Medical educatio s frot lie A review of traiig i seve emergecy medicie departmets
Cotets Itroductio 02 Why did we carry out the checks? 03 Where we checked 04 Locatio of the seve sites visited 05 Cocers about emergecy medicie traiig 06 The wider cotext 06 The pathway ito emergecy medicie 07 Commo themes 08 Icreases i ufilled core traiig posts 08 Usatisfactory outcomes i the aual review of competece progressio (ARCP) are icreasig 10 Fidig ways to maage risk 11 Tacklig uderstaffig 12 Givig doctors i traiig the right supervisio 13 Positive examples to promote learig 15 Sharig practice 15 Case study: Uiversity Hospital of North Tees 16 Clear progress for doctors i traiig ad specialty doctors 16 Improvig patiets care through better rota cover 17 Seve key ways to improve quality 18 Aexes 20 Geeral Medical Coucil 01
Itroductio This report gives a overview of the curret challeges i emergecy medicie traiig ad makes recommedatios o how these might be addressed. The fidigs come from our targeted checks of the emergecy medicie departmets i six local educatio providers (LEPs) i Eglad (NHS trusts) ad oe i Jersey, which we carried out betwee December 2012 ad February 2013. Emergecy medicie traiig faces a umber of key challeges. The high workload ca put foudatio doctors i traiig off the specialty, while supervisio o ight shifts ca be icosistet. Accordig to the College of Emergecy Medicie: The cotiued rise i attedaces ad the severity ad complexity of patiet coditios presetig, without provisio of adequate resources for assessmet ad admissio, has cotributed to severe difficulty i the recruitmet ad retetio of doctors specialisig i emergecy medicie. * * Statemet take from the College of Emergecy Medicie website. 02 Geeral Medical Coucil
Why did we carry out the checks? Our checks were prompted by the icreasig umber of cocers reported to us about educatio ad traiig i emergecy medicie, particularly about very juior doctors i traiig workig usupervised at ight. These checks are part of our role to assure the quality of medical educatio ad traiig we use them to review how traiig is beig delivered ad ivestigate, i detail, specific risks that have bee idetified. I April 2012, we audited emergecy departmet rotas. We foud 20 sites that did ot clearly demostrate o-site supervisio from a seior doctor i the emergecy departmet overight. Our Lodo regioal visit, carried out i late 2012, also highlighted issues with supervisio ad hadover this varied depedig o the emergecy departmet. These cocers iclude: a lack of cliical supervisio for doctors i traiig durig weekdays ad, to a eve greater extet, out of hours providig services across two sites with isufficiet staffig doctors i traiig beig asked to work beyod their competece or to carry out iappropriate tasks poor quality of locum doctors who are beig used to fill rota gaps. We also idetified recurrig themes about patiet safety raised by doctors i traiig i our 2012 atioal traiig survey. Some of the cocers doctors idetified were: There are curretly 16 NHS trusts where we curretly have cocers about the postgraduate traiig of doctors i emergecy medicie departmets. a reliace o locum ursig staff log waitig times o trolleys high umbers of patiets a lack of resources uderstaffig, especially at ight poor triage of patiets a lack of beds. Geeral Medical Coucil 03
Where we checked We idetified seve LEPs to check. They were selected usig evidece from the 2012 audit of rotas ad the atioal traiig survey, as well as iformatio from postgraduate deaeries, local educatio ad traiig boards (LETBs), ad medical royal colleges. We also used data from other orgaisatios such as the Care Quality Commissio (CQC). Two sites were selected because they demostrated potetial good practice, ad five were selected because there was evidece of potetial risk. We foud that each site we visited had particular stregths ad were fidig iovative ways to meet challeges. The chose sites were i Eglad ad Jersey. We did ot visit emergecy departmets i Norther Irelad, Scotlad ad Wales because of other ogoig quality assurace activity i these areas. 04 Geeral Medical Coucil
Locatio of the seve sites visited The two sites chose for potetial good practice were the Uiversity Hospital of North Tees ad The James Cook Uiversity Hospital i South Tees. SCOTLAND NORTHERN IRELAND NORTHEAST Uiversity Hospital of North Tees The James Cook Uiversity Hospital YORKSHIRE AND THE HUMBER Leeds Geeral Ifirmary NORTHWEST Kigs Mill Hospital Quees Medical Cetre EAST MIDLANDS WEST MIDLANDS EAST OF ENGLAND WALES THAMES VALLEY SOUTHWEST WESSEX KENT, SURREY AND SUSSEX Jersey Geeral Hospital Royal Bouremouth Hospital Geeral Medical Coucil 05
