Core Surgery Training - Level 2 visit report

 

Local office name: Health Education England, working across the South West

Organisation under review: Plymouth Hospitals NHS Trust

Placements reviewed: Core Surgery Training

Date of Review: 8th December 2017

 

BACKGROUND

Reason for Review

Feedback from ARCP, JCST survey, GMC NTS, Quality Panels 

No. of Learners met

 5

No. of Supervisors/Mentors met                        

 

Other Staff members met

Management Teams: T&O, General Surgery, Plastics (PHNT only)

Duration of review

 1 day

Intelligence sources seen prior to review

ARCP outcomes

2017 GMC NTS results

JCST survey results

Quality Panel data

Log book data

Trainee written concerns/exception reports

Rotas

WBA completion by Consultant trainers and others 

 

PANEL MEMBERS

Name Job Title
Martin Davis  Head of Quality, HEE
Esther McLarty TPD for Core Surgery
Lt.Col Michael Butler TPD for T&O
Jane Bunce Quality Manager, HEE
Kitty Heardman Lay Representative
Neil Squires Business and Operations Manager, HEE
Sophie Rose Quality Support Administrator

 

EXECUTIVE SUMMARY

A triggered visit was undertaken to respond to concerns raised about a number of placements in the Core Surgical Training Programme running within the Peninsula footprint. The placements raising concern were based in Derriford Hospital in Plymouth. The concerns were raised through the quality panel outcomes and individual trainee issues raised with the TPD. The concerns were primarily focussed around insufficient access to training opportunities to allow satisfactory progression of trainees.

The panel were pleased with the engagement of Derriford Hospital in the process. There was a clear desire expressed by key individuals to ensure good quality training. They need support from the wider team. There was a common theme of service commitments impacting on the quantity of training available (primarily access to surgical intervention with appropriate supervision of their operating skills).  Common themes were difficulty in recruiting to surgical posts leading to rota gaps and insufficient progress in service redesign (changing job roles and skill mix).


Derriford presented ideas but the panel did not see a workable plan that could be implemented in an acceptable time frame to address the training concerns identified.


The requirements and recommendations are contained in the body of the report. Derriford is required to produce an action plan. The implementation of the action plan and the evidence for it addressing the concerns will be monitored by HEE.


An urgent work schedule (timetable) for each Core Surgical Trainee is required immediately, in line with the new junior doctors contract and compliant with the Quality Indicators for core Surgical training, and should be submitted to HEE by 28th February 2018.  The adherence and implementation of the work schedule requires close monitoring by their Assigned Educational Supervisor with concerns raised to the College Tutor and TPD where necessary.  The posts will be formally reviewed at the Quality Panel in July 2018.

REPORT SIGN OFF

Outcome report completed by (name) Jane Bunce / Dr Martin Davis
Chair's signature Dr Martin Davis
Date signed 15th February 2018
 
HEE authorised signature Dr Martin Davis 
Date signed 15th February 2018
Date submitted to organisation 15th February 2018

 

 ORGANISATION STAFF TO WHOM REPORT IS TO BE SENT

Job title Name
Director of Medical Education Matthew Bowles

 

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?  YES 
To whom was this fed back at the organisation, and who has undertaken action? Fed back to the T&O trainers who were aware of risks and were already working towards an appropriate solution.
Brief Summary of Concern A potential patient safety issue was raised by trainees that patients can leave theatre without their drug chart having been written up.

The department is in the process of attempting to change its culture so that the Anaesthetists will complete drug charts or have this form part of the pre-op pack. We  suggest that this is formalised in both trusts as part of the WHO checklist

 

EDUCATIONAL REQUIREMENTS

Recommendations are a proposal as to the best course of action.

 

Were any requirements to improve education identified? YES

 

Related Domain(s) and Standard(s) 

Theme 1 and 3

Summary of findings

At the time of the visit there were only 6 people on a 12 person rota in T&O.  The panel felt that there were some ideas being generated on how to address this however were not convinced this was a workable plan which could be implemented in the short to medium term to implement a long-term solution.

