Homerton University Hospital

Homerton University Hospital is a district general hospital providing hospital and community services to the people of Hackney, the City of London and beyond. It was one of the first Foundation Trusts and remains financially viable. It provides specialist care in obstetrics, neonatology, foetal medicine, fertility, laparoscopic surgery, bariatric surgery, asthma and allergy treatments, HIV, mental health and neuro-rehabilitation. The hospital has over 450 inpatient beds, and the A&E sees over 120,000 patients per year. The latest CQC rating was “good” with urgent and A&E services and medical care rated as “outstanding“.

2 Respiratory trainees will be posted here (usually 1 year rotation) at each time. There is now also a respiratory clinical fellow who is part of the respiratory registrar body.

 Consultant speciality interests

• Prof Raja Rajakulasingam (RKR): asthma, allergy and immunotherapy
• Dr Angshu Bhowmik (AB): lung cancer diagnostics (EBUS), community/integrated care, management and leadership
• Dr Joshua Agbetile (JA): sleep and ventilation, lung cancer diagnostics (EBUS)
• Dr Santino Capocci (SC): TB, bronchiectasis
• Dr Raluca Macavei (Locum): TB, sleep, lung cancer
• Dr Sheena Barnett: Allergy
• Dr Timothy Watts: Allergy

All SpRs will be working closely with all 4 consultants in clinics, procedure lists and ward rounds.

Typical week for SpRs

	Mon	Tue	Wed	Thu	Fri
AM	Cons/SpR WR	Regional Barts Lung MDT	Bronch/ EBUS list	Cons/SpR WR	Asthma & allergy clinic
Lunch		Monthly local SpRs meeting Weekly grand round	Local diag. MDT
PM	Admin/ Referrals	Gen Resp/ Lung cancer clinic	Local diag. MDT or Bronch/ EBUS list	Gen Resp/ Lung cancer clinic	Admin/ Referrals

• When both SpRs are present, they share the above timetable. However, it is rare that both are on at the same time (cumulatively about 2 weeks in 6 months) with one being on call/on leave.
• The SpRs see all paper and phone referrals and this can involve staying late to see them all in a timely manner on top of the increasing numbers of pleural procedures. There are plenty of options to triage elsewhere, the local diagnostic MDT, TB nurses for TB screening, lung cancer nurse etc. A telephone conversation with the referrer is adequate most of the time.
• SpRs are also now expected to vet a handful of online GP referrals.
• Respiratory rota is organised by Prof Raj. One SpR is expected to be present at all times (except training days), therefore SpRs can only take leave when the other SpR is present. In reality, there are limited periods when it is possible to take leave so plan ahead and negotiate with your other SpR colleague.
• Both SpRs are allowed to attend training days at the same time.
• Departmental M&M meetings are held monthly.

Other optional clinic opportunities that you could join:

• TB clinic
• Sleep clinics

Bronchoscopy

• 1 morning bronchoscopy/EBUS list with 1 Consultant (present in the room 99% of the time) who gives plenty of time to teach and support.
• The afternoon list is also available for SpRs when both SpRs are present or permitted by consultants (SpRs are expected to document in diagnostic MDT on the same afternoon).
• You can expect to become independent at EBUS for the easier to access nodes (St7 and 4).
• Perhaps not ideal for an ST3 due to the need to be competent in the basics of bronchoscopy before moving onto EBUS, but good for ST4+.

Estimated number of bronchoscopic procedures in 6 months per trainee: 21 – 30 (with 1 – 10 endobronchial/transbronchial biopsies)

Estimated number of EBUS/TBNA in 6 months per trainee: 21 – 30

Thoracic US and pleural procedures

• Dedicated Resp department portable US machine available 24/7
• SpRs should ideally be Level 1 US competent as Radiology will not do pleural procedures and the consultants are already busy with other work commitments.
• No level 2 trained Consultant, but Radiology consultant is supportive. Have to make special effort, but it is possible to get Level 1 signed off.
• There are occasional opportunities for medical talc pleurodesis and pleural biopsy.
• Dr Agbetile is competent at inserting indwelling pleural catheters but this rarely happens here.

Estimated number of thoracic US in 6 months per trainee: 31 – 40

Estimated number of pleural aspirations in 6 months per trainee: 21 – 40

Estimated number of chest drain insertions in 6 months per trainee: 1 – 10

NIV/Sleep

• Adequate acute NIV experience with adequate NIV machines and easy to initiate on the respiratory ward and acute care unit. (no respiratory HDU here)
• Many cases with chronic respiratory failure requiring domiciliary NIV. These cases are then referred to Barts Sleep service.
• Overnight pulse oximetry and limited polysomnography services available.

