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Challenges in Training

Training after being an overseas doctor - by Jonathan Noël

Jonathan Noël (past BSoT Chair and former trainee in the London North Deanery) writes about coming to the UK for training after a period of time abroad:

“ ... As the Chair of BSoT (the organisation that leads urology training opinion in the UK and Ireland), I started my medical career in the UK in an SHO post with no training recognition. I graduated from the University of the West Indies, did a one-year internship (known as FY1) and did the necessary steps to GMC Registration.

GMC Registration is complicated, but the International Graduate Unit are professional and effective in the process. Depending on the location of your medical school training and nationality, the process ranges from direct registration to sitting the Professional and Linguistic Assessments Board (PLAB) test

Once you are GMC registered, the time comes for you to scout for jobs. I am so pleased that BSoT has now made available pre-National Training Number (NTN) posts that have high educational value in urology: those wishing to pursue a career in this amazing specialty should take advantage of this.

Applying direct from overseas into a training post is a challenge, but not impossible, depending on your previous experience. Options available are:

  • applying to posts without training recognition, in order to gain beneficial NHS experience;
  • applying to a research post, will always be favourable in the present evidence-based medicine world; or
  • applying to a Clinical Teaching Post.

The above will improve the application for training-recognised post.

Overall, if your goal is to secure an urology NTN, it will usually take prior experience in the NHS to get a sense of your experience, as judged from a UK standard. A research degree is not mandatory, but experience in it is; it adds another layer to the portfolio discussion. 

Applying for training with too much experience under your belt can be a disadvantage as, ultimately, the NTN must "mould" future urological surgeons from the UK and Ireland’s training scheme.

There is never a "one size fits all" in this amazing surgical career in the UK. It can take you in many directions that one could not fathom coming from overseas.

No matter where you are from, if you work hard, show commitment to the specialty and strive for excellence in yourself and in the teams/departments you work with, I can guarantee your commitment will be recognised and rewarded. ... "

Interdeanery transfers - by Katie Chan

Katie Chan (formr BSoT Communications representative) writes about the process of setting up an interdeanery transfer (IDT).

“ ... For most, people Speciality Registrar training will be completed within one deanery but, for some, there will be changes in circumstances which necessitate transfer to another region of the country. This is where the interdeanery transfer process comes in.

The IDT process is currently run through the HEE London Deanery as a national IDT programme. There are two windows for transfer - one in August and one in February. There are two stages, eligibility and allocation:

1. Eligibility

The criteria for IDT are strict, and rely on you proving that “a significant change to personal circumstances has occurred that could not have been foreseen at the time of commencing your current training programme”. There are four different categories under which you can apply:

  • a disability;
  • primary carer responsibility;
  • parental responsibilities; or
  • committed relationship.

In addition, you must have at least 18 months of training remaining, and have completed at least nine months at the point of application.

2. Allocation

Even if you are deemed eligible for transfer, your transfer cannot go ahead if there is no post for you to transfer into. This is often the stage at which transfers fail.

Urology is a small specialty and there may not be any numbers advertised in that region for the year that you are applying. Even where there is a number available, the region may be seeking a trainee with more or less experience than yourself (e.g. they may want an ST6 rather than an ST5). Additionally for urology, there is only one national selection round a year and, given the competitiveness of the specialty, most deaneries are full by the end of the process.

There is no requirement for the deaneries to prioritise the IDT process over the national selection process and, therefore, although there may be training positions available at national selection, these may not have been put forward to the IDT process. There is no easy way to overcome these issues, but urology does have the advantage of being a small specialty and most training programme directors (TPDs) are supportive of trainees with a genuine change in personal circumstances. The British Medical Association (BMA) and the IDT team regularly work together to try and improve the process for all involved.

For severely extenuating circumstances that cannot wait for the IDT window, you can speak to your TPD and to the head of your School of Surgery. Urgent transfers can happen, but they are rare, and are at the discretion of the heads of Schools of Surgery for both deaneries that are involved. 