Required action
  • Sustainable plan with timescales to be produced for T&O to address staffing issues and allow training requirements and CST QI’s to be met by trainees
  • Consultant of the week ward round arrangements to be reviewed in T&O.
  • Trust to contact workforce and transformation team to provide advice about new roles for service provision.
  • Move away from dependency on recruiting surgeons for all traditional medical tasks in the department.
  • An individual remedial work schedule plan to be drawn up for trainees currently in post at risk of not progressing at their ARCP with a process that reviews progress against this plan and escalate if not achieved – immediate action required.

 

Related Domain(s) & Standard(s)

Theme 1 and 3

Summary of findings                                                        

It was reported that there is not always consultant presence on the ward each day within some of the surgical specialities (HPB /T+O).  When consultants do have a presence, decisions are made in a more timely way, trainees receive better training opportunities and flow through the hospitals was improved.

Required action

A consultant ward round to take place each day in all surgical specialties.  

 

Related Domain(s) & Standard(s)

Theme 3 and 4 

Summary of findings

Where gaps exist in rotas, the panel heard that funding requests to fill gaps can be time consuming despite the money being within the Trust from HEE.

Required action

Trust to unblock current barriers that exist to securing approval for funding already allocated to the department to fill rota gaps.

 

Related Domain(s) & Standard(s)

Theme 1 and 3

Summary of findings

At the time of the visit there were only 12 people on the general surgical rota at CST level to provide a full shift on- call, a post take team and an out of hours ward cover service.  Whilst the post take days may constitute some training for General surgical trainees, the Urology and Vascular trainees cannot count this towards their training activities. 

Required action
  • Sustainable plan with timescales to be produced for General Surgical rota to address staffing issues and allow training requirements and CST QI’s to be met by trainees. Please consider minimum rota requirements in the Improving Surgical Training report
  • Urology trainees contribution to be removed or substantially decreased to allow adequate Urology exposure
  • Vascular trainees’ contribution to rota to be reviewed.
  • Trust to contact workforce and transformation team to provide advice about new roles for service provision.
  • Move away from dependency on recruiting surgeons for all traditional medical tasks in the department.
  • An individual remedial work schedule plan to be drawn up for trainees currently in post at risk of not progressing at their ARCP with a process that reviews progress against this plan with involvement of the College Tutors and escalate if not achieved – immediate action required.

 

 

EDUCATIONAL RECOMMENDATIONS

Related Domain(s) & Standard(s)

Theme 1

Summary of findings

Recognise the need to look at alternative workforce models to substitute for gaps in doctor rotas and that this needs to be followed through to ensure a sustainable, effective and achievable action plan is in place.

All departments need to ensure adequate time and opportunity is available to allow CST QI’s to be met and the required Work Place Based Assessments to be completed (particularly Consultant validated WBA’s)

 

 

Summary of discussions with groups

The Surgical Tutor provided a report outlining the challenges and some proposed solutions.  This is included at appendix 3.

The panel met with 5 trainees representing placements in HPB, Plastics, Vascular, Urology, T&O and Colorectal.

T&O: It was confirmed that trainees are getting to theatre however this is in-frequent and occurs haphazardly rather than a planned fashion.  There are insufficient numbers on the rota, currently 6, as soon as someone is unavailable, the rota is short and consequently trainees can’t release themselves from the ward without compromising patient safety. Trainees can be scrubbed up in theatre but have to leave at short notice when called from the ward. Trainees are pulled at short notice from planned theatre sessions to cover gaps on the wards.

Trainees said that they had requested to be on the rota for trauma lists but their understanding was that the rota coordinator had been unable or told not to roster them for this activity. CS trainees should spend 2 sessions per week in a trauma list. Trainees had been pulled to the wards because locum staff would only agree to cover shifts if they covered theatres. Consequently the trainee gets removed from theatre to cover the take and ward work whilst the locum gains the surgical experience.

There are doctors assistants on the ward six days a week but this still does not free up CST for theatre due to the volume of work and insufficient numbers of staff available.  Ward tasks include a variable consultant ward round once a week, TTAs, rewriting drug charts, reviewing sick patients, repatriating patients to other wards.  A board round is conducted every day of one ward. Consultants and registrars often see their own patients on an ad-hoc basis without involving the CST and a more structure approach to this may enhance educational opportunities

Trainees felt that more registrar and/or consultant presence on the ward would help increase flow – this had begun to happen but is at present haphazard and at times infrequent.