Cocers about emergecy medicie traiig I its 2012 aual report to the GMC, the College of Emergecy Medicie highlighted cocers about: cotiuig service pressures, which reduce the amout of time traiers ca dedicate to deliverig traiig rota gaps i Scotlad, ortheast Eglad ad the east Midlads, which have icreased the pressure o doctors i traiig to work more out-of-hours shifts a lack of seior supervisio for juior doctors i traiig, leadig to cosultats completig fewer workplace-based assessmets of competece a lack of resources, leadig to ieffective simulatio traiig. The wider cotext It is importat to see our review i the wider cotext. It is just oe of a umber of reports that have highlighted pressures o emergecy care with recommedatios for improvemet. Professor Sir Bruce Keogh has recetly aouced a review ito urget ad emergecy care that is aimig to develop a atioal framework to build a safe, more efficiet system, 24 hours a day, seve days a week. Those usig ad workig i the NHS have from 17 Jue to 11 August 2013 to feedback o a evidece base for chage ad emergig priciples that will guide that review. See the NHS website for more iformatio. We also believe it is importat to udertake this work with others ad to esure that we exchage iformatio ad work closely together with other regulators, as was highlighted by the Mid Staffordshire NHS Foudatio Trust Public Iquiry. For this review, we have ivolved the College of Emergecy Medicie, the CQC, ad deaeries ad LETBs i our checks. A local Health Educatio Eglad (HEE) member of staff with a iterest i postgraduate educatio ad traiig atteded every check we completed. The CQC gave us iformatio about the quality of care delivered at the sites ad observed two of the site checks. 06 Geeral Medical Coucil
The pathway ito emergecy medicie The typical traiig pathway for a graduate of a UK medical school who wats to become a emergecy medicie cosultat is to udertake eight years of traiig i three stages. Three years of higher specialty traiig i emergecy medicie Three years of core traiig acute care commo stem (ACCS) The ACCS traiig programme provides experiece i emergecy medicie, acute medicie, aaesthetics ad itesive care. It has bee desiged by the College of Emergecy Medicie, the Royal College of Aaesthetists, the Federatio of Royal Colleges of Physicias ad the Itercollegiate Board for Traiig i Itesive Care Medicie. Together these orgaisatios form the Itercollegiate Committee for ACCS Traiig. To move from ACCS to higher specialty traiig, doctors i traiig must pass the College of Emergecy Medicie s membership exam (MCEM) i additio to deaery or LETB workplace-based assessmets. To complete traiig, they must also pass the College of Emergecy Medicie s fellowship exam (FCEM). Two years i the Foudatio Programme Geeral Medical Coucil 07
Commo themes Icreases i ufilled core traiig posts 177 foudatio doctors i Eglad ad Wales applied for ACCS with a view to traiig i emergecy medicie. The umber of doctors i traiig movig from foudatio to ACCS traiig is low. Figures from the College of Emergecy Medicie idicate that i 2012, 177 foudatio doctors i Eglad ad Wales applied for ACCS with a view to traiig i emergecy medicie. Of those, 115 were offered a place o the programme, but oly 61 accepted, makig this the secod lowest acceptace rate of ay specialty. The cosequeces of such posts beig ufilled ca iclude: challeges i deliverig services to patiets the eed to recruit locums (who ca be expesive ad of variable quality) additioal pressures o other medical staff impact o rotas ad educatioal opportuities for other doctors i traiig. 08 Geeral Medical Coucil
73.6 % of cadidates passed the MCEM exam to make the trasitio from core to higher traiig i 2011 12. Extra resposibility ad pressure Durig this review, may of the doctors i foudatio traiig who were workig i emergecy departmets told us that they would ot apply for specialty traiig i emergecy medicie because of the high ad itese workload they had see. May felt that their seior colleagues had little or o work-life balace. May of the doctors i core traiig said they were plaig to take a break before applyig for higher specialty traiig to reassess their career choice, work abroad or sped time with their family. Doctors i higher specialty traiig told us that there is a large icrease i workload whe movig from core to higher specialty traiig posts. They are part of the middle-grade rota, have more resposibility ad must supervise doctors i foudatio, core ad geeral practice (GP) traiig i the emergecy departmet. Doctors must pass the MCEM to make the trasitio from core to higher specialty traiig. I 2011 12, 73.6% of cadidates passed the exam, up from 61.7% i 2010 11. This meas a quarter of the doctors who could move ito higher specialty traiig ed up either repeatig the traiig year, takig time out or leavig the specialty or the UK. FCEM pass rates are lower, with 46.7% of cadidates passig i 2011 12. As with may specialty exams, the college reported that wome ted to perform better tha me, as do those with a primary medical qualificatio from the UK ad those of white ethicity. At the time of our 2012 atioal traiig survey, there were 1,416 foudatio, 493 core, 716 GP ad 555 higher specialty doctors i traiig holdig a post i emergecy medicie. At Uiversity Hospital of North Tees, doctors i higher specialty traiig work daytime shifts with more experieced staff coverig iitial ight shifts. The core rota allows doctors to lear ew skills, such as supervisig others ad maagig the departmet, before havig to do so without direct supervisio. Geeral Medical Coucil 09