Tips for success

The following will help your IDT application to progress smoothly:

  • involve your TPD and educational supervisor early in the process;
  • plan, plan, plan ...
  • read the forms until you can recite them, and then read them some more; and
  • keep in regular contact with the IDT team, to make sure your information has been received and that your application is progressing as it should ... "

The 2016 Junior Doctors' Terms & Conditions of Service - by Neil Harvey

Neil Harvey (Specialty Trainee in the North West Deanery & current Chair of BSoT) answers some frequently-asked questions about the new Junior Doctors' Contract and 2016 Terms & Conditions of Service (TCS).

For reference purposes, you can view a copy of the Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016  Version 4 by clicking here.

Q1. Are the new TCS just a way of paying me less than I would otherwise have been paid?

It should be noted that, when paid appropriately and assuming an average rota of 1 in 6, a urology ST3-7 trainee should be better off over a five-year training period than with the pre-2016 TCS.  This benefit does, however, drop off rapidly in cases of prolonged training, including LTFT (see top of page) and time out-of-programme.

Q2. What should I be paid?

The incremental, yearly increase has been completely done away with and, whilst in ST3 and ST4, you are likely to be paid more than your predecessors were; the other side of this is that, year-on-year, you may be paid less if you move to a job working a less intensive rota.

The salary of a non-resident on-call (NROC) urology specialty trainee incorporates a basic salary and a number of uplifts - an example (full-time) case can be broken down as:

  • nodal point 4 (basic salary for average 40 hours / week): £47,132 plus; 
  • additional hours (commonly bringing the weekly average work up to 47 - 47.5 hours):   £8,248.10 - £8,377.25 plus:
  • on-call availability (8%): £3,771 plus;
  • weekend allowance (usually 3% for 1 in 7 or 1 in 8; 4% for 1 in 5 or 1 in 6): £1,414 - £1,886 plus; and
  • 37% hourly enhancement (an uplift to basic salary for hours worked between 21.00hr and 07.00hr. (Schedule 2 Paragraph 14: Saturdays and Sundays 07.00hr - 21.00hr are not enhanced further than the above allowance): £872 (assuming an average of two hours unsociable work per week) *.

This breakdown gives a "ballpark" total salary range of £61,437.10 - £62,038.25.

* (The average total hours, and the average hours attracting enhancements, should be given in quarter hours, rounding up to the nearest quarter hour, as per Schedule 2 Paragraph 17)

Q3. I don't think I'm being paid the correct amount - how do I check this?

Your Generic Work Schedule was issued to you before you start your placement, and should give you both your rota & a breakdown of your salary in a similar fashion to the above example. You will likely find that your “in-hours” working time is clearly documented on your Generic Work Schedule, but your “on-call” hours are less clear.

If you are not satisfied with how the salary breakdown on your Generic Work Schedule has been calculated, you will need to ask to see the specific breakdown for the hours of your “on-call” days.  If you are querying these figures in advance of starting a job, it can also be useful to ask how the figures for prospective out-of-hours cover were calculated. 

Out-of-hours activity is to be paid based on prospective estimated activity, and it is not the intention of the TCS or Exception Reporting that a trainee is not paid for out-of-hours activity but subsequently expected to claim back time in lieu, or to be regularly paid for further hours beyond their work schedule through Exception Reports. If this is occurring, it should prompt a review and alteration).

Q4. What does the term "Personal Work Schedule" mean, and how is this different from a "Generic Work Schedule"?

The Personal Work Schedule is, theoretically, the rota (day-to-day clinical activities) you agree with your Educational Supervisor that meets your training needs, within the confines of on-call periods in your Generic Work Schedule. In reality, a different person may be in charge of planning clinical activities, so it is always best to contact your Educational Supervisor before starting a placement to discuss your training needs, rather than attempting to change your Personal Work Schedule after the first meeting (a few weeks into your appointment).

Q5. What is an "Exception Report", and when should I lodge one?