It was acknowledged by the trainees that training when it occurs is of a good standard.

Plastics: There are 4 plastics doctors on the daytime rota which cross-cover out of hours with ENT, and they share out of hours work.  One trainee reported that it had been his first day in theatre in two months.  The trauma list starts at 2pm but the trainee can be holding the bleep until 4pm.  Some protected time for training was reported and trainees are free in the afternoons once the ward round is complete.  It was reported that non-training grades such as staff grades are rostered in theatre in preference to CSTs.  Trainees felt there was potential to share theatre slots and therefore opportunities. Although the plastic surgery department are ahead of many others in providing detailed work schedules to trainees, these need to be reviewed with the CST QI’s in mind. Recent training issues have occurred due to gaps in both the ENT and plastics departments, and work needs to be done to make these rotas more resilient utilising available AHP’s .

Urology: Trainee reported doing a lot of general surgical on call/ward/post take cover.  Actual experience of urology was reported as low due to the demands of the General Surgical on-call rota.  Trainees experience bursts of 2-3 days on Urology and therefore continuity with patients is difficult to achieve.  Trainees can be on call with a variety of general surgical consultants which can limit learning due to lack of consistency and their knowledge of the trainees competencies.. The panel appreciated that steps have already been taken to address these issues as the current Urology trainee has been made supernumerary and removed from the General Surgical on-call rota to redress the balance in their Urology training. There is a dedicated general anaesthetic list on a Tuesday morning specifically booked with the CST in mind with1 : 1 consultant training, but the demands of general surgical rota mean this opportunity is often missed.

Colorectal: Post was reported as good.  CSTs reported that they are supernumerary to responsibilities on the wards. There are 6 doctors at Foundation or Core level in the department which enables this.

HPB/Upper GI: No issues reported.  Rostered in to theatre and clinics.

Vascular: The trainee reported that they get to theatre on most days. There is a regular registrar ward round and a grand round on Friday.

It was reported that in vascular and urology, trainees can be on-call on the general Surgical Rota with trainers who are unfamiliar with their level of experience and/or ability.  This can negatively impact on training opportunities, whereas the other general surgical trainees tend to be on call with their own teams where possible.

 

Rota

Trainees reported that they had not been involved in the rota design. 

The trainees were asked if their experience meets the QIs required:

Opportunity to attend at least one fracture clinic a week

T&O appeared to be a problem – not rostered to this or elective clinic

Attendance at 3 theatre sessions a week – 2 trauma and 1 elective

Trauma – not sufficient experience other grades of trainee given preference/ poor elective exposure

Plastics – opportunities described as ‘thin on the ground’

Plenty of Urology opportunity when not on general surgical rota
Attendance at one consultant ward round per week Variable - daily Consultant ward rounds noted for Colorectal and Urology

 

 

TRAINERS AND MANAGEMENT

T&O

6 trainers attended the session and 1 member of the management team.

It was reported that traditionally the department has had good feedback from their training posts. They are funded to have 12 on the rota, but at the time of the visit only 6 are recruited to.  They have funding for 2 F2s, 3 core trainees, 7 trust doctors and 1 Physician Assistant. 4 trainees are needed on the ward at any one time to ensure a safe environment for patients. It was reported that cover for the rota with locums is being hampered by the agency pay cap. The consequence is individuals at all levels acting down and not being able to undertake the role and responsibilities they are employed for.

There are plans in progress to appoint Advanced Care Practitioners. Once they have completed a prescribing course in 12 months’ time will be able to make a more useful contribution to the department.  It was reported that the Trust is in the process of trying to get Physician Assistants on to a prescribing course.

The trainers acknowledged that trainees were not getting to theatre but there are now 2 all day theatre sessions running and more trauma sessions.  In the short term there was a suggestion to attach a trainee to a particular consultant so that they can ensure theatre and clinic attendance is maximised.

Trainers reported that there are 2 consultant ward rounds a week and proposed job plans would allow a job planned programmed activity to run the ward round.  This is planned for April but would be instigated before if possible.

It was acknowledged that the T&O consultants contact with trainees on a daily basis is limited but there is a desire to increase contact time.