46.7 % of cadidates passed the FCEM exam i 2011 12. Usatisfactory outcomes i the aual review of competece progressio (ARCP) are icreasig Each year doctors i traiig must show that they have leart eough to move oto the ext stage of traiig. If they have ot, they are awarded a usatisfactory outcome at ARCP. The figure below shows the proportio of doctors i emergecy medicie who were awarded a usatisfactory outcome i 2010, 2011 ad 2012. I geeral, doctors i traiig who gaied their primary medical qualificatio i the UK have a lower proportio of usatisfactory outcomes i emergecy medicie tha those who gaied their primary medical qualificatio i the Europea Ecoomic Area (EEA) ad iteratioal medical graduates (IMGs). * From 2010 to 2012, the proportio of usatisfactory outcomes has icreased across all specialties overall i UK medical traiig. 35% 30% 25% UK EEA IMGs All 20% 15% 10% 5% 0% 2010 2011 2012 * IMGs are doctors who gaied their primary medical qualificatio outside the UK ad EEA. 10 Geeral Medical Coucil
The Uiversity Hospital of North Tees has brought together two emergecy departmets o oe site, ad the departmet is ow better staffed. Fidig ways to maage risk I every site visit, staff reported icreasig umbers of patiets, reflectig the atioal tred. Each trust sought to maage risk both i the emergecy departmet ad elsewhere i the hospital. We foud that frequetly patiets remaied i the emergecy departmet despite beig ready to move to a relevat specialty ward, because of pressures elsewhere i the hospital ad i some cases a lack of beds. It is preferable to let high risk patiets stay i the emergecy departmet where staff are traied to deal with them. Creative ways to limit emergecy admissios Risk maagemet works well at the Uiversity Hospital of North Tees, where much work has bee doe to build relatioships betwee the emergecy departmet ad other areas of the hospital. The hospital has brought together two emergecy departmets o oe site, ad the departmet is ow better staffed. At Leeds Geeral Ifirmary, several iitiatives have bee put i place by the emergecy medicie departmet to reduce umbers of patiets ad to maage risk across the hospital. For example, a helplie has bee itroduced for GPs who are cosiderig referrig patiets to the emergecy departmet. GPs ca also admit patiets directly to the relevat specialty ward without havig to go through the emergecy departmet. The umber of patiets cotiues to rise but, without these iitiatives, the icrease could be at a much higher rate. Liaisig with other services ad makig quick decisios All emergecy departmets have to maage the flow of patiets, especially whe trasferrig them to other acute or metal health services. This ca be particularly challegig out of hours. May of the departmets we checked struggle with their out-of-hours access to metal health services, so patiets remai i the emergecy departmet util they ca be see by a specialist ofte util the ext workig day. Geeral Medical Coucil 11
A key aspect of maagig risk i a emergecy departmet is beig able to make decisios, ofte quickly. The Royal Bouremouth Hospital has a liaiso psychiatrist who is based i the emergecy departmet ad available to deal with patiets ad support doctors i traiig with regular educatioal sessios. Doctors i traiig told us that this works very well. A key aspect of maagig risk i a emergecy departmet is beig able to make decisios, ofte quickly. Because of the shortage of higher specialty doctors i emergecy medicie, most are i the early years of traiig. With less cliical experiece, ad ofte o previous experiece i emergecy medicie, they are ofte ot able to make difficult decisios quickly. Some also said that they felt their eed for supervisio ad seior review of cliical decisios could be a burde o already over-worked colleagues. Tacklig uderstaffig There are a umber of iitiatives ogoig at a atioal level to deal with recruitmet ad retetio i emergecy medicie. I all the departmets we checked, every effort was beig made to maage the workload of doctors i traiig. But this ofte resulted i cosultats workig beyod their cotracted hours ad doig the work of doctors i higher specialty traiig to fill rota gaps. At most of the departmets we checked, we were told that curret rotas at all levels were ot sustaiable. The oly rota adequately staffed was at the Uiversity Hospital of North Tees, which had recetly brought two emergecy departmets o to oe site. May doctors i foudatio ad core traiig told us that this made them feel margialised ad cotributed to their decisio ot to apply for specialty traiig i emergecy medicie. 12 Geeral Medical Coucil
