Postgraduate School undertaking visit : South West Peninsula Post Graduate Medical Education

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

Provider visited : South Devon Healthcare NHS Foundation Trust

Date(s) of visit : 27.1.2014

Visit team (names and educational job titles)

Chair

Mark Westwood, Head of School of Surgery

Panel member 1

Mark Medcalf, TPD for ENT, SWPPME( absent for general surgery, T&O, urology)

Panel member 2

Esther McLarty, TPD for Core Surgical Training, SWPPME

Panel member 3

Patricia Boorman, TPD for General Surgery, SWPPME (absent for T&O)

Lay representative

Maria Harding

Programme

No. of trainees seen

No. of trainers seen

Surgery

Core Surgery:3

ENT: 1

General Surgery: 5

Trauma & Orthopaedics: 4

Urology: 1

ENT: 1

General Surgery: 5

Trauma & Orthopaedics: 4

Urology: 2

Evidence considered prior to review taking place: SWPPME pre-visit report, previous GMC NTS reports

Date visit report ratified by HESW – Peninsula

12^th September 2014

Date visit report made available to provider

12^th September 2014

Date provider ratifies visit report

23^rd September 2014

Circulation of this report: Peninsula Postgraduate Medical Education Quality Team, Director of Medical Education

Key recommendations

1

Improve quality of induction provided to core trainees from gynaecology.

2

Address undermining and bullying in orthopaedic theatres.

3

Improve operative exposure in colorectal surgery.

4

Improve operative training opportunities from one elective orthopaedic job.

5

Improve supervision for urology trainees in outpatient clinics and theatre lists.

6

Formalise handover process for urology and ENT registrars.

Department / Programme / Specialty

Area of good practice

All

All trainees from all specialties reported that they felt very well supported from their trainers as an overall subjective impression.

Trauma & Orthopaedics

Core & Higher surgical trainees in trauma & orthopaedics felt particularly valued & appreciated by their trainers. Particularly the involvement and support of trainees in clinical decision making.

ENT

Teaching and training was considered to be excellent by the trainee. The overall support by the trainers towards the trainee achieving learning objectives was specifically praised by the trainee.

Core surgery

Induction provided by ENT was considered to be excellent by the trainees. It was thorough, timely and very well targeted at the trainees’ needs.

Core surgery

Excellent training provided by vascular surgery trainers. The trainees at core level were very impressed by the surgical opportunities they had been given.

Patient safety inc. handover and induction

Trainees did not report any patient safety concerns.  Whilst, most departments had robust and routine hand over arrangements from shift to shift, Urology and ENT did not have a routine, formal handover process for registrars.

All trainees reported that they had not been asked to take consent from patients outside their level of competence.

Most trainees had a satisfactory induction. The induction for hospital at night doctors covering gynaecology was considered unsatisfactory and not tailored to the needs of the core surgical trainees who had attended.

A trauma & orthopaedic trainee reported missing the ENT induction due to being on call. Another core trainee felt that induction was too brief for someone who had not worked in the NHS before.

Department / Programme / Specialty

Area of development

Hospital at Night (Gynaecology)

Review induction provided to hospital at night core trainees from ENT and as well as that provided to Trauma & Orthopaedics trainees who cross cover gynaecology.

Urology

Formalise process of handover from registrar to registrar at shift changes.

ENT

Formalise process of handover from registrar to registrar at shift changes.

Core surgery / trauma & orthopaedics

Ensure that trainees attend departmental induction and that induction is of sufficient quality to be valuable for trainees if they have not worked in the NHS before

Supervision – clinical and educational (inc. career guidance, feedback)

All trainees felt that they were well supported by their trainers. They all had been assigned a educational supervisor who they met regularly with.

All trainees report that they receive regular, appropriate feedback from their trainers.

A trainee in urology felt that whilst undertaking appropriate duties for their training level, there were occasions on which she has conducted unsupervised lists that she felt uncomfortable with.  The trainee also reported that she conducts some clinics unsupervised, with no routine way of going through the cases seen with a consultant. In addition, the trainee felt that it was not always clear which consultant to call when working unsupervised. However, as a rule the on call consultant for the week is normally contacted.

A core trainee informed of an occasion where they were unable to contact an associate specialist who was acting as middle grade on call at a weekend. The trainers in that specialty (T&O) were already aware of this issue and had addressed it, since which time the situation had not recurred.

Department / Programme / Specialty

Area of development

Urology

Ensure that trainees have access to adequate and appropriate supervision.  Match level of case complexity more closely to trainee competence when requiring trainees to perform unsupervised lists or cease unsupervised lists

Urology

Ensure that trainees have access to adequate and appropriate supervision during outpatient clinics.

Trauma & orthopaedics / core surgery

Ensure that trainees have access to adequate and appropriate supervision while working on-call.

Training environment (inc. access to educational resources)

The training environment was generally considered to be good by the trainees, with the facilities available at the Horizon Centre singled out for particular praise.

Department / Programme / Specialty

Area of development

Work load

All trainees reported that their work load was generally acceptable.

A urology trainee felt that training could be improved by reducing the number of patients seen in clinics. The panel was informed that a LAS has recently been employed to ease this pressure

A urology trainee reported that there is a discrepancy over what the acceptable procedure is for dealing with overnight retentions when sharing the on-call with General Surgery. This discrepancy is most keenly noticed with one particular general surgical consultant. A meeting between the two departments has been called to resolve this.

Department / Programme / Specialty

Area of development

Urology

Reduction in numbers to be seen by trainee in outpatient clinics to manageable levels to ensure that training quality is not compromised.