Estimated number of adequate involvement in management/initiation of NIV in 6 months per trainee: 11 – 20

GIM

• 4-week block in every 3 months is spent on the Acute Care Unit running the take with no Respiratory responsibility during this time. One weekend covering as ward SpR (i.e. two SpRs on weekend days with one starting early and one starting late).

	Mon	Tue	Wed	Thu	Fri	Sat	Sun
Week 1	Long Day	Long Day	Long Day	Long Day	OFF	OFF	OFF
Week 2	Nights	Nights	Nights	OFF	OFF	Short Day	Short Day
Week 3	OFF	OFF	OFF	Nights	Nights	Nights	Nights
Week 4	OFF	OFF	OFF	OFF	Long Day	Short Day	Short Day

• Takes are not too busy with enough experience to easily cover GIM curriculum requirements – days average 15 – 20 admissions and nights average 8 – 10 admissions
• There are not many arrests on the wards. Expect a high number of sickle cell crises cases.
• The on-call team are as below:
  • Weekday: 1 SpR, 1 early clerking SHO, 2 late clerking SHOs, 1 late ward FY1
  • Weekend: 1 early SpR, 1 late SpR, 1 early clerking SHO, 1 late clerking SHO, 1 full-day ward SHO, 1 short-day ward SHO, 1 ward FY1
  • Night: 1 SpR, 1 clerking SHO, 1 ward SHO, 1 ward FY1
• Swapping out of the on call block is nearly impossible but swapping weekends can be done.
• Most GIM consultants are friendly, approachable and willing to complete assessments.
• Possible to take study leave on some days after negotiation with rota co-ordinator who is always willing to find cover.
• Medical services available: Upper GI bleed, Gastro/limited Hepatology, Haematology, Geriatrics, Neurology & Epilepsy nurse, Cardiology (non-interventional), Endocrine & Diabetes nurse, Rheumatology, Microbiology/limited ID and HIV (local HIV nurses available daily), Acute Oncology nurse, Palliative Care nurse.

GIM experience has been rated “excellent” by trainees here.

Teaching

• Simulation facilities (which can be accessed by you)
• Prof Raj will invite SpRs to teach in undergraduate lectures
• Contribution to PACES teaching
• Opportunity to be undergraduate OSCE examiner

Management/leadership

• Junior doctor rep on Local Negotiating Committee
• Local SpRs’ meetings

Quality improvement

• Consultants encourage trainees to get involved in QIP, audits and writing case reports.
• Dr Bhowmik will delegate the leadership to SpRs with regard to completing BTS Audits

Other services/specialist training opportunities

• Lung function – full lung function tests and FeNO testing available (opportunity for experience with friendly physiologists)
• TB – plenty of cases, including drug resistant TB, extrapulmonary and complex cases (in and outpatients)
• Allergy – clinic experience include specialist investigations such as skin prick testing and challenge testing, and use of novel therapies such as immunotherapy
• Integrated care – go on a visit with the ACERs team to COPD patients in the community
• Pulmonary rehab – talk to the ACERs physio and volunteer to give a patient education session (then get them to fill in a teaching observation)
• Palliative care – attend St Joseph’s Hospice Breathing Space clinic for pharmacological and non-pharmacological interventions for breathlessness and advance care planning

Trainees have reported inadequate experience in ILD, CF, occupational/genetic/developmental lung disease and pulmonary hypertension.

Research

• Dr Bhowmik is involved in some research trials for COPD and will encourage you to recruit eligible patients. You will have to complete the Good Clinical Practice course before you can start consenting patients.
• Opportunities for projects related to Consultant specialist interests

Stage of training best suited to this rotation

• ST4+ (ideally ST5+)

 Recent trainee comments:

“Excellent post, wide range of learning opportunities, great consultants, one of the best rotations in the deanery.”

“Good access to excellent COPD and lung function services. Nice mix of clinics. Perfect for ST4 or ST5 (more EBUS than normal bronchoscopy)”

“Homerton is a great place for an ST4. There is plenty of good general and specialist Resp work, and GIM is not too intense. There is enough independence but with good support. The department is cohesive with a good relationship with specialist nurse/physio teams and Resp physiologists. I would highly recommend Homerton.”

“Excellent place for any stage. Lots of exposure to TB and asthma specialist services. I learnt a lot there in a friendly hospital environment.”