1,416 foudatio At the time of our 2012 atioal traiig survey, there were: 493 core 716 GP 555 higher specialty doctors i traiig holdig a post i emergecy medicie. Fidig time for traiig The high itesity of workload leads to doctors i traiig ad their cosultats focusig largely o service provisio, with learig opportuities that are opportuistic rather tha maaged. Doctors i traiig said they were uable to complete workplace-based assessmets. At The James Cook Uiversity Hospital, Kig s Mill Hospital ad Leeds Geeral Ifirmary, a cosultat allocates time each week to complete these assessmets. Uderstaffig ad rigid rotas ca make it challegig for doctors i traiig to atted regular teachig sessios ad to take time out for study leave. Most doctors that we spoke to i all seve emergecy departmets said that the day-to-day busiess of their departmets, as well as the itesity of the work, has a log-term effect o persoal well-beig. We heard from staff that makig repeated high-risk decisios withi tight timescales, while workig log hours, ca cause burout. Givig doctors i traiig the right supervisio Oe of the aims of the rota audit was to idetify the areas where a large umber of foudatio doctors work without adequate supervisio at ight. Some of the sites we checked were selected o the basis that they might fall ito this category, but we were pleased to see this geerally was t the case at the seve LEPs we visited. Supervisio ca take may differet forms, icludig the physical presece of a more seior doctor or havig access to a more experieced colleague (either i perso or by telephoe) to aswer questios or assist whe eeded. Of course, the quality of that supervisio ca deped o a umber of factors, icludig persoalities, competig pressures, approachability ad accessibility. Geeral Medical Coucil 13
We foud that while most of the doctors i traiig were beig supervised, the mai issue was the quality of that supervisio. Cocers about the quality of supervisio We foud that while most of the doctors i traiig were beig supervised, the mai issue was the quality of that supervisio. May of the departmets we visited relied o locum cover durig out-of-hours shifts, whe the doctors i traiig that we spoke to are most likely to be workig. The experiece of doctors i traiig suggests that there is a differece betwee emergecy departmets that use regular locum doctors who kow the hospital ad staffig team well, ad those that rely o locum doctors who ca be iexperieced i the specialty or the hospital. Iexperieced locum doctors may eed more support from the doctor i traiig tha they are able to retur. The locatio of the supervisor is also crucial. For example, we were told of situatios where the supervisor spet the etire shift i the resuscitatio room with the highest risk patiets, ad so were uavailable to give ay support or supervisio. Agai we were told that supervisors are sometimes uable to come to a patiet whe a doctor i traiig eeds seior review ad istead has to give advice based o a verbal accout of the patiet s history ad physical state. Accessibility of cliical supervisio ca also effect admissio ad discharge. At Quee s Medical Cetre, a seior review is oly required whe a patiet is admitted, rather tha o discharge. This carries serious risk it meas that doctors i traiig miss out o key learig opportuities ad, with o seior review, they ru the risk of becomig more cofidet without becomig more competet. 14 Geeral Medical Coucil
The latest postgraduate deas reports to the GMC (October 2012 ad April 2013) idetified six elemets of good practice relatig to emergecy medicie. Positive examples to promote learig Cosultats at the Uiversity Hospital of North Tees ad the Royal Bouremouth Hospital review case otes the morig after a ight shift to see what their doctor i traiig has experieced. They the discuss these with the doctor i traiig to stregthe their learig. The James Cook Uiversity Hospital, Kig s Mill Hospital ad Uiversity Hospital of North Tees assig supervisors thematically. This meas supervisors with specific iterests are paired with doctors i traiig with a similar iterest, meaig that cosultats ca egage i detail with oe traiig curriculum ad focus more effectively o the traiig they deliver. Sharig practice The latest postgraduate deas reports to the GMC (October 2012 ad April 2013) idetified six elemets of good practice relatig to emergecy medicie. These icluded usig USB sticks cotaiig cliical guidelies for all doctors traiig i emergecy medicie, a how to guide for foudatio doctors, ad good quality of regioal teachig ad iductio (aex 1). The College of Emergecy Medicie is pilotig a ew assessmet tool for seior doctors i traiig across five LETBs or deaeries across the UK. After evaluatio, this pilot will iform chages to the curriculum ad assessmet system i 2014. Geeral Medical Coucil 15
