The Whittington Hospital

Updated in Feb 2020

The Whittington Hospital provides general hospital and community services to 500,000 people living in Islington and Haringey as well as other London boroughs including Barnet, Enfield and Camden.

The organisation was established in April 2011 following the merger of The Whittington Hospital NHS Trust with NHS Islington and NHS Haringey community health services. Since it provides both hospital and community services, it is an “Integrated Care Organisation”. This is apparent when working at the Whittington, particularly in Respiratory medicine, as many staff members work both in the hospital and in the community. There are also strong links with local GPs.

The hospital has 360 beds with a 21-bedded respiratory ward, with the potential for outliers on the ward next door. The latest CQC rating was “good” overall, an improvement from previous “requires improvement”. The medical services and A&E received a “good” rating.

2 Respiratory trainees will be posted here (usually 1 year rotation) at each time. There is one acute medical trainee posted here during the April – October rotation.

Consultant speciality interests

• Dr Louise Restrick – Integrated care including mental health, Emergency oxygen, Smoking cessation, Leadership
• Dr Myra Stern (semi-retired) – Bronchiectasis, Integrated care, Smoking cessation, Service development
• Dr Sara Lock – Lung cancer, Asthma, Research
• Dr Ruvini Dharmagunawardena – Pleural disease, Bronchoscopy, Integrated care
• Dr Anna Gerratt – Sleep and ventilation, Bronchiectasis, Education and training
• Dr Melissa Heightman- Interstitial Lung Disease, Integrated care
• Dr Alan Shaw – Pleural disease, Lung Cancer

NB. TB clinics at the Whittington are run by the UCL ID/Respiratory team, as part of a co-ordinated TB service for North Central London.

Typical week for SpRs

Dr Restrick	SpR
	Mon	Tue	Wed	Thu	Fri
AM	General Clinic	SpR WR	Cancer MDT Ward MDT	Cons WR	SpR WR
Lunch	Departmental meeting		Radiology meeting Ward Grand Round
PM	Cons WR	Pleural work/ Referrals	Bronch list/ SpR WR/ Referrals	General/ Cancer Clinic	Pleural work/ Referrals

Dr Shaw	SpR
	Mon	Tue	Wed	Thu	Fri
AM	SpR WR	Cons WR	Cancer MDT Ward MDT	General clinic	Cons WR
Lunch	Departmental meeting		Radiology meeting Ward Grand Round
PM	General Clinic	Pleural work/ Referrals	Bronch list/ SpR WR/ Referrals	Ward work/ Referrals	Pleural work/ Referrals

Integrated care	SpR
	Mon	Tue	Wed	Thu	Fri
AM			Integrated care/ CoRe MDT
Lunch	Departmental meeting
PM			Home visit

• There are 2 consultant teams:
  • Dr Restrick, Dr Dharma and Dr Lock (they rotate to cover their ward patients) – one SpR under this team
  • Dr Gerratt and Dr Shaw (they rotate to cover their ward patients) – one SpR under this team
• The SpRs will be under their respective teams for 3 – 6 months. They will swap teams after that or one of them will take up the integrated care SpR role when the acute medical trainee posted here covers as one of the ward SpRs.
• The integrated SpR does not work on the wards and mainly does clinics (including post-COVID), home visits, attending oxygen and integrated care/CoRe MDTs. The schedule is pretty fluid upon negotiation with the integrated care consultants depending on the SpR’s aims and objectives of the job.
• The 2 ward SpRs’ schedules are independent of each other and you do not usually cover each other’s clinics/ward work although you do help each other with referrals/pleural work.
• The ward SpRs see all the referrals which can be a burden when only one of you is present, but consultants who are not on the wards do respiratory ‘in-reach’ to MAU which lightens the load.
• Ward SpRs should expect longer ward rounds due to the excellent holistic care provided by the consultants here.
• Departmental M&M meetings are held monthly.
• Weekly departmental meeting will include case discussions, journal club and service evaluations.

Bronchoscopy

• Weekly Wednesday afternoon list with 2 consultants alternate to supervise with the 2 SpRs sharing the same list. The 2 respiratory SpRs will negotiate between themselves on how to split the list.
• Low volume of bronchoscopy so not the best place to get your numbers up. There are usually 1 to 2 bronchoscopies a week but there are weeks with no procedures booked.
• Supportive training environment for bronchoscopy when it happens
• EBUS service is not available here

Estimated number of bronchoscopic procedures in 6 months per trainee: 1 – 10 (with 0 endobronchial/transbronchial biopsies)

Estimated number of EBUS/TBNA in 6 months per trainee: 0

Thoracic US and pleural procedures

• Dedicated Resp department portable US machine available 24/7.
• Dr Dharma, Dr Shaw and Dr Gerratt are Level 2 competent operators and can support trainees for sign off.
• Trainees reported no opportunity for pleural biopsy and indwelling pleural catheter insertion.
• Medical thoracoscopy is not available here.

Estimated number of thoracic US in 6 months per trainee: 61 – 70

Estimated number of pleural aspirations in 6 months per trainee: 21 – 30

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

NIV/Sleep

• NIV is mainly run by the physiotherapist with consultant oversight.
• This centre provides full sleep service with overnight pulse oximetry and limited and complex polysomnography services available.

Estimated number of adequate involvement in management/initiation of NIV in 6 months per trainee: 1 – 10

GIM

• GIM time is not organised into blocks, but instead in single day shifts on different days across different weeks. In a 13-week pattern, SpRs do three weekends (long day take shift, shorter ward cover shift and night shift), 1 weekday nights and random split on-call days. Weekends are Fri – Sun. Nights are in blocks of 3 (weekend) or 4 (weekdays).
• The random weekday on-call can make ensuring the right clinics are cancelled a bit of a hassle so will need some planning ahead.
• Takes are very manageable – days average 15 – 20 admissions and nights average 8 – 10 admissions
  • Days: 1 SpR, 1 long day take SHO, 1 late clerking SHO and a clerking FY1 from 5pm, 1 late ward cover SHO and 1 late ward cover FY1
  • Nights: 1 SpR, 1 ward SHO and 1 clerking SHO
• There are not many arrests on the wards (about 1 every 2 shifts) and the shifts are not too busy but with enough experience to easily cover GIM curriculum requirements.
• The ambulatory care department is well-known to be fantastic. There are ambulatory care pathways for many acute conditions and you can easily bring people back there to review/do procedures sooner than a clinic appointment would offer.
• The post-take setup is not ideal for educational feedback as it is split into 3 (2 acute medicine Consultants post take on each of the acute admission units, and 1 medical Consultant post-takes the outliers). This is good for the patients as they get seen earlier, but this would mean you need to make more effort to get feedback. However, an ACAT can now be completed by a consultant who has not seen your patients but discussed the cases with you so this setup might not be a big issue.

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

Teaching

• Regular bedside teaching commitment of undergraduate medical students on Tues morning 11 am
• Opportunities to give seminars to undergraduate students on Resp/Cardio block
• Opportunities to teach IMTs and help with PACES teaching
• Opportunities to be undergraduate OSCE examiner

Management/leadership

• SpRs run the weekly educational meeting
• SpRs are also invited to sit in departmental management meetings
• Opportunity to undertake Advanced Development Programme (training in supporting people with long term conditions to optimally self manage)
• Consultants are involved in lots of service improvement projects locally and regionally so opportunities to get experience

Specialist training opportunities

• Integrated care – attend community MDT, go on visit with CoRe team, attend Care Planning Conferences, work with respiratory psychologist who is also on-site to review inpatients.
• Pulmonary rehabilitation – opportunities to join the respiratory physiologists.
• Smoking cessation – work with quit smoking advisors and the lead Elizabeth Pang to get level 1 trained. Department provides some training in motivational interviewing techniques.
• ILD – Opportunity to attend ILD clinic with Dr Heightman if make particular effort.
• Respiratory physiology – lung function services available.

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

Research

• No in-house research, but the department takes part in several studies, particularly related to lung cancer (eg TracerX, Streamline L).
• Trainees are involved in BTS Audits.
• Plenty of QIP opportunities – get involved with Dr Restrick.

Stage of training best suited to this rotation

• ST3 – 4
  • This post provides very limited bronchoscopy experience but junior trainees will get good pleural exposure
  • Junior trainees will likely pick up valuable practices and good habits early on in their career particularly in terms of holistic patient care
  • More senior trainees may find the degree of oversight frustrating.
• ST5 – 6 (if trainees have an interest in integrated and holistic respiratory care)

 Recent trainee comments:

“My experience at the Whittington will change my practice forever. Acquiring skills in motivational interviewing has made me approach smoking cessation in a new, more successful, more satisfying way. The strong focus on integrated, holistic care, and frequent care planning conferences can be exhausting, but have shown me what impact a motivated MDT can have on the lives of people with chronic conditions. I now can’t believe other departments function without a dedicated psychologist!”

“The Whittington is a really nice hospital with friendly consultants and a focus on the patient as a person. You do not come to the Whit to experience specialist procedures or technologies – instead what you learn is how to work in a team that crosses boundaries of primary and secondary care, how to treat the whole person and how to make an impact on individual lives. If you can let go a little and get down with the quirks of the NIV service and the high involvement of Consultants in day to day decisions, you will have a great rotation.” 

“My training at the Whittington encouraged an approach to holistic patient care and my ability to work in a team that crosses the boundaries of primary and secondary care. My integrated care post gave me exposure to dealing with respiratory illnesses in patients with complex mental health issues, how to work effectively with a community integrated team to improve patient care and the value of pulmonary rehabilitation.”

“Not my favourite job. Too much ward work – you are a glorified SHO. Not much time for referrals and pleural work. But the newer consultants are aware of the pulls on trainee. Have gained lots of experience in managing breathlessness, smoking cessation and COPD/asthma. Not many bronchs.”

“Whilst there are some learning opportunities specifically holistic/integrated care of COPD patients, overall they are limited. SpRs are actively discouraged from attending cancer MDT, benign MDT, bronchoscopy, seeing referrals, and sometimes attending training days. Aside from an average of one clinic per week, the registrar is expected on the ward at all times, including completing routine jobs. Consultant ward rounds last all day and often into the evening, leaving very little time for projects, etc. GIM experience is good on the whole – consultants are supportive and willing to complete assessments. Take is generally manageable and the A&E department are helpful and supportive.”