Clinical Oncology - Level 2 visit report
Local office name: Health Education England, working across the South West
Organisation under review: Royal Cornwall Hospitals NHS Trust
Placements reviewed: Clinical Oncology
Date of Review: 16th November 2017
Reason for Review
|Feedback through GMC NTS and Quality Panel process|
No. of Learners met
No. of Supervisors/Mentors met
Other Staff members met
Duration of review
Intelligence sources seen prior to review
Trust policies for escalation of concerns
GMC NTS results for 2017
Quality Panel data
|Dr Hiu Lam||Interim Head of Foundation School and Associate Dean, HEE|
|Dr Mike Waldron||GP Associate Dean, HEE|
|Dr Nick Withers||Head of School for Medicine, HEE|
|Dr Steve Boumphrey||Foundation Programme Director, PHNT|
|Mr Bill Wylie||Lay Representative|
|Ms Jane Bunce||Quality Manager, HEE|
The 2017 GMC National Training Survey (NTS) and HEESW Quality Panel process highlighted a number of trainee concerns within the clinical oncology programme at Royal Cornwall Hospitals NHS Trust (RCHT).
A Triggered Visit was instigated and the main areas of concern highlighted through the review are the need to:
As a consequence a number of recommendations have been made.
It should also be highlighted that the department had already started to put in place some necessary actions, prior to the review, which are designed to support the trainee experience and improve the learning environment.
REPORT SIGN OFF
|Outcome report completed by (name)||Dr Hiu Lam / Ms Jane Bunce|
|Chair's signature||Dr Hiu Lam|
|Date signed||20th February 2018|
|HEE authorised signature||Dr Hiu Lam|
|Date signed||20th February 2018|
|Date submitted to organisation|
ORGANISATION STAFF TO WHOM REPORT IS TO BE SENT
|Director of Medical Education||Dr Chris Williams|
|Associate Director of Clinical Support and Cancer Services||Karen Jarvill|
|Cancer Services Lead||Louise Hunt|
|Consultant Oncologist||Dr Alistair Thomson|
|Consultant Oncologist||Dr Richard Ellis|
|Scores prior to review||4x3|
|Proposed scores following review||3x3|
PATIENT/LEARNER SAFETY CONCERNS
Any concerns listed will be monitored by the organisation. It is the organisation's responsibility to investigate/resolve.
|Were any patient/learner safety concerns raised at this review?||NO|
|Related Domain(s) & Standard(s)||
Developing a sustainable workforce
|Summary of findings||
The Department discussed the difficulty it faces in recruiting consultant oncologists. They are already looking at doing things differently and described being open and receptive to anything that will help them recruit.
The HEE Quality Team will discuss with the HEE Workforce Transformation Team and liaise with the Trust in due course.
|Learning environment / Prof. group / Dept. / Team||Good practice||Related Domain(s) & Standard(s)|
|Learning environment||Consultants and Specialty trainees are very approachable for advice||Learning environment and culture; Supporting learners|
Summary of discussions with groups
The visiting team met with 3 trainees: An F2, GP Registrar and ST5.
When fully staffed with juniors, the oncology department has 2 foundation trainees, a GP registrar and 2 registrars. The more junior trainees cover the inpatient ward and acute oncology service whilst the 2 registrars cover the consultants and support them in clinic. The Higher trainees do not do ward work but support different consultants in four month blocks.
Ward round and inpatients
The trainees explained that they are responsible for the ward round. There are generally around 8-10 patients on the ward but they can have very complex needs and are often quite sick. The process has been that each inpatient has their own oncologist and they tend to be seen by them once a week. There is a pattern to which day a consultant oncologist will visit the ward, dependant on the individual consultant. There are 9-10 consultant oncologists. The trainees take up until around 12 noon to complete the ward round. The trainees reported that they don’t have the specialist knowledge to efficiently and effectively conduct the ward round and the F2 and GPST have been doing it together.
It was reported that the consultants are now starting to input in to the ward round from 9am but this is currently variable.
The trainees reported that if a very sick patient comes in to the ward, it varies as to whether a consultant will see them, often they will not. One trainee reported that if a patient is admitted on a Monday, a junior doctor may be the only person to see a patient before they die. If someone is admitted on a Friday, they are more likely to see a consultant as the oncologists do come in at the weekend.
Trainees commented that conversations with patient families can be very difficult. These conversations are stressful in part because of the seriousness of the health issues but also because they felt they do not have the oncology expertise to have these conversations, for example, to comment on prognosis.
The Headland bleep for the chemotherapy clinic can be quite busy. There was a perception that although other registrars cover the bleep, that everything comes to the more junior trainees. There can often be questions that they can’t answer, some jobs are appropriate for their level, some are not.
The trainees felt that they needed most support with patients medical issues. The patients undergoing chemotherapy have a plan but there can be a lot of queries from the Headland clinic ranging from the serious such as breathlessness and chest pain to more minor issues such as a sore toe.
Acute Oncology Service (AoS)
There are two acute oncology nurse specialists and a junior doctor is supposed to team up with them. Due to the time it is taking the trainees to do the ward round, they can’t often support this service.
The AoS can see a variety of patients such as referrals from ED, complications from previous diagnosis or new impacts of cancer. It was reported that the AoS nurse specialists want the trainees with them every day as medical support. The busiest time for the AoS is in the morning which clashes with the trainees doing the ward round which impacts on their ability to accompany the AoS.
Patients admitted to the ward through the AoS service are seen by a consultant on admission and therefore get given a plan. These patients are therefore easier to manage on the ward round.
The trainees confirmed that all the consultants are approachable and they know where to find them. They reported that they felt the induction did not adequately cover how to contact them, which was a problem at the start of the placement. Induction generally could be improved.
There was no resistance from other departments to help when contacted.
The pathway to access advice was something that the trainees felt could be made clearer.
The trainees said that the time they spend in clinic is valued and enjoyable.
Tuesday teaching was reported as being more targeted at registrars and a ‘bit over the heads’ of the more junior doctors, although they valued this time to meet up with other trainees and said that it has got better recently. Friday teaching was said to be better but is quite a recent addition.
The trainees felt that they had learnt a lot during the placement.
One trainee reported being able to leave on time, whilst one said they do not.
The trainees commented that you never know what day you’re coming in to. The post can be stressful and one trainee commented that the job had drained them more than any other job. The ward work was described as exhausting.
The trainees suggested employing a third registrar so that each consultant group had increased support.
Would trainees recommend this post?
Trainees were asked if they would recommend the post. They said that they would recommend aspects of the job. They would not recommend the ward work.
The visiting team met with 2 consultants.
The consultants explained that the trainees’ first responsibilities were inpatient care and the Headland unit.
They confirmed there tends to be 4-10 in-patients. It is the responsibility of the F2 trainee to manage the ward independently and to contact the specific consultant for any decisions. In principle it should take a sole F2 anything from ½ an hour – 2 hours to do the ward round.
The GP registrar should be responsible for managing the Headland bleep and working with the AoS.
The third junior trainee should be working in clinic all week.
The consultants acknowledged that there may have been a lack of clarity provided with respect to the differing responsibilities.
The trainers recognised that the acute level of patient care can be challenging for trainees. They confirmed that they are available at all times and induction states that consultants can be called when needed. They acknowledged that 1 or 2 of their colleagues may be less proactive than others but that help would never be refused.
The trainers informed the panel that over the last 3-4 weeks, a consultant is now conducting a board round in the morning. Going forward, outpatient clinics will be starting later to facilitate this. This should also mean that every patient is seen by a consultant sooner than in the past and should also help trainees with patient family discussions. All consultants had committed to conducting the board round, although not currently recognised in job plans.
The consultants acknowledged that due to the specialised nature of oncology, they can lack knowledge in certain areas but can all manage general issues. The registrars are also available for help and support.
The panel were informed that there is a vacant consultant post, a new consultant is due to commence in January. It was understood that consultant numbers are behind those at Plymouth Hospitals and Royal Devon & Exeter. There is a national shortage of oncologists and vacancies are difficult to recruit to.
The Trust had been using Trust doctors who worked exclusively in clinic and they hold a separate bleep for Headland so not all issues are directed towards the F2. The majority of Trust doctors had left the department though and replacements are difficult to recruit. The panel discussed the possibility of dividing the consultants in to two groups to ensure all had the support of a registrar. This had previously been considered but was not deemed good for the registrars as it would dilute their experience. The registrars receive very site specific training.
The trainers acknowledged that the oncology posts are challenging jobs for F2s and those trainees are likely to struggle for half their time with the department. Historically, pre-F2, the posts were staffed by SHO level doctors.
Pressure on consultants varies depending on the complications of different tumour sites.
The trainers recognised that there may be an educational requirement to advise the nursing staff where best to direct different bleeps depending on the seriousness of issues.
Acute Oncology Service
The AoS was discussed. The service was described by the trainers as a mutually beneficial relationship – the trainees provide medical input whilst the nurse specialists provide the oncology expertise.
The management team acknowledged that the department is facing capacity issues due to senior consultant recruitment difficulties. There is a rolling open advert to recruit. They are currently looking at increasing the pool of expertise by providing cover through consultant, middle grade and GPs with special interest. They are also looking at how other staff groups can support management of patients and are open and receptive to anything that will help recruit. Nurse-led clinics are also being investigated.
It was reported that the Executive Team are meeting with the oncology consultants in two weeks to discuss a plan for cancer services. In the meantime, the consultants are committed to providing a board round. It has taken some time to remove obstacles in order to support this.
It was acknowledged that Induction needs to improve and agreed that towards the start of F2 placement, the board round would be longer initially to provide additional support.
In addition, it has been recognised that a more robust process for escalation is necessary.
The panel was informed that the Trust’s End of Life Strategy has just been re-launched.
The Cancer Services Lead agreed to look at delivering some Breaking Bad News training.