Urology

Resolve expectations between urology and general surgery trainers over management of urology out of hours admissions, with particular reference to one general surgeon’s expectations of the urology trainees on call overnight.

Adequate experience / achievement of curriculum competencies

The general surgical higher speciality trainees felt that the overall standard of training was good, however, whilst there was adequate operative experience available in elective surgery, there were some minor concerns over the low volume and low breadth of cases available within Vascular surgery.

The trainees reported that, in colorectal surgery, whilst there are a lot of opportunities to assist, there are limited opportunities for operating as the primary surgeon. This issue has been raised with the consultants. One trainee stated that they would not recommend the colorectal training post to colleagues, due to the low operative experience provided. The remaining two Colorectal trainees agreed that they did not feel that they had progressed operatively. The Colorectal Trainees reported that operative opportunities were available, but the allocation of these opportunities is dependent on the trainer that you work with, with some consultants identifying training cases from lists more successfully than others.

Core surgical trainees report that they typically get  3- 5 sessions of theatre time per week. Both the trainees and the panel were satisfied with this and believe this represents acceptable exposure. The trainees report that there are 4 surgical care practitioners within the department, and that they feel that some consultants have a preference for working with the surgical care practitioners (SCPs) to the core trainees which limits their operative experience.

The T&O HSTs also reported that SCPs often assist hip lists, which would be a good training opportunity for trainees The trauma & orthopaedic trainees also reported that whilst they considered the shoulder post as excellent, it provided limited opportunities in outpatients for trainees to see new patients, who were typically seen by consultants. Conversely, trauma and orthopaedic trainees were very positive about the training opportunities and experiences provided by particular placements and trainers, in particular foot and ankle posts and Mr Davis and Mr Wansborough

The trauma & orthopaedics trainees reported that one of the posts that they had rotated through provided very little elective operative exposure. Two consecutive trainees in this post reported 0 and 6 total hip replacements, respectively, in a hip specialty job. The panel agreed that the exposure to elective operating in that post was not acceptable. The trainers were made aware of this and the TPD for trauma & orthopaedics reassured the panel that this would be addressed. The hip post was considered to have limited case numbers.

Department / Programme / Specialty

Area of development

Vascular Surgery

Review concerns regarding low volume and low breadth of cases

Colorectal surgery

Increase primary surgeon operative opportunities for trainees.

Trauma & Orthopaedics

Ensure that core trainees have sufficient exposure to learning opportunities in theatre and avoid subjugating their training compared to that provided to the surgical care practitioners.

Trauma & Orthopaedics

Increase trainee exposure to new patients in shoulder clinics.

Trauma & Orthopaedics

Address the sub-optimal exposure to elective operating in one specific job with one specific trainer.

Teaching – local, regional and study leave

The trauma & orthopaedic trainees at core and higher levels report that at present there is no formal local orthopaedic teaching, although there is reasonable informal teaching available if you go and look for it.

The general surgical trainees report that a formal local teaching programme operates on Tuesdays. However there are consistent problems with attending these sessions due to rota commitments. Due to the low number of attendees the teaching programme has been tailored by the organiser to suit the educational requirements of those who can attend.

The general surgical trainees report that they are generally released for regional training days, but attendance is dependent on on-call rotas. One trainee has not been able to attend any training days due to such commitments.

Trauma & orthopaedic trainees reported good quality teaching in trauma meetings and clinics generally, with teaching from Mr Wansborough particularly commended. However, fracture clinics are normally performed with very limited interaction between the trainee and trainer, consequently minimal teaching occurs within this environment. Whilst there is no local teaching programme for Trauma & Orthopaedics, the regional teaching programme was highly praised for its format, focus on the exam, content and delivery.

Department / Programme / Specialty

Area of development

Core surgery

Formal local teaching programme needs to be provided and accounted for in the rota of trainees.

General surgery

Ensure attendance of trainees at local and regional teaching sessions.

Trauma & orthopaedics

Develop and implement a local teaching programme.

Trauma & orthopaedics

Improve communication and interaction between trainees and trainers in fracture clinic, in order to improve teaching.

Bullying and harassment

The core trainees reported that whilst the atmosphere in the hospital was generally very good, orthopaedic theatre is viewed differently. An example provided was that on one occasion a core trainee was in a busy staff room and was aggressively asked to move by a theatre sister so that she could sit down and have her lunch. The core trainees felt that in the orthopaedic theatres they were often treated as second class citizens.

The higher surgical trauma and orthopaedic trainees reported that they always feel welcomed in orthopaedic theatre, but had witnessed episodes of behaviour by the orthopaedic theatre staff towards core trainees that they felt was unpleasant and could be easily construed as undermining and bullying. The trainers were made aware of this during the school visit.

Department / Programme / Specialty

Area of development

Trauma & orthopaedics / core surgery

Actively investigate and address allegations of undermining and bullying by orthopaedic theatre staff towards trauma and orthopaedic core trainees.

Additional comments / feedback

The ENT trainee covers patients at Royal Devon and Exeter hospital out of hours at weekends. Whilst the present trainee has previously worked in Exeter and is very able to provide this cover, the panel had concerns over how robust the induction, supervision, senior support would be if the trainee was more junior and had not worked in the RD&E in the past.

Department / Programme / Specialty

Area of development

ENT

Ensure there is a clear known agreement regarding cross-cover with the RD&E, identifying clear arrangements for trainees, including induction to both departments and clearly identifying the supervision arrangements out of hours and the contact arrangements.

Chair name:

Mr Mark Westwood

Chair educational role:

Head of School for Surgery

Date of signature: