Peninsula Postgraduate Medical Education Triggered Review Report to Trauma and Orthopaedics in Northern Devon Healthcare NHS Trust

 

 

Primary Author of report (name and job title): Mr Mark Westwood, Head of School for Surgery

Postgraduate School / training programme undertaking review: Peninsula Postgraduate Medical Education (PPME) / Trauma & Orthopaedics

Provider under review: Northern Devon Healthcare NHS Trust (NDDH)

Date of review:  12th January 2015

Reason for review:

In December 2014, the GMC visited the NDDH as part of a national review of issues of Undermining & Bullying. The GMC had previously announced that it was going to carry out a series of short, targeted check visits to investigate how concerns around bullying and undermining reported by doctors in training are being responded to. These were planned to focus on obstetrics and gynaecology and on surgery and the GMC intended to report on these check visits in early 2015.

The initial feedback from the GMC’s visit to NDDH on 28th November 2014, was that there was neither a culture nor a systemic problem of undermining and bullying in the general surgery department. However, the visiting team identified a serious concern regarding workload, work intensity, out of hours support and a lack of communication about rota changes by the doctors in training in Trauma & Orthopaedic (T&O) surgery. Health Education South West undertook to provide a written update on these specific issues and action taken by the trust to address these concerns.

Review team (names and PPME job titles): Mr Mark Westwood, Head of School for Surgery and Ms Georgia Jones, Head of Foundation School

Date review report ratified: 26th February 2015

Date review report made available to provider: 26th February 2015

Circulation of this report: General Medical Council, Postgraduate Dean, Quality  Team (PPME), Director of Medical Education, NDDH

 

 

1            Background

1.1          The North Devon District Hospital (NDDH) in Barnstaple provides a full range of district general hospital services, including accident and emergency, critical care, coronary care, general medicine (including elderly care), general surgery, orthopaedics, anaesthetics, stroke rehabilitation, midwifery-led maternity care and a breast service.

1.2          The trust has a total of 644 beds, of which there are 341 at the district hospital in Barnstaple. The hospital has 2,111 staff.

1.3          From 2013 to 2014, the hospital treated 40,706 inpatients and had 553,748 outpatient attendances. The A&E department at NDDH had 36536 attendances between May 2013 and April 3014.

1.4          In December 2014, the GMC visited the NDDH as part of a national review of issues of Undermining & Bullying. The GMC had previously announced that it was going to carry out a series of short, targeted check visits to investigate how concerns around bullying and undermining reported by doctors in training are being responded to.  These were planned to focus on obstetrics and gynaecology and on surgery and the GMC intended to report on these check visits in early 2015.

1.5          The initial feedback from the GMC’s visit to NDDH on 28th November 2014 was that there was neither a culture nor a systemic problem of undermining and bullying in the general surgery department. However, the visiting team identified a serious concern regarding workload, work intensity, out of hours support and a lack of communication about rota changes by the doctors in training in Trauma & Orthopaedic (T&O) surgery.

1.6          Health Education South West (HESW) undertook to provide a written update on these specific issues and action taken by the trust to address these concerns.

1.7          On 12th January 2015 a HESW team visited NDDH comprising of Mark Westwood (Head of School of Surgery HESW, Peninsula) and Georgia Jones (Head of the Foundation School HESW, Peninsula) and interviewed trainees and trainers in T&O and General Surgery specialties at Foundation and Core trainee level. 

1.8          During the course of the visit interviews were held with 7 foundation doctors, 1 core trainee, the Royal College of Surgeons of England’s college tutor, 2 consultant general surgeons, 1T&O consultant surgeon and 1 associate specialist in general surgery. The consultant surgeons were trainers and also held directorate management roles. The foundation doctors had not been in post at the date of the original rota change in August.

2            Issues raised

The original change in working pattern in August 2014

2.1          There had been a change in the general surgery and T&O rotas in the summer of 2014. The stimulus for this change was twofold. Firstly, there was a need to ensure that T&O foundation doctors had permanent, onsite senior support to comply with GMC requirements regarding the supervision of foundation doctors. Secondly, there was a reduction in the number of core surgical trainees at NDDH.

