School of Anaesthesia - Level 2 Report

Chair Dr Jeremy Langton, Deputy Postgraduate Dean
Level 2 Visit Date Wednesday 14th September 2016
Trust under review North Devon District Hospital

School/Programme/department      under

Anaesthesia (Core and ACCS)
Grade of trainees under review Core
Reason(s) for review Review of the delivery of Core Anaesthesia Training and ACCS Anaesthesia to ensure that the programmes allow trainees to meet the requirements of the curriculum
Visiting team

Dr Jeremy Langton, Deputy Postgraduate Dean

Dr James Pitman, Head of School for Anaesthesia

Neil Squires, Specialty Training Manager

Dr Ian Mettams, Regional Advisor Wessex & External Representative

Trust team

Dr George Thomson, Medical Director

Dr Julian Cox, Director of Medical Education

Caroline Rawlings, Medical Education Manager

Dr Cecily Don, Anaesthesia Lead Clinician

Dr Nigel Hollister, College Tutor

Dr Guy Rousseau, Clinical Tutor / Simulation Lead

Gillian Taylor, Service Line Lead

Quality Register Item no. (s)  


  1.        Background to Level 2 Visit (including description of issue requiring improvement, actions already taken and evidence considered)


  1.1       The School of Anaesthesia became aware of difficulties in the delivery of the curriculum for Core and ACCS Anaesthesia in relation to training in Head, Neck and Maxillofacial and Dental Surgery module and this primarily concerned the experience to be gained in ENT Surgery.


  1.2       The meeting opened with the Trust representatives describing the current position regarding the provision of ENT Surgery in North Devon District Hospital (NDDH). In summary, due to a shortage of ENT Consultant workforce NDDH can no longer provide in-patient ENT Surgery. Current staffing is one Consultant and one Associate Specialist. There is presently one list of day case grommets per week.


There are plans to develop a network solution with the ENT service in the Royal Devon and Exeter Hospital and this forms part of the sustainability and transformation plans that are being developed within Devon.


1.3         As a consequence it is not possible for Core and ACCS Anaesthesia trainees to obtain the competencies for Head, Neck and Maxillofacial and Dental Surgery in NDDH which is a mandatory requirement of the GMC approved curriculum.


1.4         There are currently four CT2 Core Anaesthesia trainees in NDDH who require ‘sign-off’ of the Head, Neck and Maxillofacial and Dental Surgery module by July 2017. A plan was agreed for the provision of this training and is described in the action plan below (2.1).


1.5         There are also two ACCS Anaesthesia trainees who will require ‘sign-off’ of the Head, Neck and Maxillofacial and Dental Surgery module by July 2018 and a plan was agreed as per the action plan below (2.2).


1.6         The discussion then focused on the options appraisal drawn up by the School of Anaesthesia. See enclosed document.


1.7         Options 3 and 4 were not considered viable by Health Education England.


1.8         Option 2, whilst a solution for existing trainees, was not considered viable long-term. Seconding trainees to other acute providers for their Head, Neck and Maxillofacial and Dental Surgery module would present challenges in term of rota coordination and potentially diluting the experience for other trainees.


1.9         There followed discussion regarding the arrangements for newly appointed Core and ACCS Anaesthesia trainees (i.e. those commencing August 2017). This focused on options 1a) and 1b) of the options appraisal.


1.10       Option 1a) would mean that NDDH would only ever have CT1 trainees who would then rotate to a larger centre for their CT2 year. This was a model the external advisor was familiar with in Wessex. The Anaesthesia dept. in NDDH raised significant concerns, in particular how they would cover the service if they were only to receive novice trainees. The external described the situation in Wessex to help mitigate this by appointing in both the August and February intake.


1.11       Option 1b) was received more favourably as it would allow the department to maintain a balance of CT1 and CT2 trainees by setting up rotations with other local education providers. However there was concern from the School around the provision of Obstetrics experience as the CT2 trainees rotating would not have gained Obstetrics in their first trust and would therefore be gaining there Obstetrics experience in NDDH. There was also concerns raised that they may end up (because of the on-call structure in North Devon) being exposed to excessive Intensive Care Medicine in contrast to Emergency Anaesthesia.


1.12       The outcome of the meeting was that it was agreed that the College Tutor, the Head of School and the Training Programme Director will explore option 1b) in more detail and discuss with the School Board.


1.13       Due to the uncertainty in relation to the sustainability and transformation plans for North Devon it was felt premature to change the structure of the intake for August 2017 and that this would remain the same with Core Trainees coming to North Devon for two / three years.


1.14       It was also felt that there should be greater clarity about the likelihood in the future of trainees rotations not being fixed in terms of where they are placed due to the likely changes in the model of service delivery, it was agreed to introduce a caveat into the offer to reflect this uncertainty.


1.15       It was also discussed at the meeting that should there be any further changes to the provision of services in NDDH then this would precipitate further re-evaluation of the structure of training required for Core and ACCS Anaesthesia trainees in NDDH.


2. Action Plan (including staff responsible for actions and expected dates of review and resolution)


2.1         The four CT2 trainees with an estimated completion date of August 2017 will undertake a placement at one of the other acute providers on the programme where they will have a consolidated two week block to gain the Head, Neck and Maxillofacial and Dental Surgery competencies described in the curriculum.


The College Tutor at NDDH (Dr Nigel Hollister) has already been in contact with his counterparts in Taunton, Exeter, Torbay and Plymouth to make the arrangements. The trainees will be issued an honorary contract during this attachment and any costs, such as travel or accommodation, will be met by NDDH. It was emphasised that close coordination between the College Tutors in these trusts will be required to ensure that the placements were of adequate duration to allow the trainees to gain the required competencies.


It was noted that the trainees’ will require a departmental induction and possibly a Trust induction; although it was noted a significant proportion of the Trust induction may be completed on-line before commencing the placement.


2.2         The two ACCS Anaesthesia trainees due to programme to CT3 in August 2017 will have the same arrangements as described in 2.1 above.


2.3         It was agreed that the Head of School Dr James Pitman), College Tutor (Dr Nigel Hollister) and Training Programme Director (Dr Justine Elliott) will explore the feasibility of option 1b) which would allow NDDH to retain a balance of CT1 and CT2 trainees and therefore not negatively impact on service delivery. The report will need to be taken to the School Board for ratification and may necessitate a further visit to NDDH.


3.             Suggested RAG and status for Risk Register as a result of Level 2 visit (please choose one)

Green – de-escalate to standard quality processes and monitoring

Amber – continue with Level 2 visiting

Red – escalate to Level 3 PGME Triggered visit

Red* - escalate to Level 4 GMC Enhanced Monitoring


4.              Quality Process

Once the panel Chair has shared and agreed this report with all attendees for factual accuracy, it should be sent to the relevant Quality Manager (see below).

The final report will be issued to the DME by the Quality Team, as appropriate.


Quality Managers:

Peninsula: Jane Bunce (

Severn:    Allegra Etheridge (


The Quality Team will review and update the quality register and report to the General Medical Council (GMC), as appropriate.


5.              DECLARATION BY CHAIR

I confirm this completed report is a true and accurate account of the level 2 visit. The key recommendations have been identified within this report in good faith.

I confirm that any significant areas of concern e.g. trainee safety or patient safety concerns have been brought to the attention of the relevant Director of Medical Education (or equivalent) and Medical Director for immediate attention.


Name:  Dr J Langton (Deputy Postgraduate Dean)                               Date: 19th September 2016