Case study: Uiversity Hospital of North Tees The Uiversity Hospital of North Tees, part of the North Tees ad Hartlepool NHS Foudatio Trust, had eight areas of good practice i our report from the site check. We asked staff at the Trust how they achieve such positive results. The emergecy medicie departmet has udergoe several sigificat chages sice the Trust formed i 1999. Util 2006, there were two separate emergecy departmets: oe at Uiversity Hospital of Hartlepool ad the other at the Uiversity Hospital of North Tees, early 14 miles away. The departmets had oe directorate, but worked idepedetly for most activities. Achievig adequate medical staffig levels i the emergecy departmet had bee challegig for may years, despite fudig attempts to recruit eough medical staff for two 24-hour, middle-grade emergecy departmet rotas. It became clear that the Trust could o loger cotiue to rely o a sigle doctor i traiig at ight i the emergecy departmet at Hartlepool. As a result, the emergecy departmet i Hartlepool was closed i August 2011 ad replaced with a urget care cetre. The two departmets were amalgamated at Uiversity Hospital of North Tees. Protocols were put i place for direct ambulace admissios to the Uiversity Hospital of North Tees emergecy assessmet uit. Clear progress for doctors i traiig ad specialty doctors To maitai adequate staffig levels, both emergecy departmets developed strog educatioal programmes for medical staff. With the rotatio of medical staff ad a steady icrease i cosultat umbers, the educatio programme was modified ad more closely liked to the various curricula. 16 Geeral Medical Coucil
To maitai adequate staffig levels, both emergecy departmets developed strog educatioal programmes for medical staff. Separate middle-grade teachig, i additio to regioal higher teachig, was started, with separate itermediate grade teachig beig itroduced slightly later. Teachig is ow provided o a fourmoth cycle, with virtually all teachig comig from withi the directorate. A CD of all policies ad guidelies is give to each doctor i traiig, ad guidelies ca be accessed through the directorate website. The feedback from doctors i traiig about these programmes was overwhelmigly positive ad this, combied with a high retetio rate of doctors, suggests that the support withi this departmet is workig well. There were also sigs of career progressio i the departmet with several doctors movig from juior to middle grade. Two doctors who started with cliical attachmets are ow associate specialists. Improvig patiets care through better rota cover Amalgamatig the departmets at oe site allowed cosultats to cover from 8 am to 10 pm, seve days a week, with a secod cosultat from 9 am to 5 pm, Moday to Friday. Doctors i traiig ca easily access these cosultats to complete workplace-based assessmets. All staff kow each other ad commuicate readily o ay problems, from cliical decisio makig to the trivial matters that help to make teams work. Doctors at the Trust poit to the overarchig priciple that quality of care comes first ad suggest that has bee key to implemetig these chages both i the emergecy medicie departmet ad i the Trust as a whole. This has meat that ay chages must demostrate improvemets i patiet care, ad that achievig targets is secodary. They also believe that havig a easily accessible executive team has made it easier to create this ethos. The executive team is happy to be questioed ad act o suggestios made by cliical teams. Geeral Medical Coucil 17
Seve key ways to improve quality We have idetified seve ways i which those ivolved i traiig i emergecy medicie may be able to improve quality. We accept that ot all of these recommedatios may fit ito every local cotext ad that we oly checked a small sample of sites. 1 3 Maagig a patiet s care i the emergecy departmet, ad i subsequet departmets, eeds to be the collective resposibility of the trust, its board ad seior maagemet team. Risk should ot be held solely withi the emergecy departmet. LEPs eed to develop plas to address the curret issues facig emergecy medicie to esure sustaiable delivery of services. These plas should iclude a exteded iductio, more itesive shop floor teachig ad use of simulatio to develop the juior medical workforce s cofidece ad competece i maagig the care of acutely ill patiets. 2 4 The healthcare system at a atioal level eeds to educate patiets, the public ad colleagues o the best care pathways for patiets to address the overdepedece o emergecy medicie departmets. LEPs, deaeries ad LETBs eed to work together to esure that they balace service ad traiig appropriately i workig arragemets to miimise burout i the traiig workforce. 18 Geeral Medical Coucil
5 Recruitig doctors ito the specialty eeds to be a higher priority. May of the curret problems arise from staff shortages, which i tur place greater pressures o doctors ad make it a less attractive area of medicie i which to work. 6 There appear to be sigificat advatages from combiig services o to a sigle site. If this is possible, it ca trasform rotas ad help to esure safer care ad better traiig. 7 There are real beefits to be gaied from deaeries ad LETBs workig more closely with trusts to support doctors who are makig trasitios betwee stages of their traiig programme. This ca help to make sure that there is guidace at each step ad that the ext level is achievable ad appropriate. Uderstaffig has placed may emergecy medicie doctors i a difficult positio. Oe of the most reassurig messages from these checks is that the vast majority of emergecy medicie doctors are committed ad carig, ad work beyod their cotracted resposibilities to give patiets safe care. Furthermore, seior doctors ad other healthcare professioals try hard to give their doctors i traiig a positive educatioal experiece. We have set a umber of requiremets for each LEP ad these will be moitored through our quality assurace process. I additio, the checks have uderlied the overall pressures o this area of medicie ad medical traiig, ad we will cotiue to keep a close eye o the positio of doctors traiig i this area, icludig the possibility of carryig out further checks i the future. Geeral Medical Coucil 19
Aexes Aex 1: Good practice from the October 2012 ad April 2013 deaery reports * Trust Imperial College Healthcare NHS Trust North Middlesex Uiversity Hospital NHS Trust North Tees ad Hartlepool NHS Foudatio Trust Norther Health ad Social Care Trust Portsmouth Hospitals NHS Trust Summary All A&E traiees give USB sticks cotaiig cliical guidelies Creatig the Foudatio Doctors How to guide website liked to the hospital itraet, which provides easy access to practical iformatio for all juior doctors startig at the hospital. I additio, a mobile app has bee created. Emergecy Medicie -Provisio of a 3 tier rota ad 3 tier traiig programme Iductio. Iductio rus o three half days immediately after chageover ad the i a series of 1 hour sessios over the ext week. Cosidered by traiees to be comprehesive ad of very good quality. Experieced staff cover the first ight. A very good hadbook is also provided. The Oe Miute Woder Network. A Oe Miute Woder (OMW) board was itroduced to the Quee Alexadra Hospital Emergecy Departmet. The board was positioed i the Emergecy Departmet resus room, ext to the gas machie to take advatage of the 60-90 secods spet stood waitig for a blood gas result. The OMWs were focused educatioal displays which cotai iformatio that could be read ad absorbed i just oe miute. Aex 2: Good practice from the College of Emergecy Medicie aual specialty report 2012 * The College ra a review of the assessmet system ad have foud that the system has characterised the cocers of traiees ad traiers highlighted by the Natioal Survey feedback. The College would pilot a ew assessmet system, icludig a ovel assessmet tool, for ST5s i five Deaeries i 2012-13 to iform potetial curriculum chages for 2014. The College was oted for developig College Tutors, Traiig Programme Directors ad Educatioal Supervisors to provide exterality to ARCP paels ad deaery visits. * This text has bee take from reports submitted to us by the deaeries, LETBs ad the College of Emergecy Medicie. 20 Geeral Medical Coucil
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Email: gmc@gmc-uk.org Website: www.gmc-uk.org Telephoe: 0161 923 6602 Geeral Medical Coucil, 3 Hardma Street, Machester M3 3AW Joi our coversatio @gmcuk facebook.com/gmcuk likd.i/gmcuk youtube.com/gmcuktv This iformatio ca be made available i alterative formats or laguages. To request a alterative format, please call us o 0161 923 6602 or email us at publicatios@gmc-uk.org. Published July 2013 2013 Geeral Medical Coucil The text of this documet may be reproduced free of charge i ay format or medium providig it is reproduced accurately ad ot i a misleadig cotext. The material must be ackowledged as GMC copyright ad the documet title specified. The GMC is a charity registered i Eglad ad Wales (1089278) ad Scotlad (SC037750) Cover image: istockphoto.com/sturti Code: GMC/MEFL/0713