2.2          The pre-August 2014 rota had separate rotas for General Surgery and T&O trainees. The rotas in August 2014 amalgamated the weekend and night time junior doctor (core trainees and foundation grades) rotas of T&O and general surgery.

2.3          This meant that there was one core trainee (or trust doctor) and one foundation doctor (F1 or F2) covering both T&O and surgery. For weekend days, there were two foundation trainees, each covering surgical and T&O wards, working with a single core trainee (or trust doctor).

2.4          The junior doctors reported to us that they felt that this caused unacceptably high work load that they also felt was unsafe and had a high likelihood of causing concerns regarding patient safety, although no specific examples of harm were presented to us.

2.5          It became apparent that the F2s’ working pattern in particular was non-compliant due to insufficient days off being built into the rota. In addition, trainees did not feel equipped to deal with the breadth of patients.

The interim change to the working pattern in October 2014

2.6          The problems with the new working arrangements were acknowledged by the trust prior to the GMC’s visit in November.

2.7          From October, the rota was altered to increase the number of doctors during the day time at weekends to a core trainee and a foundation doctor on the general surgery side and one core trainee or F2 doctor on the T&O side. This is the same at night as well now.

2.8          The trainees reported that the rota changes implemented in August 2014 have been changed with interim measures until February 2015.

2.9          The present interim measures were felt to provide a temporary solution that was acceptable to the trainees pending the permanent changes due to start in February 2015.

2.10       It was agreed with trainees that further changes would not be made before February 2015 in order to honour time-off that had already been planned.

2.11       The temporary rota changes had increased the number of weekends that the trainees were having to cover. The trainees reported that they felt that they should be remunerated for these additional sessions but so far had not.

2.12       The trainees report that this new rota is a great improvement and means that they now do not have concerns regarding work intensity or work load.

2.13       They also report that they now believe that there is appropriate out of hours support.

2.14       They believe that the new rota is compliant but that they haven’t been specifically shown evidence of this, ie the “Zircadian rota calculations”.

2.15       The doctors in training also reported that they felt that there had been a slightly chaotic handover process during the period of the rota that involved cross covering the two specialities but that this process is now much smoother after an initial bedding in process and now is not necessary as there is no cross cover.

2.16       They do report that they feel the handover in mornings is still slightly haphazard as it occurs in differing fashions on different days depending on which consultant has been on call. On some days the consultant is involved in the hand over process, on other days the outgoing junior doctor on call hands over to an incoming junior doctor who then hands-on the patients to the consultant on call when they arrive at a later time.

2.17       They reported that they felt that this ad hoc system was confusing and meant that many good training opportunities were lost and that there were potential patient safety issues.

2.18       The trainees  also reported that they were not aware of receiving a directorate induction in December 2014 when many of them had started in general surgery and T&O and that there had not been a cross cover induction for trainees in general surgery who were expected to cover T&O and vice versa. This was still the case as a urology F2 had been expected to cover the ward patients for T&O during the day the weekend immediately preceding our visit to NDDH and had received no T&O induction.

2.19       The majority of the trainees reported to us that they were aware that there had been problems regarding work intensity, workload, out of hours support and a lack of communication regarding the rota. The vast majority of trainees still did not understand the rota and had questions regarding how it worked and how it was due to work over the coming months.

Changes planned from February 2015

2.20       The only cross cover that will remain between the T&O rota and the general surgery rota is that the core trainee from general surgery has been tasked with being the resident senior within the hospital to provide immediate cover for the T&O F2 doctor in order to ensure there is always onsite senior support for the foundation doctor.  F1s in T&O will return to day-time hours working only.

Other comments

2.21       The general surgery trainers reported that the rota change had been implemented by trainers in both specialties but that one of the architects of the plan had left the trust at the time of its implementation. They also reported that there had been a feeling within the general surgery department that the rota proposed for August 2014 onwards, that was based on cross cover, would not be sustainable due to workload, “we knew that there wouldn’t be enough doctors around during the day but the rota was put in place despite us raising this.”

2.22       The general surgery trainers now believe that the rota is safe, sustainable, compliant and an improvement on the cross cover rota. No one was able to provide evidence as to the impact on the availability for training of the trainees ie the “Zircadian rota calculations of normal working days” due to the sequential rota changes.