Exception reporting is performed via a locally agreed mechanism - it has replaced the previous system of hours monitoring, and is used to flag four areas of variation:

  • The average weekly workload volume (i.e. time at work) exceeds your work schedule​​;
    • it is worth noting that, in reality, every day (including normal days) should be documented / reported at least on a weekly basis if there are serious concerns about workload, since weekly average workload has to be calculated across a whole rota cycle (for more detail see Schedule 4 Paragraph 12).It is worth noting that in reality every day (even normal days) should be documented / reported on an at least weekly basis if there are serious concerns about workload, as weekly average workload has to be calculated across a whole rota cycle (for more detail see Schedule 4 Paragraph 12).
  • Additional work to secure patient safety​​ (see Schedule 2 Paragraphs 63 - 69) deviates from the generic work schedule (allowing time off in lieu to be taken within 24 hours if rest requirements are breached); otherwise can be accrued and taken with the next 3 months, or additional payment (at the usual rates of pay, at time of writing, £22.66/hr, £31.04/hr enhanced);
    • of particular note is Paragraph 69: “These provisions also apply to additional hours of actual work over the prospective average estimate during non-resident on-call”;
    • these deviations are, under ideal circumstances, to be agreed with your manager in advance;
    • time off in lieu should not, where possible, compromise your training (See Exception report type 4 below).​
  • Differences in support;
    • ​​this refers to issues with senior support, and is also the method of highlighting areas where a lack of more junior support affects training/workload.
  • Differences in educational opportunities;
    • ​​this is the key method of highlighting where the educational opportunities in your personal work schedule are being compromised to meet service commitments.

Q6. Are there any absolute limits on hours worked?

There are three main deviations in workload recognised as severe enough, within the contract, to result in the Trust being fined 4x the contractual hourly rate, with 1.5x the national locum rate of this fine going to the doctor (i.e. £41.38/hr basic; £56.68/hr enhanced): 

  1. A breach of the 48-hour average working week across the reference period agreed for that placement in the Generic Work Schedule – in almost all cases, this will be a single rota cycle;
  2. A breach of the maximum 72-hour limit in any seven days;
  3. A reduction of the minimum 11 hours’ rest requirement between shifts to fewer than 8 hours  - this doesn't apply to "on-call", see below

Q7. How do the non-resident on-calls (NROCs) work? I've been up all night and I don't feel safe to work, what should I do?

Important parts of the TCS to be aware of are:

  • Schedule 3 Paragraphs 15 - 16: the maximum number of consecutive shifts is 8, and must immediately be followed by at least 48 hours rest;
  • Schedule 3 Paragraphs 24 - 34 are all very relevant and, at a side of A4, worth reading in the original form, given they cover both the rules surrounding frequency of non-resident on calls and the rest expected within those  periods;
  • Being 'on-call' whilst on site during your normal daytime hours is not considered an "on-call" period in the eyes of the TCS.
  • An "on-call" period is a maximum period of 24 hours, and you cannot be rostered to work two periods back-to-back, with the exception of Saturday and Sunday, nor more than three in seven consecutive days (niche locally-agreed exceptions may apply, see Paragraphs  27 - 28);
  • Rest requirements during on calls: you should expect at least 8 hours rest, 5 of which is continuous/undisturbed between 22.00hr and 07.00hr;
  • The day after an on-call (except for the Saturday - Sunday combination) may not be rostered to last longer than 10 hours; limited to 5 hours if it is expected you may not get the minimum rest requirements above. The contract does not, however, specify how likely a breach in the minimum rest requirements must be before prospective rostered hours for the following day must be restricted to 5 hours;
  • From Paragraph 33: “If, as a result of actual hours worked during the on-call period, a doctor’s rest has been significantly disrupted, [...] the default assumption is that the doctor may be unsafe to undertake work because of tiredness and, if this is the case, the doctor must inform the employer that the doctor will not be attending work as rostered, other than to ensure safe handover of patients. No detriment to pay will result from the doctor making such a declaration”;
  • From Paragraph 34: In the TCS, the definition of work includes " ... any actual clinical or non-clinical work undertaken either on or off site, including telephone calls and travel time arising ...". 

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