical Perfusion Scientist’s employers.

Interim Order

12. The Investigating Committee will consider applying an interim order which restricts the

registration of the Clinical Perfusion Scientist if the allegation or event is considered

serious enough. It will only make such an order if it determines that it is either:

a) necessary for the protection of members of the public

b) in the public interest

c) in the interests of the Clinical Perfusion Scientist concerned

13. The Committee can make an order directing the College Council to suspend the

registration (an Interim Suspension Order) or impose conditions that the person must

follow (a Conditions of Practice Order).

14. A risk assessment in relation to every allegation that is under investigation to find out

whether it may be necessary to impose such an order will be carried out.

15. The decision to make an interim order may be made in the absence of the Clinical

Perfusion Scientist provided sufficient opportunity has been given to attend and make

representations. They and their employer will be informed of this decision and this will

be published on The Society of Clinical Perfusion Scientists of Great Britain and Ireland

website.

16. The duration of an order will be set by the Committee having regard to all of the

particular circumstances of the case. It will be reviewed every three months, when new

evidence relevant to the interim order becomes available and on receipt of

representations from the Clinical Perfusion Scientist.

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17. On review, the Investigating Committee may not vary any condition imposed by it or

replace one interim order with another without giving the Clinical Perfusion Scientist the

opportunity to appear before the Committee and give their views on whether such an

order should be made. This requirement is met by sending an interim order notice to the

Clinical Perfusion Scientist.

18. Notice will be given to the Clinical Perfusion Scientist where the Committee revokes or

confirms the interim order.

Conduct and Competence / Fitness to Practise Committee

19. The Fitness to Practise Committee shall consider any formal allegations against a Clinical

Perfusion Scientist referred to it by the Investigating Committee and decide whether a

Registrant’s fitness to practise is impaired. The Fitness to Practise Committee will not

include any member of the Investigating Committee.

20. These hearings will be held in public with the parties.

21. In considering the allegations, evidence and mitigation, the Fitness to Practise Committee

will consider the following when determining sanction:

i) The number and nature of offences or events

ii) The seriousness of the offences or events

iii) When and where the offences or events took place

iv) Information provided by the Clinical Perfusion Scientist to explain the

circumstances

v) Character and conduct since the offence or events

22. This is not a full list of factors which can help to decide the seriousness or significance of

the issues being considered.

23. The possible sanctions the Fitness to Practise Committee may apply but are not limited to

are that they may be:

1) Sent a warning letter with advice and or specific conditions with respect to

periods of re-training aimed at improving clinical or other skills as deemed

necessary.

2) Moved from the full College Register to the Provisional section of the Register

with the right to restoration retained. During this time, the Clinical Perfusion

Scientist will have to meet criteria for returning to work under the rules of

provisional registration. See Registration document – Provisional Registration.

This may include a period of supervised practice for a designated number of

cases over a scheduled return to work programme.

3) Suspension for period of time not exceeding twelve months but remaining on the

Register. This may include a period of supervised practice of a designated

number of cases over a scheduled return to work programme.

4) Struck off the College Register.

24. The Clinical Perfusion Scientist cannot apply for restoration until 5 years have elapsed.

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Appeals Committee

25. The Clinical Perfusion Scientists and any other individuals that have been involved in an

investigation by the College Council or by a Professional Practice Committee will be

informed in writing by the Secretary of the College of any decision and recommendations

made.

26. After being informed of the decision the Clinical Perfusion Scientist may appeal within 21

days by giving written notice of appeal to the College Administrator. The letter must give

the reason for the appeal and why he or she feels that the decision, the notice or the

recommendations or sanction were wrong.

27. The Appeals Committee will determine if:

• due process was followed

• decisions made were based on accurate data and evidence

• recommendations and actions taken were reasonable

28. The Appeals Committee will review all the paperwork from the original case. The Appeals

Committee will not include any member of the Investigating or Conduct and Competence

/ Fitness to Practice Committee. If it is deemed necessary to review the case in full the

procedure for the appeal hearing shall be similar in form and structure in terms of

evidence and procedure applied to the first hearing.

29. A note of evidence must be taken during the course of the appeal hearing.

30. A general right of appeal shall be retained by those justifiably aggrieved by a decision

against them. The sorts of reasons why a wrong decision will be made will probably

surround the grounds for:

• review of administrative actions and the reasons for the decision

• granting an appeal in the criminal courts

31. With respect to the grounds for review of administrative action, these are:

• error of law on the face of the record

• if decisions external to the College are amended the College can review the case

• excessive use of powers

• fettering discretion

• improper delegation

• improper purposes

• irrelevant considerations

32. With respect to appeals, a decision can be set aside because in all of the circumstances of

the case, it is unsafe or unsatisfactory, or that there was a material irregularity in the

course of the hearing. With respect to appeals against recommendations or sanctions, an

appeal can be launched on the basis that the recommendations were wrong in law or that

the recommendations were wrong in principle or manifestly excessive. If none of the

general grounds for allowing an appeal against conviction applies, the appeal must be

dismissed. If one or more does apply, then the Appeals Committee must be for allowing

the appeal. The test for a decision that it is either unsafe or unsatisfactory is a subjective

one.

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33. All appeal decisions will be relayed in writing to the Clinical Perfusion Scientist via the

College Administrator or the College Secretary on behalf of the College Council or the

Professional Practice Committee.

34. It is essential that all correspondence goes through the College Administrator and or the

Secretary to protect all parties from influence or unwanted involvement.

35. In a situation whereby the Secretary of the College is involved in the Professional Practice

Committee, a nominated member of the College Council, not involved in the case, will act

as Secretary to the College. This will normally be the President, Vice President or

Treasurer.

36. The Appeal will be conducted in accordance with the Appeals Policy and procedure.

Membership, Quorum and Voting of Practice Committee Members

37. The College Council holds a list of people from which Professional Practice Committee

members can be selected to hear a particular case. This is done on a case by case basis.

38. Each Practice Committee shall consist of not fewer than three members appointed by the

College Council.

39. The quorum of each panel shall be equal to its membership.

40. Each Committee will contain a Clinical Perfusion Scientist, Cardiac Surgeon or Cardiac

Anaesthetist and where possible a Lay Member although an alternative medical

professional may otherwise be used. A Legal Assessor may also be appointed to advise all

parties on the proceedings. A Chair will be appointed for each Committee. A Case

Presenter (Prosecutor) may be appointed who will present the case on behalf of the

College. Where a legally qualified panel member is appointed he/she will fall within the

role of Chair and may also fulfil the role of Legal Assessor in which case the requirement

to have a Legal Assessor may be dispensed with.

41. No member of the Professional Practice Committees shall sit on the hearing of a Clinical

Perfusion Scientist’s case if that member has previously been concerned with that case ie.

participated in one of these panels.

42. Decisions of all Committees shall be taken by simple majority and the Chair may exercise

a casting vote.

43. Each Practice Committee will be assisted by a clerk or panel secretary who shall be

responsible for the administrative arrangements for the hearing. The clerk will not

participate in the decision making of the Committee and will not have a vote.

44. A record of the proceedings and events will be made.

Conflicts of Interest

45. If any member of the Professional Practice Committee has or considers there to be a

conflict of interest, which may affect or may appear to affect his or her judgement in

dealing with a complaint, then he or she must declare that conflict and decline to sit on the


58

46. If circumstances change and a conflict subsequently arises or appears to arise, then this

must also be declared and that committee member shall stand down.

47. A conflict of interest will arise if:

• the committee member has had a personal or close professional relationship

with the complainant or Clinical Perfusion Scientist

• the committee member has been involved in the matters that are the subject of

the complaint

• there is any other factor that may cast reasonable doubt as to the fairness and

impartiality of the handling of the case

48. Where a subsequent conflict or the appearance of a conflict arises, the committee member

concerned must take no further part in the handling of the case on the Committee.

Removal of Committee Members

49. A person:

a) is not eligible to be appointed or sit as a member of a committee if disqualified or

suspended from membership of another committee or panel and

b) shall cease to be a member of a committee if:

i) the member resigns which they may do at any time

ii) a conflict of interest arises

c) may be removed pursuant to the procedures of the College Council

Appointment of a Legal or Medical Assessor

Legal Assessor

50. The College Council may appoint a Legal Assessor to assist the Committee in procedural

or legal matters.

51. The role of the Legal Assessor shall be to advise the Committee on questions of law and to

ensure that the proceedings before the Committee are conducted fairly. The Legal

Assessor shall inform the Committee immediately of any irregularity in the conduct of the

proceedings.

52. The parties shall have the opportunity to make representations on the contents of any

legal advice before any decision is announced by the Committee.

53. The Legal Assessor may also assist in the drafting of the reasons for any findings,

determinations or decisions of that Committee.

54. The Legal Assessor shall not be entitled to vote nor take part in any deliberations or the

decision making process.

Medical Assessor

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55. The College Council may appoint a Medical Assessor to advise the Committee whenever it

is considering a formal allegation that the Clinical Perfusion Scientist’s fitness to practise

is impaired by virtue of their physical or mental ill health.

56. The role of the Medical Assessor shall be to give evidence on matters as an expert witness

relating to the Clinical Perfusion Scientist’s physical or mental health.

Postponing or Adjournment of a Hearing

57. Hearings may be postponed by the Committee Chair on their own motion or following a

written request by the Clinical Perfusion Scientist stating the reason for this request.

58. Where a hearing is postponed the Clinical Perfusion Scientist will be given notice of the

new date to which the postponed hearing will be held which will not be before 14 days

after the original scheduled date.

59. Hearings may be adjourned by the Committee Chair or at the request of the Clinical

Perfusion Scientist providing no injustice is caused to either party. This decision can only

be made after hearing representations from the parties and taking advice from the Legal

Assessor.

60. In considering whether or not to grant a request for postponement or adjournment, the

Committee Chair must consider the following:

• the public interest in the case being completed quickly and efficiently

• the potential inconvenience caused to a party or witness to be called by that party

• fairness to the Clinical Perfusion Scientist

Service

61. Any form, warning, notice, decision or request for information given by the College may be:

a) sent by post to the home address of the Clinical Perfusion Scientist as it appears on

the Register and shall be treated as having been sent on the day of which it was

posted

b) sent to the Clinical Perfusion Scientist’s last known address and shall be treated as

having been sent at the time of its posting

c) served on the Clinical Perfusion Scientist by hand at either of the addresses at a) or

b) above or otherwise and shall be treated as having been sent at the time of the

personal service

d) sent by email to the email address provided to the College by the Clinical Perfusion

Scientist as it appears on the Register and shall be treated as having been sent at the

time of its sending

e) service shall be deemed the second day after posting.

PART THREE – INVESTIGATING COMMITTEE

Referral of Complaint / Information

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62. Where the College receives a complaint or information about a Clinical Perfusion Scientist

and that individual is already the subject of an inquiry by the police, the Hospital Trust

Board, NHS Protect or equivalent, another regulatory body, or there are ongoing criminal,

civil or regulatory proceedings, the College may defer the investigation or referral of a

complaint or information until the enquiry or proceedings have concluded.

Procedure of the Investigating Committee

63. The Investigating Committee will sit in private in the absence of the parties.

64. The Committee must send to the Clinical Perfusion Scientist:

a) a copy of the complaint or information and any documentation in support

b) information on how to access these rules

65. The Committee shall invite the Clinical Perfusion Scientist to submit written

representations upon the complaint or information or other matter to be considered,

together with any additional documentation.

66. Where written representations are received, the College may if it seems fit, send the

complainant a copy of the written representations inviting them to provide any written

comment on these representations for consideration by the Committee. The Clinical

Perfusion Scientist will be sent a copy of the complainant’s response.

67. If the Committee considers there is not a realistic prospect of a finding of impairment in

relation to the grounds of misconduct, lack of competence / seriously deficient

performance, a criminal conviction or caution, mental or physical health, or the proficiency

level of the known and spoken English language, then it shall inform the complainant, the

Clinical Perfusion Scientist and any interested third party that no further action will be

taken and provide an explanation for that decision. All decisions shall be made in writing.

68. In respect to any earlier allegations which the College previously determined there was no

case to answer may be taken into account subsequently if the Clinical Perfusion Scientist

has been notified. The notification contains a statement that the case may be taken into

consideration if further allegations arise.

69. The Committee must decide based on the evidence available to them as to whether the

Clinical Perfusion Scientist has been in breach of the Codes of Practice, Standards of

Practice, and Codes of Ethical Conduct or has brought the profession into disrepute.

70. Where the Committee determines there is a case to answer and decides to proceed to the

next stage, it must provide written reasons for its decisions for referral to the Conduct and

Competence / Fitness to Practise Committee.

Procedure for an Interim Order

71. Where the College Council or Investigating Committee wish to apply for an Interim Order,

it shall send a notice of hearing to the Clinical Perfusion Scientist. This notice shall:

a) include details of the matters upon which the application is based

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b) include a statement setting out why the Clinical Perfusion Scientist’s practice should

be restricted or registration of the individual should be suspended

c) provide reasonable notice of the hearing

d) include notification that the hearing may proceed and be decided in the absence of

the Clinical Perfusion Scientist should he or she (or their representative) not attend

e) inform the Clinical Perfusion Scientist of:

i) his or her right to attend the hearing

ii) the time and venue for the hearing

iii) his or her right to give evidence in person, to call witnesses and to cross-

examine any witnesses called by the panel

iv) his or her right to make oral submissions to the panel in person or to be

represented by another person (e.g. solicitor, barrister, professional body or

trade union representative)

72. Where the Committee is considering whether or not to make an Interim Order, the order of

proceedings shall follow:

a) the College shall outline the facts of the case and set out the reasons why the Clinical

Perfusion Scientist’s registration should be made subject of an Interim Order,

together with any evidence in support

b) the Clinical Perfusion Scientist may set out the reasons why such as an application

should not be granted by the panel, together with any evidence or other material in

support

c) the Committee may obtain advice from the Legal Advisor where one is appointed

d) the Committee shall determine the application and announce its decision and the

reasons for it in the presence of the parties if present and applicable

73. As soon as possible after the decision and conclusion of the hearing, the College shall send a

notice of decision to the Clinical Perfusion Scientist which shall:

a) set out the decision of the Investigating Committee

b) specify the reasons for the decision

c) where an Interim Order has been imposed, set out the period of suspension or

restriction, beginning on the date on which the order is made

d) inform the Clinical Perfusion Scientist of the right to appeal to the Appeal Committee

PART FOUR – CONDUCT AND COMPETENCE / FITNESS TO PRACTISE COMMITTEE

PROCEDURES

Notice of Hearing

74. The College shall send the Clinical Perfusion Scientist notification of hearing no later than

28 days before the hearing of the formal allegations before the Fitness to Practise

Committee. This shall include:

62

a) the date, time and venue of the hearing

b) the allegations / charges against the Clinical Perfusion Scientist

c) his or her right to

i) attend the hearing

ii) give evidence to the panel

iii) make oral submissions to the panel either in person or through a

representative (e.g. solicitor, barrister, professional body or trade union

representative)

iv) call and cross examine witnesses

d) the possible sanctions open to the panel in the event of a finding of impairment

e) the panel’s power to proceed and determine the matter in the absence of the Clinical

Perfusion Scientist, or their representative at the hearing

75. The evidence to support the allegations will be sent out to the Clinical Perfusion Scientist

with the letter of notification or to follow shortly after.

76. The hearing shall not be scheduled for a date earlier than the 28 days from the day after the

sending of the notice of hearing except with the agreement of the Clinical Perfusion

Scientist.

77. The College shall publish the notice of the hearing on The Society of Clinical Perfusion

Scientists of Great Britain and Ireland website.

Disclosure of Case and Service of Documents

78. No later than 6 weeks before the date of the hearing, the College shall serve on the Clinical

Perfusion Scientist copies of all documents and reports relied upon which it intends to use.

79. No later than 14 days before the date of the hearing, the Clinical Perfusion Scientist shall:

a) advise the College what if any of the evidence served by the College they agree and

b) serve on the College copies of all documents and reports upon which they intend to

reply.

80. Upon receipt of the Clinical Perfusion Scientist’s case, the College shall consider whether

there are any further documents in the College’s possession which may assist the Clinical

Perfusion Scientist and shall serve copies of such documents, if any to him or her.

81. No later than 7 days before the hearing, the College shall send to members of the panel

copies of any documents or reports provided by the parties (whether agreed or otherwise).

Preliminary Meetings

82. The Fitness to Practise Committee may hold a preliminary meeting in private with the

parties, their representatives and any other person the panel considers appropriate if such

a meeting would, in the opinion of the panel or the Chair, assist the panel to perform its

functions.

Joinder

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83. The Fitness to Practise Committee may consider an allegation against two or more Clinical

Perfusion Scientists at the same hearing if considered fair to do so.

84. Consideration of one or more categories of allegation relating to a conviction or caution is

heard after any allegation of misconduct has been heard and determined although this may

not always be the case.

85. Consideration may be given to a new allegation, which is of a similar kind or is founded on

the same facts, at the same time as an existing allegation, even when the new allegation was

not included in the notice of hearing.

Absence of the Clinical Perfusion Scientist

86. Where the Clinical Perfusion Scientist has been notified of the hearing and he or she does

not attend and is not represented, the Committee may nevertheless proceed with the

hearing if it is satisfied that all reasonable steps have been taken to give notice of the

hearing to the Clinical Perfusion Scientist and that it is in the public interest to proceed.

Vulnerable Witnesses

87. In proceedings before the Committee, the following may be treated as a vulnerable witness,

if the quality of their evidence is likely to be adversely affected as a result:

a) any witness under the age of 17 at the time of the hearing

b) any witness with a mental disorder within the meaning of the Mental Health Act

1983

c) any witness who is significantly impaired in relation to intelligence and social

functioning

d) any witness with physical disabilities who requires assistance to give evidence

e) any witness, where the allegation against the practitioner is of a sexual nature and

the witness was the alleged victim

f) any witness who complains of intimidation

88. Subject to any representations from the parties and the advice of the Legal Assessor, the

Committee may adopt such measures as it considers reasonable and desirable to enable it

to receive evidence from vulnerable witness.

89. Where a formal allegation concerns an allegation of a sexual nature, the Clinical Perfusion

Scientist shall not be permitted to cross-examine the complainant in person without the

consent of that person.

Procedure at the Hearing

90. Subject to the requirements of a fair hearing, the panel may decide its own procedures

generally and may issue directions with regard to the prompt and just determination of the

proceedings but will follow all the stages of the process, being:

a) preliminary matters

b) findings of fact

c) deciding whether the Clinical Perfusion Scientist’s fitness to practise is currently

impaired

d) mitigation and sanction

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91. The Committee may exclude from the whole or part of the hearing, any person whose

conduct in their opinion has disrupted or is likely to disrupt the hearing.

Reading of the Formal Allegations

92. At the opening of the hearing, the Chair will commence with introductions where all

present will identify themselves and confirm that all have the same and complete set of

paginated papers.

93. The Chair will confirm the registration number of the Clinical Perfusion Scientist and swear

in or affirm them.

94. The formal allegations will be read out to the Clinical Perfusion Scientist where upon the

Chair shall ask him or her whether any facts or convictions, cautions, relevant

determinations, health issues or false entries alleged in the formal allegation are admitted.

95. Subject to the requirements of a fair hearing, the Committee may amend the formal

allegations at any stage prior to findings of facts of the case and having taken advice from

the Legal Advisor if appointed.

Presentation of the Case

96. A member of the Investigating Committee or Case Presenter (Prosecutor) if appointed will

begin with a presentation of the case against the Clinical Perfusion Scientist including the

investigation, documentary evidence and allegations.

97. Where no admissions are made or some relevant facts remain disputed, the Case Presenter

(Prosecutor) shall present evidence in support which may include calling witnesses.

Evidence

98. Subject to the advice of the Legal Advisor, the requirements of a fair hearing and of

relevance, the Committee may:

a) admit evidence whether or not it would be admissible in a court of law in the UK and

Ireland

b) exclude evidence, where doing so ensures fairness to the Clinical Perfusion Scientist

and or the College

99. The panel may receive oral, documentary or other evidence of fact or matter which appears

to it to be relevant to its consideration of the case.

100. Either side may instead of or in addition to calling witnesses, present a written statement

or affidavit by or on behalf of a witness who is unable to attend the hearing. Any such

document must clearly identify the name and address of the person making the document

and must be signed and dated. The panel may at their discretion agree to receive or reject

such written evidence having regard among other things to the reasons for the absence of

the person giving evidence, the nature of the content and the unavailability for questioning

of the witness.

101. The findings of fact and certification of conviction of any UK or Irish criminal court or the

findings of a judge in any UK or Irish civil court shall be conclusive proof of the conviction

65

or finding and the underlying facts.

102. Any relevant determination and findings of fact by any regulator or an equivalent regulator

outside the UK and Ireland shall be conclusive proof of the determination and the

underlying facts.

Witnesses

103. Witnesses shall be sworn or required to affirm.

104. Witnesses shall be examined by the party calling them and may then be cross-examined by

the opposing party. The party calling the witness may then re-examine the witness.

105. The parties may then question the witnesses on matters arising out of the panel’s

questioning. The party calling the witness shall question the witness last.

106. Further questioning is at the discretion of the Chair.

107. Witnesses shall not be allowed to attend or watch the proceedings other than to give their

evidence.

Half Time Submission

108. At the close of the case against the Clinical Perfusion Scientist, he or she or their

representative may submit that the College has not presented sufficient evidence to

demonstrate that, taken at its highest:

a) the facts of the formal allegations are capable of proof

b) the grounds are not capable of being made out

c) there is no realistic prospect of a finding of impairment

109. The Conduct and Competence / Fitness to Practise Committee will consider any such

submissions after having heard representations from both parties and having received any

such advice as it considers necessary.

The Clinical Perfusion Scientist’s Evidence

110. At the end of the evidence presented against the Clinical Perfusion Scientist, he or she or

their representative may address the panel before calling evidence in support of their case.

111. The Clinical Perfusion Scientist will then give their own evidence followed by any

witnesses called following the above procedure again.

Closing Submissions

112. After completion of the evidence, the Clinical Perfusion Scientist or their representative

may make closing submissions to the panel. The Investigating Committee Chair or the

prosecutor will then make a closing submission.

113. The Legal or Medical Adviser if appointed will then provide any advice required by the

Fitness to Practise Committee.

Burden and Standard of Proof

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114. The burden of proving the facts alleged in the formal allegation which are in dispute shall

rest upon the College.

115. The standard of proof shall be on the balance of probabilities.

Findings of Fact

116. The Conduct and Competence / Fitness to Practise Committee shall retire to consult and

not give their decision orally or immediately. The decision may be by a majority.

117. If no relevant facts have been proved or there is no finding that the allegations have been

made out, the formal allegations will be dismissed.

118. The Committee shall makes findings as to whether some or all of the allegations are

proved.

119. The panel shall make findings as to whether the Clinical Perfusion Scientist has been in

breach of the Codes of Practice, Standards of Practice, and Codes of Ethical Conduct or has

brought the profession into disrepute.

120. The Committee shall inform the College Council of its findings as soon as possible and give

reasons on how it reached this decision. The Clinical Perfusion Scientist will be informed of

the decision and outcome as soon as possible thereafter.

121. Findings will be posted on The Society of Clinical Perfusionists of Great Britain and Ireland

website.

Fitness to Practise

122. If the allegation(s) are found to be proved, the Conduct and Competence / Fitness to

Practise Committee shall then consider if the Clinical perfusion Scientist’s Fitness to

Practise is impaired.

123. The Clinical Perfusion Scientist may address the Committee and call any evidence as to

current fitness to practise.

124. Where witnesses are called, they may be questioned by the Committee and the Prosecutor.

125. After completion of any evidence, the Clinical Perfusion Scientist or their representative

may make closing submissions to the Committee. The Fitness to Practise Committee Chair

or the Prosecutor will then make a closing submission.



127. The Conduct and Competence / Fitness to Practise Committee shall retire to consult and

not give their decision orally or immediately. The decision may be by majority.

128. The Committee shall inform the College Council of its findings as soon as possible and give

reasons on how it reached its decision. The Clinical Perfusion Scientist will be informed of

the decision and the outcome as soon as possible thereafter.

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129. Findings will be posted on The Society of Clinical Perfusionists of Great Britain and Ireland

website.

Mitigation

130. The Clinical Perfusion Scientist may address the panel in mitigation, present references and

testimonials and call character witnesses in support.

131. Where character witnesses are called, they may be questioned by the Committee and the

Prosecutor.

132. Where the Clinical Perfusion Scientist has chosen not to attend the hearing, he or she may

provide details of mitigation in writing in advance to the College which will be presented to

the panel.

133. Where the Committee finds the Clinical Perfusion Scientist’s fitness to practise is impaired,

the College shall provide the panel with details of his or her previous disciplinary record

with the College and may present evidence and make submissions in relation to the

appropriate sanction to be made by the Committee.

134. After completion of any evidence, the Clinical Perfusion Scientist or their representative

may make closing submissions to the Committee. The Fitness to Practise Committee Chair

or the Prosecutor will then make a closing submission.



Notice of Decision

136. As soon as reasonably practicable at the conclusion of the hearing, the Committee shall

send a notice of its decision to:

• the College Council

• the Clinical Perfusion Scientist

• the complainant

• any interested third party

137. The notice of decision shall

a) set out the panel’s findings of fact, its decisions on the grounds, impairment and

sanction

b) state the reasons for the panel’s decisions

c) where a Suspension Order or Restriction Order has been imposed, set out the period

of suspension, restriction or retraining

d) inform the Clinical Perfusion Scientist of the right of appeal to the Appeals Committee

e) inform the Clinical Perfusion Scientist that any sanction imposed by the panel took

effect from the date it was made

138. Where there is a finding of impairment, the College shall publish the notice of decision on

The Society of Clinical Perfusionists of Great Britain and Ireland website.

139. The names of Clinical Perfusion Scientists struck off the Register shall remain on the

website for 10 years and remain on the College’s record indefinitely.

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140. The College may also at any time provide a copy of the notice of decision to any of the

regulatory bodies or interested third parties if it is in the interest of justice to do so.

PART FIVE – SANCTIONS

141. The Committee will retire to consider the appropriate sanctions having heard any evidence

and/or submissions as to mitigation. The possible sanctions are set out in paragraph 23.

Restoration to the Register

142. Clinical Perfusion Scientists stuck off the Register will be considered for restoration to the

Register after five years have elapsed if the Clinical Perfusion Scientist makes a request to

the College at that time subsequently.

143. This procedure will follow similar guidelines to the Appeals Committee.

144. If there is as an overturning of a criminal or civil conviction or a miscarriage of justice has

been proven, then the Clinical Perfusion Scientist has the right to make a request to the

College for it or the Appeals Committee to review their case.

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GLOSSARY

Appeals Committee shall mean the committee established under the College’s Disciplinary

Policy and Procedure which forms part of a Professional Practice Committee. It hears the case

for appeal and determines if the outcome and any recommendations or sanctions are fair and

just.

Appellant shall mean the Clinical Perfusion Scientist appealing against a decision,

recommendation or sanction against them and their registration.

Burden of Proof shall mean that the burden of proving the facts alleged in the formal allegation

which are in dispute shall rest upon the College.

Chair shall mean the chairman or chairwoman of the Investigating Committee, The Conduct and

Competence / Fitness to Practise Committee or the Appeal Committee that collectively form the


College shall mean The College of Clinical Perfusionists of Great Britain and Ireland.

Conditions of Practice Order shall mean an order imposed by the College or Investigating

Committee that imposes restrictions or conditions on them in their practice to work. This may

also be called a Restriction Order.

Conduct and Competence / Fitness to Practise Committee shall mean the committee

established under the College’s Disciplinary Policy and Procedure which forms part of the

Professional Practice Committee. The disciplinary panel hears the case and determines

outcome and any recommendations and or sanctions to be imposed.

Day(s) means any day including weekends, bank holidays and religious days.

Formal Allegation shall mean the allegation that the Clinical Perfusion Scientist’s fitness to

practise is impaired by reasons of one of the grounds set out in the Disciplinary Policy and

Procedure.

Investigating Committee shall mean the committee established under the College’s

Disciplinary Policy and Procedure which forms part of a Professional Practice Committee. It

investigates the case, reviews evidence and determines if there is a case to answer.

Interim Order shall mean an order made by the Investigating Committee or College to limit the

practice or suspend the registrant’s registration prior to a Conduct and Competence / Fitness to

Practise Committee having disposed of the matter.

Joinder shall mean where the Conduct and Competence / Fitness to Practise Committee may

consider an allegation against two or more Clinical Perfusion Scientists at the same hearing if

considered fair to do so.

Professional Practice Committee shall mean a committee set up by the College to investigate

serious complaints concerning Clinical Perfusion Scientists that are not straight forward and or

complicated which cannot easily be dealt with by the College Council.

Register shall mean the register or directory the College holds of all Clinical Perfusion Scientists

working in Great Britain and Ireland. This includes Accredited, registered, limited or

provisional registrants and trainee Clinical Perfusion Scientists.

70

Registrant shall mean any Clinical Perfusion Scientist, whether Accredited, limited with

restrictions or training, on the Register.

Respondent shall mean the College in an appeal process lodged by a Clinical Perfusion

Scientist.

Standard of Proof shall mean that the proving of something which is disputed lies on the

balance of probabilities.

Suspension Order shall mean an order imposed by the College or Investigating Committee that

suspends the registration of a Clinical Perfusion Scientist.

71

THE COLLEGE OF CLINICAL PERFUSION SCIENTISTS

OF GREAT BRITAIN AND IRELAND

APPEALS POLICY AND PROCEDURE

Function and Purpose

1. These rules set out how the Appeals Committee established by the College will consider

appeals by Clinical Perfusion Scientists made:

a) against a decision by the College to refuse to enter that individual onto the

Register

b) against a decision by the College to refuse to renew the registration of a

Registrant

c) against a decision by the College or the Investigating Committee to impose an

Interim Order restricting the practice or suspending the Clinical Perfusion

Scientist

d) against a decision by the Conduct and Competence / Fitness to Practise

Committee that a registrant’s fitness to practise is impaired and or any sanction

imposed

2. Appeal hearings shall not be way of a re-hearing, rather they will review all the

paperwork from the original case and the previous decision made to determine that if

due process was followed, the decisions made were based on accurate evidence and that

any recommendations and/or sanctions taken were within the range of reasonable

decisions.

3. If it is satisfied that it is just and reasonable to do so, the Appeals Committee may permit

the Clinical Perfusion Scientist or appellant to rely on grounds not stated in the notice of

appeal.

4. If it is deemed necessary to review the case in full, the procedure of the appeal hearing

shall be similar in form and structure in terms of evidence and procedure applied to the

first hearing.

5. Appeal hearings will be held in public.

Notice of Appeal Hearing

6. The Clinical Perfusion Scientist may appeal the decision within 21 days of being

informed by giving written notice of appeal to the College Administrator. This must be

addressed to the College and state that it is the notice of appeal, be signed by the Clinical

Perfusion Scientist themselves or their representative and shall include:

i. the name and address of the appellant Clinical Perfusion Scientist

ii. his or her College registration number

iii. the date, nature and any relevant details of the decision against which the appeal

is brought

72

iv. a concise statement of the grounds of the appeal reasoning why he or she feels

that either the decision, the notice or the recommendations or sanction were

wrong

v. the name and address of the appellant’s representative (if any) and a statement

as to whether the College should correspond with that representative or directly

with the Clinical Perfusion Scientist concerned

7. The Clinical Perfusion Scientist shall attach to the notice of appeal a copy of any

documents on which he or she proposes to rely on for the purposes of the appeal.

8. Once the College has received the notice of appeal, it may serve evidence or

representations in response to the evidence replied upon by the appellant. This must be

served within 28 days from receipt of the notice of appeal.

Acknowledgement and Notice of Hearing

9. Within 28 days of receiving a valid notice of appeal, the College shall:

a) acknowledge receipt and confirm a date and time for the appeal hearing which

shall not be more than 90 days following the receipt of a valid notice of appeal

b) send a notice of appeal hearing to the appellant which will inform him or her of:

i) the right to attend the hearing

ii) the date, time and venue for the hearing

iii) the nature of the appeal hearing, namely that it is by way of review

rather than re-hearing

iv) the right to give evidence in person and to call witnesses in accordance

with the restrictions on evidence

v) the right to make oral submissions to the panel in person to be

represented by another person (e.g. solicitor, barrister, professional

body or trade union representative) and

vi) that if he or she does not attend, the appeal may proceed in their absence

Notice of Attendance

10. Within 28 days of the notice of hearing being sent, the appellant shall inform the College

whether or not they intend on attending or to be represented at the hearing and

whether or not they intend to call any witnesses or submit any other fresh evidence

subject to the requirements specified and if so, must provide their names and addresses

to the College.

11. If the Clinical Perfusion Scientist does not intend on attending or to be represented at

the hearing, may no less than 7 days before the date of the hearing send to the College

additional written representations in support of his or her appeal.

Appeal Committee

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12. The Committee shall comprise no fewer than three members appointed by the College

under the rules of the College’s Disciplinary Policy and Procedure and shall include a

Clinical Perfusion Scientist, a Cardiac Surgeon or Cardiac Anaesthetists and a Lay

Person. A Chair will be appointed from the former two professions.

13. A person who has been involved in any other capacity in a case which is to be

considered by the Committee shall not be appointed as a member of that panel.

14. Decisions will be made by a majority vote of the panel and in the event of a tie, the Chair

shall have the casting vote.

15. A clerk or panel secretary will assist the Committee and shall be responsible for the

administrative arrangements for the hearing. The clerk or panel secretary will not

participate in the decision making of the panel and shall not have a vote.

Removal of Committee Members

16. A person:

a) is not eligible to be appointed or sit as a member of a committee if disqualified or

suspended from membership of another committee or panel and

b) shall cease to be a member of a committee if:

i) the member resigns which they may do at any time

ii) a conflict of interest arises

c) may be removed pursuant to the procedures of the College Council

Representation

17. The College may be represented in appeal proceedings by any person and shall be

known as the respondent.

18. The appellant may be represented in any proceedings by any person whether or not

legally qualified, except a Registrant on the College Register.

19. Where the appellant or the College are represented at an appeal hearing, references in

these rules to them may also be read as references to the representatives.

Preliminary Meetings

20. The Appeal Committee may hold a preliminary meeting in private with the parties, their

representatives or any other person the Committee considers appropriate if such a

meeting would, in the opinion of the panel or the Chair, assist the panel to perform its

functions.

21. Preliminary meetings may be held electronically or by telephone if the Committee

considers that it would be in the public interest to do so.

Powers to determine an Appeal without Hearing

22. The Appeals Committee may determine an appeal without an oral hearing on the basis

of any documents provided as set out in the rules where:

74

a) the College does not receive a reply from the appellant within the time specified and

the Committee is satisfied that all reasonable steps have been taken to give notice or

b) the appellant replies to the effect that he or she does not wish to attend or be

represented or

c) both the appellant and respondent consent to the appeal being determined without

a hearing and

d) the Committee consider it to be in the public interest to do so

23. If the Committee determines an appeal without a hearing, it shall take into account any

written representation provided by the appellant and the respondent.

Absence of the Appellant

24. Where:

a) the appellant has been notified of the hearing

b) the appellant does not attend and is not represented

c) the respondent does not consent to the appeal being determined without a

hearing

the Committee may nevertheless proceed with the hearing if it is satisfied that all

reasonable steps have been taken to give notice of the hearing to the appellant and that

it is fair and in the public interest to do so.

Postponement or Adjournment of a Hearing

25. Hearings may be postponed by the College either of its motion or at the request of the

appellant up to 14 days in advance of a hearing after receiving representation.

26. Where a hearing is postponed, the College shall send the appellant notice of the

rescheduled date of the hearing. This shall not be less than 14 days unless the appellant

agrees otherwise.

27. Hearings may be adjourned by panels from time to time as they see fit either before or

after the commencement of the hearing, either of the Committee’s motion or at the

request of the appellant.

28. Reasonable notice of the rescheduled hearing date must be provided by the College to

the appellant.

Conduct of Hearing

29. The Committee Chair shall conduct the hearing in such a manner as it considers most

suitable to the clarification of the issues before it and the just handling of the

proceedings.

30. The appellant shall present their case for why the decision should be overturned

followed by the respondent as to why the decision, recommendations or sanctions are

correct.

Evidence

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31. If the Appeal Committee is satisfied that it is just and reasonable to do so, the Clinical

Perfusion Scientist may be permitted in exceptional circumstances to present evidence

not previously relied upon (fresh evidence) if he or she seeking to rely on the material

and can satisfy the panel that:

a) the fresh evidence was not reasonably available at the time the decision being

appealed against was made and

b) the fresh evidence is relevant to an issue that is being considered by the panel

32. If fresh evidence is relied upon by the appellant, the College may serve evidence in

rebuttal.

33. Witnesses shall not be permitted to give live evidence to the Appeal Committee unless it

is connected to the fresh evidence being submitted.

34. Subject to the rules on evidence and the advice of the Legal Adviser, the requirements

for a fair hearing and of relevance, the Committee may:

a) admit evidence whether or not it would be admissible in a UK court of law

b) exclude evidence, where doing so ensures fairness to the College

35. The Committee may receive oral, documentary or other evidence of any fact or matter

which appears to it to be relevant to its consideration of the case.

36. The findings of fact and certification of conviction of any UK criminal court or the

findings of a judge in any UK civil court shall be conclusive proof of the conviction or

finding and the underlying facts.

Powers of the Appeal Committee

37. The Appeal Committee shall have the power to:

a) allow the appeal whether in full or part or

b) refuse the appeal or

c) remit to the original Conduct and Competence / Fitness to Practise Committee

for rehearing or redetermination of any issue, finding or sanction imposed or

d) substitute any decision of fact, grounds, impairment or sanction made by the

original Conduct and Competence / Fitness to Practise Committee (where the

substituted decision is one that the previous Committee could have made)

38. Where the Committee decides to remit the original decision, a person who has been

involved in any other capacity in the case shall not be appointed as a member of the

Committee to which the decision is remitted.

Notice of Decision

39. Within 7 days of the hearing, the Appeals Committee shall notify the appellant and the

respondent in writing of its decision and the reasons for reaching that decision.

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40. The decision of the Appeals Committee shall be final and there shall be no further right

to appeal to the College.

simonwhkendall

Sticky Note

Perfusion Representative. ACTION POINTS:1. Report received: SM asked that the Perfusion COuncil should always have lay representation2. Perfusion Council still seeking professional recognition from DoH3. Update on Mycobacterium contamination in heater cooler units. PHE downgraded the overall risk and devolved it local level.4. Updated working document / pack awaited from PHE - this will include the consent document used at Papworth hosptial5. SK / IF to make Papworth consent document available on web site

77

xvi. STANDING REPORT FROM THE FIPO REPRESENTATIVE

R Uppal


We currently do not belong to FIPO and pay no subscription to this body. There are currently 2

issues that are live.

1. FIPO has gone to the high court to appeal on the matter of fees, network arrangements

and preferred providers. The hearing for this is scheduled for next summer. In essence,

if FIPO were to lose this we would see a fundamental shift in practice and the evolution

of managed networks etc.

2. PHIN has been mandated by government to provide data on clinical outcomes and

quality and plan to begin publishing next year. This is likely to be highly contentious in

that there appears to be little infrastructure to look at the nuances of outcome

assessment. They are keen to have SCTS input and I know Tim is in the loop through the

FSSA.

B. MATTERS FOR CONSIDERATION BY THE EXECUTIVE COMMITTEE:

1. The executive should consider us becoming a fully fledged member of FIPO cost

£1000/yr. It allows the SCTS to be involved rather then observe.

simonwhkendall

Sticky Note

ACTION POINTS FIPO:1. It was agreed that SCTS join FIPO - especially with the desire to publish outcomes in the private sector2. SM informed executive of 2017 deadline of PHIN report to publish outcomes in private hospitals.3. TRG to write to Rakesh Uppal4. GC to check with constitution that we can contribute to FIPO

78

xvii. STANDING REPORT FROM CHAIR OF GOVERNANCE/PROFESSIONAL STANDARDS

A Owens

Terms of Reference

Professional Standards and Governance Committee

Society for Cardiothoracic Surgery Great Britain and Ireland

The demands on the Professional Societies are increasing. To meet this demand the SCTS has

formed three core committees for the sub specialties of cardiac, thoracic and congenital cardiac

surgery. There is also the Education committee.

Throughout the year there are several matters arising that require specific attention referring to

Professional Standards. At present the SCTS structure is not able to give appropriate time nor

adequate responses to such matters.

It is proposed that a Professional Standards Committee ("the Committee")is formed to handle

these specific tasks as well as issues pertaining to sound governance in the structures and

processes of the SCTS.

The Committee will be responsible for advising the Executive Committee (the "Executive")on all

matters relating to Governance including the self-assessment report and the appointment of

Members to the Executive. Specifically it will:

1. Review and make recommendations on the composition and balance of the

Exceutiveand its sub-committees.

2. Gather, screen and shortlist and, as a routine, administer the appointment of non-elected

Members to the Executive and its sub-committees.

3. Review the process whereby candidates are nominated for non elected positions on the

Executive.

4. Develop and recommend to the Executive, policies and procedures for induction and

further governance development of Members.

5. Advise the Executive on Standing Orders for the Conduct of its Business.

6. Advise the Executive on the Code of Conduct and Register of Interests for its Members.

7. Ensure, as appropriate, compliance at all times with legislation.

It is proposed that the Committee will consist of President Elect and Elected Trustee (co-chairs)

with the Lay Representative. The Committee will co-opt other members from time to time,

appropriate to specific tasks.

The Committee will, with the Executive, establish a rolling program of actions and activities to

ensure sound governance of the Society. It will respond to requests for advice from the

Membership, through the Executive,

Proposed Structure:

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Co Chairs – President Elect (2 years) and Elected Trustee (3 years)

Members – Lay representative (3 years),

Co-opted members as appropriate - including but not limited to chairs of sub specialty

committees, industry advisers, HR advice (Royal College of Surgeons)

Report to President.

Submit Report to each Executive committee.

Items of work will come through the Executive, the sub specialist committees and the SCTS

administrative office.

(http://www.scts.org/sections/society/constitution/index.html).

Isabelle Ferner [email protected]. Simon [email protected]

simonwhkendall

Sticky Note

Professional Standards Committee: Action Points:1. To explore Equality / Diversity agenda2. To start a register of Conflicts of Interest3. To clarify EUCOMED rules re relations with industry4. Initial focus will be on SCTS governance5. Business to be done by ad hoc teleconferences and appropriate co-opting of colleagues / advisors

80

xviii. STANDING REPORT FROM CHAIR OF RESEARCH COMMITTEE

G Murphy

Summary of SCTS Academic and Research Committee (ARC) Members

Co-Chairs: Prof GJ Murphy and SCTS President

Role: To coordinate the activities of the ARC. To communicate developments, opportunities

and initiatives related to research to the SCTS executive. To communicate where appropriate

and when requested with external agencies (CRUK, BHF, Wellcome, RCS) on behalf of the

committee and the executive.

SAC Representative: Prof Marjan Jahangiri

Role: To sit as an invited member of the SAC on the ARC. To communicate the status of

current academic trainees (numbers, successful mentorship, successful applications for

fellowships, trajectory) to the SAC. To communicate the views of the SAC to the ARC with

respect to recommendations of the numbers of academics in training, their success and the

likelihood that the academic workforce will be sustainable.

Scientific Meeting lead: Mr Clifford Barlow

Role: To sit as an invited member of the Scientific Meeting Committee on the ARC. To

coordinate with the SCTS scientific meeting/ University committee with respect to the

organisation of suitable research seminars within or co-localised with the annual scientific

meeting and University.

RCS Lead: Prof Gavin Murphy

Role: To communicate with the ongoing RCS initiative to develop academic surgery. It is

hoped that this candidate will be able to make representations to the RCS Academic and

Research Board. To communicate the views and policies of the RCS Academic and Research

Board, new funding opportunities and other opportunities for engagement to the ARC and to

the SCTS Executive.

Specialty Leads:

Adult cardiac surgery lead: Mr Mahmoud

Loubani Thoracic surgery leads: Mr Eric Lim

Congenital cardiac surgery lead: Mr Massimo Caputo

Roles: To inform important stakeholders in cardiothoracic surgery research; NIHR, BHF, CRUK,

Wellcome, as to the opportunities and infrastructure that are available in the UK to address

important research questions or for the development of evidence based guidelines. To

communicate the views and strategic objectives of these organisations as well as possible

funding or investment opportunities to the SCTS executive or relevant academics in the field.

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NIHR ACF/ ACL Lead: Mr Nishith N Patel, (Dr Claire Burdett co-opted)

Role: To provide up to date information on the status of all NIHR ACFs/ ACL nationally. It is

envisaged that the ACF/ACL lead will be aware of the career stage of each ACF/ACL, their

named supervisor, timeline for fellowship or grant applications and important barriers to

career advancement. The ACF/ ACL lead will also be able to inform these post holders as to

new opportunities for funding or career development.

NASCA Research lead: Mr Joel Dunning (TBC)

Role: To communicate developments and research opportunities that may be relevant to the

aims of both the ARC and the NASCA to the relevant SCTS committees and the executive.

simonwhkendall

Sticky Note

Research Committee: ACTION POINTS:1. GM congratulated on positive start to committee2. 6 monthly reports to Executive3. 3 monthly teleconferences

82

Society for Cardiothoracic

Surgery Academic and

Research Committee Terms

of Reference

1. Terms of reference:

1.1. Advise the SCTS Executive and Board on academic issues relevant to cardiothoracic

surgery.

1.2. Provide advice to the SCTS Scientific Meeting Committee regarding education and

research activities through representation on this committee.

1.3. Advise the SCTS Executive in relation to SCTS Research Fellowship Awards.

1.4. Provide advice to the SAC in Cardiothoracic surgery through academic

representation on the SAC.

1.5. To represent academics, and trainees, in matters related to academic

cardiothoracic surgery careers and cardiovascular/ thoracic medicine research in

the UK on behalf of the SCTS and as agreed by SCTS Executive and Board.

1.6. Represent the SCTS in other national and international research initiatives at the

request of the SCTS executive.

1.7. Advise on and undertake other activities related to academic cardiothoracic

surgery and cardiovascular/ thoracic medicine research as agreed by SCTS

Executive.

2. Constitution

2.1. The Committee shall be called the Academic and Research Committee of the

Society for Cardiothoracic Surgery in Great Britain and Ireland.

2.2. The Committee is accountable to the SCTS Executive.

2.3. The SCTS Executive shall appoint the chairman of the committee which is

not open to election by the Ordinary Membership.

2.4. The SCTS Executive, having considered nominations of the committee chair shall

determine the membership of a committee.

2.5. Membership of the committee is restricted to Ordinary Members of the Society.

In exceptional circumstances non-members may, with the approval of the

Executive, be co- opted to serve on the committee.

2.6. The committee should have a maximum of eleven members, including the

chairman. In exceptional cases the Officers may endorse the appointment of

additional members.

2.7. The chairman of a committee will normally serve for a term of three years.

83

Members will normally serve for three years.

2.8. The membership of the Committee will include a Chairman and the President or

another Executive member of the SCTS, a representative from the SCTS Scientific

Meetings Committee, and SAC. The Committee will have also have designated

leads for Thoracic Surgery, Congenital Surgery and a representative for NIHR

Academic Clinical Fellows and Lecturers.

2.9. The committee will normally meet twice a year. The chairman may convene

extraordinary meetings with the approval of the SCTS President. One of the two

meetings of the committee will normally take place during the annual scientific

meeting of the Society. The second will normally take place at the Society’s offices

at the Royal College of Surgeons of England but an alternative venue, if more

convenient to the committee members, may be used at the discretion of the

chairman and with the agreement of the SCTS Secretary.

2.10. Facilities for meetings at the Society’s offices or during the annual conference will be

arranged by the Secretary of the Society in consultation with the Chairman of the

committee.

2.11. The Chairman of committee will be responsible for ensuring that minutes of every

meeting are recorded and submitted to the Executive via the SCTS President.

2.12. The Society will provide secretarial services for the typing of minutes,

correspondence and reports.

2.13. The Society will reimburse travelling and subsistence expenses from within the

United Kingdom for members of committee for meetings not held at the time of the

annual conference. Members meeting at the annual conference will be expected to

meet their own expenses.

2.14. No financial arrangements with any organisation may be enacted without the

approval of the SCTS Executive.

GJM Sept 2015

84

7. Specific Issues

RCS AAC

Meeting summary

Royal College of Surgeons of England 7th August 2015

Agenda:

1. Review of SCTS role and contribution to reviewing and approving Consultant job

descriptions.

2. Review of SCTS role and contribution to supporting AACs for Consultant posts.

Attendees:

Andrew Chukwuemeka (AC) - SCTS

Tim Graham - President (TG) - SCTS

Lee Honeyball - Professional Support Manager – RCS(Eng)

Justine Clarke - Assistant Director of Professional and Business Support – RCS(Eng)

• The RCS has recently published new guidelines and a checklist for Consultant JDs. This

deliberately leaves little flexibility and is designed so that minimum standards are

maintained across all surgical specialties.

• It was agreed that in contrast to many specialty associations, the SCTS is engaged and

provides effective assistance to the RCS in reviewing and approving JDs.

• It was agreed that all SCTS JD reviewers will be sent an updated list of outstanding JDs

on the first Monday of every month. An updated list of recent Consultant appointees will

be included in the same email.

• RSPAs and DPAs will not to be copied into the original JD review request – the original

request will only go to either TG, AC, Richard Page, David Barron or Simon Kendall –

with AC copied into them all.

• AC (or relevant reviewer) will then copy the local RSPA into the reply – or if not, the RCS

will forward to the RSPA for information. Any Trust comments will only be forwarded to

the reviewer.

• All Senior Lecturer requests – for both JDs and AAC assessors – will be sent to AC who

will recommend someone to review and to sit on the AAC as an assessor.

• AC will be informed of who is sitting on each AAC by copy of the confirmatory email.

• The RCS is responsible for training College Assessors for AACs. The SCTS can continue to

assist by ensuring that there are sufficient numbers of appropriate assessors for each of

cardiac, cardiothoracic, congenital and thoracic AACs.

• The current list of assessors was reviewed and updated. A need for more assessors in

thoracic and congenital surgery was identified.

• The next College Assessor training days are on 13/11/15 and 26/02/16 and 24/06/16.

The SCTS will seek volunteers to attend these courses.

85

• Refresher training for current assessors who have not had training in the last five years

will be investigated by the RCS.

simonwhkendall

Sticky Note

College Professional Advisors. AAC Assessors: Action points:1. Need more volunteers to be AAC assessors - especially congenital. DB / AC to approach colleagues2. Current Assessors to have refresher training every 5 years

simonwhkendall

Sticky Note

Other Items: BORS meeting - 1. In 2016 the BORS meeting will be in March ( at the AGM ) and then September so it is every 6 months.