2.23       The T&O trainer, who is also the surgical directorate clinical lead, reported that there had been genuine reasons for wishing to implement a rota change. The trainer reported that there was no policy for the process of changing rotas at NDDH and was surprised that very few of the issues raised to us during the visit had been brought to their attention by the trainees prior to our visit.

2.24       The trainer also explained that the trainees were not owed any additional remuneration for the additional weekends worked as the “extra” work hadn’t changed their banding.

2.25       The trainees reported that they still had not had a face to face meeting with trainers or managers about the present rota and the proposed changes to the rota for February 2015. They had received email communications that they still felt left them confused as to how the rota is due to change and its implications to them and their training.

2.26       General comments were made regarding the need for better rota planning in T&O with regards to allocating rest days in particular, as the current facility for “choice” means that ward coverage and workload is highly variable.

3            Conclusions

3.1          From the information given to us, we concluded that the original motivation for a change to the working arrangements in surgery and T&O was based on sound reasons that related to improving supervision arrangements and managing a service with a changing workforce.

3.2          However, a number of factors meant that the change was perhaps always likely to be unsuccessful e.g. its introduction was rushed, more face-to-face engagement with and support from different staff groups was needed both before and during the process, one of the primary architects of the change left before it was introduced and, a policy for making rota changes was not followed.

3.3          We were assured by the descriptions of the current and planned arrangements that the trainees’ concerns about the changes had been listened to. However, ongoing communication with trainees was still patchy and confusing.

3.4          Trainees generally felt well supported by the supervision arrangements and did not have the concerns about workload and supervision that were expressed at the GMC visit.

3.5          With low-frequency exceptions at a level often found in such trainee groups, overall we found that the trainees were happy to be working in NDDH and recommended their posts and working in the trust.

4            Key recommendations

4.1          NDDH to review and implement its policy on junior doctors rota changes and ensure that it includes the requirements for junior doctor involvement, educational oversight to ascertain whether the rota change significantly affects the training provision, a minimum time interval between new rota publication and its implementation date by June 2015

4.2          NDDH to organise a face to face meeting between members of the senior surgical staff and the junior doctors to explain the rota by end March 2015. NDDH to consider regular departmental fora to improve trainee communication and involvement by April 2015 training.

4.3          NDDH to ensure that there is a mandatory face-to-face departmental induction for every new doctor. In the case of surgery, this must include the role of the surgical core trainee in supervising the T&O F2. By start of April 2015 post.

This will require a robust process to provide induction at every junior doctor changeover. The induction requirements for December F2s, new to the trust, who start their first post in GP, needs particular attention.  By December 2015

4.4          NDDH to provide evidence of the “Zircadian” rota calculation to prove rota compliance, normal working day changes. By March 2015

4.5          NDDH to explain to the trainees affected whether they have been correctly financially remunerated for the increased weekend working frequency that the interim rota changes caused. By March 2015.

4.6          NDDH to clarify the consultant role/presence in handover and ward rounds so that trainees are clear what to expect and duplication is avoided e.g. such as starting ward rounds without consultants and then re-doing them when they arrive. By March 2015.

 

 

Review Chair Declaration

This completed report is a true and accurate account of the discussion that I participated in or were reported to me from this visit.

The key recommendations have been identified within this report have been identified with good faith.

I can confirm that any areas of significant concern and that have a direct impact upon patient safety has been brought to the attention of the relevant Director of Medical Education (or equivalent), responsible Medical Director and Executive Lead for Quality at the South West Peninsula Postgraduate Medical Education.

Chair of visit panel signature:

 

Chair name:

 

Mr Mark Westwood

Chair educational role:

 

Head of School of Surgery

Date of signature:

 

 

 

 

 

 

 

 

 

Peninsula Postgraduate Medical Education Declaration

I as signatory on behalf of the Peninsula Deanery confirm that the information and associated key recommendations provided via this report has been reviewed and deemed appropriate for the purpose as stated.

That key recommendations contained within this report have been documented as part of the quality management processes of South West Peninsula Postgraduate Medical Education and where appropriate will be reported to the General Medical Council (GMC) as required.

Signature:

 

Name:

 

Dr Martin Davis

SWPPME educational role:

 

Associate Dean for Quality

Date of signature: