Learner / Educator Meeting to discuss progress of action plan following the Triggered Visit to review Trauma and Orthopaedics posts at University Hospitals Plymouth NHS Trust
3rd May 2019
Dr Martin Davis (Chair), Associate Dean for Quality, HEE-SW
Ms Jane Bunce, Quality Lead, HEE-SW
Mr Eng Ong, TPD
Ms Esther McLarty, Head of School for Surgery
Mr Graham Stoate, Lay Representative
Concerns had been raised by trainees in 2017 and 18 via the Quality Panel and ARCP processes regarding the learning environment in the T&O department at University Hospitals Plymouth (UHP). This was in respect of both CST and HST trainees. The learning environment concerns related to opportunities to obtain surgical exposure in line with curricula requirements, access to clinics and rotas that limited learning opportunities. The rota has been subject to concern in the Guardian of Safe Working report with the Trust being fined because of non-compliance.
The trigger visit in December 2017 and January 2018 required increased access to theatre opportunities for all trainees. The action from the Trust was to pilot a working relationship with the local ISTC where the trainees’ supervisors were already operating. One aspect of this visit was to assess this initiative from the trainees perspective. Training site approval was granted from the GMC.
The visit found that there were positive outcomes to use of the ISTC in respect of the HST although more objective data is required. The CST trainees had not had access to the ISTC. Their theatre opportunities remain limited. There are some practical issues with use of the ISTC which require action (induction being an example).
The rota remains a concern with too many short-term changes made. These affect moral and the working lives of trainees in addition to limiting their educational opportunities.
It was a concern to HEE SW that so few trainees were made available to give feedback to the visiting team. This was also reflected in the number of trainers interviewed. This may be attributable to some communication issues prior to the visit.
Whilst some progress has been made in the HST training requirements there remains concern in HEE SW about the environment for CST in T&O. There is an urgent need for the department to meet the requirements set out in this report. If not met in a short time frame then HEE SW will remove the CST trainees from the T&O department in UHP and look to either placing them in another training environment in UHP or to another LEP where their educational requirements can be met.
Findings and Conclusions
1. The rota for CST T&O trainees needs to meet the approval set by the Guardian of Safe Working (GSW) requirements. HEE SW require sight of the rotas for the period Jan 19- Mar 19 and Mar 19- May 19 with a record of the short term alterations made during these periods.
HEE SW requires ongoing evidence from the GSW that the rota meets their ongoing approval.
Time frame 3 months
2. UHP to send work schedules that comply with JCST quality indicators, to HoS and HEE.
Time frame 3 months
3. HEE SW require logbook evidence from HST and CST base in T&O UHP during the period Jan19-May 19 and will compare this with data from other Trusts.
To ensure anonymity HEE SW will collect the data and then feedback to the Trust in an anonymised format.
Time frame 3 months
4. Induction to the ISTC for trainees prior to their first shift must occur on all occasions. HEE SW require evidence of this having taken place
Time frame 3 months
- The panel recommended that the management team contact the rota co-ordinators of the other specialities in the CST programme in UHP to explore a co-ordinating working arrangement which has proved fruitful to addressing previous concerns in those areas.
The panel also recommended contacting Mr Will Thomas in Exeter who has instigated change in the T&O department where similar concerns existed in the past.
Central Surgical Rota Management Dept/team - It was recognised during the course of the review that Gemma Cochrane had instigated an example of good practice through a junior doctor welcome pack. This includes things such as a voucher for the hospital café, a drink etc and was designed to make the trainees feel valued.
Summary of discussions with groups
The visiting panel had anticipated seeing a number of trainees on the day as part of the review, however confusion with communication resulted in trainees not being informed of the visit and consequently were unavailable for their feedback. Feedback was limited, received verbally from two trainees present. Specific comment is not included in order to maintain trainee confidentiality. The panel concluded at the time of the visit that the lack of trainees present for the review reflected the lack of engagement and priority the department had given to the previous trigger visit and the recommendations made, however following the visit, it became clear that there were some issues with communication that led the department to believe that this was not a formal visit hence the lack of trainee availability.
In summary of the discussions held, it was reported back to the Director of Medical Education on the day that:
The arrangement with Care UK appears to be working well; however, it could be improved:
- The continuity of supervision is reportedly working well, with trainees being supervised by the same consultants as in UHP
- Exposure to pre and post operative patients is limited; however this would be the same with elective patients at UHP
- Induction does not always appear to be happening at the ITC
- Higher specialty trainees are undertaking training opportunities at the ITC but this has yet to be rolled out to the core trainees
- The management team commented that the use of Physicians Associates (PAs) and Advanced Care Practitioners is not working in the short term in terms of filling gaps; largely because they cannot prescribe. As a result of this PAs, are in some instances, getting in to theatre more than the trainee surgeons, as this is where they can undertake the most useful role within the limits of their profession
- The visiting team highlighted that the central rota management within UHP is working well and T&O are encouraged to follow this model by moving rota management away from the T&O department
- The management team confirmed that the fine for the previously failed rota was unlikely to reoccur as issues had been resolved
- It was agreed by the panel that the T&O department needs to provide evidence of engagement with trainees within 3-months. Failure to provide this reassurance will mean that HEE SW will move the CST training places to another department within the Trust; or to another LEP where the training environment meets regulatory requirements. A decision will be made at the end of the 3 month period which will depend upon the department/Trust making sufficient progress against the educational requirements that have been set out within this document.
- It was agreed that trainees would be asked to provide a summary of their log books for the next 3-months through the TPD and HoS. These will also be compared to other Trusts
- The panel recommended that the management team contact the rota team in the other surgical specialities who have CST trainees to discuss ways that rota management could work more effectively; Mr Will Thomas in Exeter was also recommended as a contact in the context of the T&O rota working well
- Issues to be escalated to a risk rating of ‘12’ on the HEE Quality Register which means they are reported to the South LETB and the Joint Strategic Oversight Group (JSOG)
Jane Bunce / Martin Davis
Quality Lead / Head of Quality