 

General Surgery, Colorectal, Gastric, Urology, HPB

7 trainers and management team were present at the meeting.

It was reported that vacancies are impacting on the trainee experience.  The on-call rota, contract, study leave etc. cannot be managed effectively with the current vacancies.

Time for exams and training days is timetabled within the rota.  Sickness and vacancies cannot however be planned for.

Even though funding is in place for 12 posts to run the rota, approval still has to be sought from finance before any locum arrangements can be put in place. This slows the recruitment process to locum shifts unnecessarily.

It was reported that Doctors Assistants (also working at weekends) have been introduced to Urology and general surgery and there is a Physician Assistant working within the HPB team.

Trainers present were confident about the long term solutions being put in place.  However it was acknowledged that for some trainees, short term solutions need to be actioned so that their training is not adversely affected.

The Urology trainee cannot full fill their training requirements within the current rota and thought should be given to a 50% rota slot or removal from the rota altogether. The panel also have concerns about the vascular posts in this respect. 12 doctors are not enough to run the rota at this this level on a full shift basis because of the additional post take days and ward cover shifts. Please see the Improving Surgical Training document which outlines what posts need to look like and what the minimum rota standards should be: 

https://www.rcseng.ac.uk/news-and-events/news/archive/pilot-sites-announced-for-new-surgical-training-programme/ 

 

Plastics

Disappointingly no Plastic Surgical Trainers were present but 2 managers attended

Excellent feedback had been recorded for the Plastics post up until August 2017.  Recruitment was reported as an issue and locums are being used due to a reduced number of SpRs – there should be 10 on rota, but at the time of the visit there were 8.

It was reported that numbers should be increased from February.  The department has an advanced Nurse practitioner who holds the SHO bleep during the day 3 days per week but only works part time until 4pm.  There are two further advanced nurse practitioners being trained.

It was agreed that the Plastics CST trainee would get preference to go to theatre.

It was reported that training is recognised in job plans however WBAs are not always getting completed.  It was suggested that there is an opportunity each morning for WBAs to be completed and the Trust was asked to promote this amongst the trainers. Since August 2018 the department has the lowest number of completed WBA’s by consultants of any training CST department in the region and this needs urgent attention.

The panel stated a requirement for a short term solution to be put in place until February when the current trainee in Plastics is due to move on.

It was however acknowledged that although the panel had wanted to meet with the Plastics team, the issues within the department would not have been sufficiently concerning to have necessitated a triggered review at this time, however unless WBA activity is increased this is likely to have been triggered after the next round of Quality Panels in July 2018.

 

Summary - Plymouth

  • There were concerns with trainees in some specialities being able to achieve the necessary  competences to progress satisfactorily
  • The visiting team acknowledged the Trust’s engagement with the process and acknowledgement that issues exist
  • There are concerns that the rotas in General Surgery, T+O and Plastics/ENT are currently unsustainable to enable safe patient care and achievement of trainee’s necessary competency acquisition.  HEE needs to see a robust plan for sustainability in the near future, to include rota redesign and detailed work schedules for trainees that encompass the CST QI’s. This will enable quality assurance of educational opportunities in posts and allow trainees to exception report when they miss their scheduled training opportunities.
  • The Urology Trainees contribution to the general Surgical on call rota needs review, and omitting or reducing to a 50% share.There is no sustainable action plan in the short to medium term to solve the problems in T&O.
  • A tailored training plan for the trainees at risk in Orthopaedics needs immediate development with a system in place to monitor progress against the plan. If these trainees move to other departments in February as part of their rotations care will need to be taken to ensure that their training needs are met . This will need oversight by the AES and formal management by the College Tutors.
  • Consultant presence on the ward needs to be addressed in HPB and T+O. This will increase training opportunities as well as potentially helping patient flow through hospital
  • Process for filling rota gaps could be improved by unblocking barriers to access funding already allocated.
  • The Trust recognises the need to look at alternative workforce models to substitute for gaps in doctor rotas and these needs to be followed through with sustainable action plans. Contact with the workforce and transformation team at HEE is recommended

 

  

Date of report: 19th January 2018

Author: Jane Bunce / Martin Davis

Job Title: Quality Manager / Head of Quality