Clinical Oncology - Level 2 visit report

 

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

Organisation under review: Plymouth Hospitals NHS Trust

Placements reviewed: Clinical Oncology

Date of Review: 24th January 2018

 

BACKGROUND

Reason for Review

The 2017 GMC National Training Survey (NTS) raised 12 red outliers at post level (i.e ranked in the bottom 25% of the country). Amongst others this included adequate experience, overall satisfaction, supportive environment and clinical supervision out of hours. Trainees raising these concerns included those at Foundation, CMT and SpR level.

No. of Learners met

5

No. of Supervisors/Mentors met           

2

Other Staff members met

1 (Deputy Service Line Cluster Manager)

Duration of review

 4 hours

Intelligence sources seen prior to review

2012-17 GMC NTS

2017 Quality Panel data

 

PANEL MEMBERS

Name Job Title
Dr Martin Davis Head of Quality, HEE (Chair)
Dr Alastair Thomson TPD for Oncology, Peninsula
Dr Sarah Rawlinson Head of Foundation School, HEE
Dr Alison Cameron TPD for Oncology, Severn
Mr Martin Cooke Lay Representative
Ms Jane Bunce Quality Manager, HEE

 

EXECUTIVE SUMMARY

A triggered visit was instigated to review the Clinical Oncology programme at Derriford Hospital in response to the 2017 GMC NTS which produced 12 red outliers including adequate experience, overall satisfaction, supportive environment and CS OOH.  Prior to the visit, HEE SW quality panel data (produced several months after the GMC NTS results) indicated that some improvements had been made.  Specialty Training Committee notes indicated the same.  Foundation trainees had previously recorded the posts as requires improvement in two of their end of post surveys; however the quality panel in 2017 graded the posts as good, showing a slight improvement. 

Overall the panel were reassured by the feedback the trainees, currently in post, gave about their training environment.  Clinical workload for supervisors, within the department, remains high and therefore there is potentially an impact on their educational supervision time. However there is good engagement with the ethos of good quality training.  The panel were reassured that the learning environment was fit for purpose. It was recognised that, at the time of the GMC NTS, events and thereby consequences had existed to impact on the poor quality feedback contained in the survey.  Whilst recognising the good work that the department has done to rectify areas of concern, a number of requirements and recommendations are included within the report which are required to be addressed.  

REPORT SIGN OFF

Outcome report completed by (name) Jane Bunce / Dr Martin Davis
Chair's signature Dr Martin Davis
Date signed 19th March 2018
 
HEE authorised signature Dr Martin Davis
Date signed 19th March 2018
Date submitted to organisation 19th March 2018

 

 ORGANISATION STAFF TO WHOM REPORT IS TO BE SENT

Job title Name
Director of Medical Education Dr Matthew Bowles
Deputy Director of Medical Education  Dr Peter Davies
Deputy Service Line Cluster Manager Ms Kelly Haynes-Brown
Educational Supervisor Dr Rebecca Goranova
Educational Supervisor Dr Geoffrey Cogill

 

RISK SCORES

Scores prior to review 4x3 = RED
Proposed scores following review

4X4 = RED (due to patient safety issue)

2x3 = GREEN (one patient safety issue resolved)

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 to action? 
Mr Matthew Bowles, DME; Dr Peter Davies, DDME and Dr Phil Hughes, Medical Director
Brief summary of concern

A patient safety issue was brought to the attention of the panel by a Foundation trainee and which requires urgent attention. The panel were informed that medical outliers on the Oncology ward (Brent) do not have a named consultant who accepts responsibility for their ongoing care. The foundation doctors looking after them on the ward therefore do not know to whom they should escalate issues. The panel understood that because they are on a ‘medical ward’ (Oncology) there is an assumption that the Oncologists will take responsibility, if this is the assumption it doesn’t happen.

The Trust should look into this as a matter of urgency.   It is possible that a process exists which is unclear to the Foundation doctors working in the department.

Clarity about the arrangements for radiotherapy prescription required for out of hours prescribing when a medical oncologist is the name on the on-call consultant rota.

 

EDUCATIONAL REQUIREMENTS

Related Domain(s) & Standards Theme 1, 2, 3, 4 & 5
Summary of findings There is currently no service line lead. This leads to a lack of clarity and sense of direction from a clinical perspective.
Required action

The department should continue its efforts to recruit to this role. In the absence of a clinical service lead the educational lead should not be disempowered to make necessary changes to the training programme when these arise.

 

Related Domain(s) & Standards

Theme 1, 2, 3, 4 & 5
Summary of findings There is currently no dedicated foundation lead in the department to support foundation trainees and ensure the regulatory standards of training are met.
Required action

The department should appoint a dedicated foundation lead. This can be amalgamated with the educational lead role for SpR training assuming time to undertake the activity is identified.

 

Related Domain(s) & Standards

Theme 1 & 3
Summary of findings Foundation trainees are regularly pulled away from the ward to other medical specialties.
Required action

The impact on their training placement needs assessing. The movement should be equitable with other areas. Induction and supervisory arrangements for their work in another area should be clear.

 

 

EDUCATIONAL RECOMMENDATIONS

Related Domain(s) & Standard(s)

Either Regulatory or HEE

Summary of findings
  • There were concerns that the hours worked by the current registrars are not a true reflection of their work schedules. This presents a risk to the department with a new cohort of registrars. The department ought to consider mitigating this risk, for example, by a lead consultant ensuring the continuation of the systems implemented beyond the current cohort.
  • The department should consider how to ensure a culture exists whereby trainees feel able to ask any consultant for advice, where appropriate, without feeling they may receive an unsupportive response.

 

 

GOOD PRACTICE 

Good practice is used as a phrase to incorporate educational or patient care initiatives that are worthy of wider dissemination, deliver the very highest standards of education and training or are innovative solutions to previously identified issues worthy of wider consideration.

Learning environment / Prof. group / Dept. / Team  Good practice Related Domain(s) & Standard(s)
  The trainees were positive about their training and the working environment.  
  There was enthusiasm and willingness from the recently appointed trainers to ensure a good quality training environment.  

 

 

Summary of discussions with groups

Learners

 

The panel saw 5 trainees in total.  Initially 4 SpRs were seen followed by 1 Foundation trainee.

 

Higher trainees

Overview

The trainees confirmed that they were all very comfortable with their training experience.  They were aware of the significant difficulties faced by the department last year, caused by retirement, resignations and a death within the senior clinical workforce. They felt significant change had since taken place since Spring of 2017.

Prior to the positive changes, one trainee commented that the service element of the post dominated and it was very busy.  The introduction to the department was not good, a consultant was not always available and they had felt thrown in at the deep end.  Training opportunities had been difficult to find.  Conversely, a trainee who started in August described the post as ‘brilliant’ and said they had no issues when they started in post.  The trainees present reported that now they generally feel well supported and the two educational leads sit down with trainees to establish learning needs. There is help with preparation for postgraduate exams.  The department was described as working well as team.

Trainees said that the department is a really good place to train and when asked if they would recommend the post to a friend, they said they were more likely to try and swap with the friend so they could stay.

 

Workload

Trainees reported that they felt able to keep on top of day to day workload.  They are able to ask anyone for advice.  If a particular consultant is off work, they are able to get help elsewhere.

The core number for the department is 4 and it reportedly feels well-staffed.  However it was reported that other wards short of staff will call Foundation trainees away from the department, which can impact on the workload of other staff within oncology. 

There is a registrar on call every day.  Board rounds take place at 9am and 3pm every day.  The department also has an Advanced Nurse Practitioner who was described as very good.

The SpRs confirmed they are generally happy to complete SLEs for foundation trainees but this had probably been more difficult lately due to exam preparation.  Consultants are also reportedly willing to undertake SLEs but not always approached by trainees.

 

On call

Out of hours is 1 in 7, working a full day Saturday and ¾ of a day on Sunday.

There are 2 medical oncologists who are part of the senior on call rota.  They are not able to prescribe radiotherapy.  This hasn’t resulted in a clinical incident but in theory this is possible.

Trainees confirmed that they have a day off before being on call at the weekend.

 

Clinics

Trainees are able to get to clinics – 2 acute and 2 radiotherapy.  They do 2 sessions a week of radiotherapy planning, both on their own and with a consultant.  90% of the radiotherapy plans are discussed with a consultant.  Consultants are happy to check palliative plans but trainees typically only have around 1% checked.  Due to there being a registrar on call, trainees are able to work in clinic without disturbance from dealing with urgent clinical issues.  There is also 1 trust grade doctor in clinic on a similar rota to trainees.

 

Teaching

Teaching takes place on Tuesday lunchtime and is bleep free.  Consultants attend and it is focussed on preparation for postgraduate exams.  Teaching also takes place on Monday at 8am for one hour.  This is not part of the fixed commitment of the individuals involved. It is appreciated by the trainees.

Regional teaching can be difficult to attend due to rotating between Severn, Peninsula and Wales.  Ideally the trainees would want a session once every two months.  The registrar clinic is cancelled on the day of regional teaching to allow attendance, although the registrar on call would not be able to attend.  In theory sessions could be attended virtually, but generally those present felt they would prefer to have the opportunity to meet up with colleagues.

The trainees reported many opportunities for research and subsequent publications. This achieved either in their admin time or more often outside of their working hours.

 

Summary

  • It was agreed that there had been problems in the department at the time of the 2017 GMC NTS.
  • The Clinical Oncology programme at Derriford Hospital is now meeting most of the regulatory standards.
  • Trainees confirmed that it was a supportive environment in which to work.
  • There were no issues with bullying and undermining.
  • The induction to radiotherapy was good and the radiographers were described as excellent.
  • If trainees could change anything:  (1) recruit more training registrars – there is a difficulty recruiting staff grades, but if training jobs they felt these would be filled (2) increase the lunchtime teaching from 1 hour.

 

Foundation

There are 5 foundation trainees in the department.  There are approximately 30 beds and the foundation doctors cover the on call hospital rota.  F1s don’t do any nights, but F2s do some nights.

In the last 6 weeks, the trainee in attendance confirmed that they had been called away to work on another medical ward 3-4 times.  Notification of the move is usually received on the day and might be half way through the day or a ward round.  Issues are that the trainee will not know the patients and it is likely to be very busy with an expected finish time of around 6pm.  A named medical consultant will supervise and a CT2 may also be available.  The trainee felt that there was an appropriate escalation process in place.

A patient safety issue was brought to the attention of the panel by a Foundation trainee. The panel were informed that medical outliers on the Oncology ward (Brent) do not have a named consultant taking responsibility for their care allocated to them. The foundation doctors looking after patients on the ward therefore do not know to whom they should escalate issues. The panel understood that because they are on a ‘medical ward’ (Oncology) there is an assumption that the Oncologists will take responsibility, if this is the assumption it doesn’t happen.

The trainee confirmed that the majority of time has been spent on oncology and in most instances will be able to provide continuity for a patient through their hospital stay.  The trainee felt part of the team and appreciated.

No formal induction was received. 

The team was extremely welcoming and friendly.

The time of consultant ward rounds can vary.  Foundation trainees split patients between them which may mean covering a number of different consultant’s patients.  Due to night shifts and being moved to other wards, foundation trainees may need to alter which patients they have responsibility for.  This can lead to a lack of consistency and continuity.  The consultants and registrars provide the continuity and senior reviews take place 2-3 times a week.  It was agreed by those present that the on call registrar system has helped the foundation trainees, as has the Advanced Nurse Practitioner.

Whilst it is fully understood that trainees can call consultants, the preference tends to be to call the registrar as there is reticence to call a consultant.

Having SLEs completed is difficult but not impossible.

The trainee confirmed that a named CS had been allocated when started in post.

The trainee confirmed he would recommend the post and described it is as valuable.  Conducting own ward rounds had been unexpected but escalation routes are known.  However the timely availability of a consultant can lead to delays in management to the detriment of patient outcomes.

The Foundation trainees can attend weekly teaching and have learnt about radiotherapy.

 

Supervisors

The panel saw 2 trainers.

 

It was acknowledged that at the time of the 2017 GMC NTS the department was very short staffed and as such training had suffered.  Since then 4.7 full time oncologists have been appointed.  There are still 3 full time vacancies but the department is far more stable.  At the time of the visit there was an advert open until the end of January to try to recruit to the remaining vacancies. 

GC confirmed that at the time of the poor GMC NTS results, 1 consultant had died, 1 had left and another had retired.  The department could not recruit staff grades and the remaining consultants were spending their time trying to deliver the service.  They provided on-the-job supervision but other aspects of training deteriorated.  At the same time coincidentally the regional teaching also broke down.

 

Teaching

The trainers confirmed that there is regular weekly lunchtime teaching sessions and structured exam preparation is taking place once a week.

Notice of regional teaching sessions can be with less than 6 weeks which makes clinic adjustments difficult. Sufficient notice of training days is required ideally 12 months in advance.

 

Supervision

The trainers described the department as ‘very caring’ in terms of day-to-day supervision.  Everyone knows each other and all are onsite and easy to access.  If there is a problem with patient care, there is always a consultant on call.  All trainees have a named supervisor.

The 2 supervisors present unofficially share the role of educational lead for the department.  Time for supervision is allocated in their job plans at 0.125 PA per trainee.

There is currently no service line lead within the department as with current workload, no-one is willing to take the role on. 

The panel observed that there seems to be less ownership of the foundation trainees within the department and a dedicated departmental lead for foundation trainees is needed. However, there did appear to be support in place for trainees if they had specific issues.

The majority of consultants are available via mobile phone.  It was acknowledged that some trainees are very good at contacting consultants by phone but others can be reticent.  The trainers recognised a need to encourage them further. 

Both trainers present were happy to be approached by trainees to complete assessments and were not aware of anyone unwilling to do so.

 

Workload

It was acknowledged that Foundation is a problem.  There should be 5 on the ward and core numbers are 4.  This can drop to 3 trainees and although the department try to protect them from being moved to other wards, they also have a responsibility to support colleagues elsewhere in medicine.  They would like to feel that the foundation doctors feel part of the team and are well supported.  They do however do one month of palliative care off site.

Due to the problem recruiting staff grades, the department has extended nursing roles.  The introduction of more consultants has significantly improved the situation and they continue to develop non-career grade roles to help with service on wards and outpatients.

 

Induction

At the time of the visit it was believed that a registrar organises the induction for foundation trainees.  The registrars are provided with an induction pack.  A session is provided on chemotherapy and computer use.  The panel observed some uncertainty about who organises and what the plan would be when the current registrar leaves.  Subsequent to the visit, it was confirmed that departmental induction is organised by Kelly Haynes-Brown who has undertaken this duty for some time.  An induction is arranged for each new trainee and a record is kept.  Kelly is able to ensure continuity of the process.

 

Management

One member of the management team attended.

It was confirmed that the rotas are compiled by the registrars and the whole team has input in to making it work.

It was confirmed that the rota office regularly approaches the management team to borrow juniors when other departments are below core numbers.  Overall there are 20 medical vacancies across the trust which is difficult to manage.  The management is very protective of the registrars as can’t cancel outpatient clinics.  The frequency with which foundation trainees are called away from the ward is unpredictable but roughly once every two weeks.  When they are pulled away, they could be placed anywhere within medicine.  Before anyone is moved a consultant has to approve the arrangement to ensure patient safety.  If above core numbers, the department is expected to help, if below, it will depend on the patient list.  KH-B was not aware of the ‘green weeks’ which are designated periods when trainees cannot be moved from their department.

As much study leave as possible is granted by the department.  The Advanced Nurse Practitioner will cover the on call bleep and the on call registrar will have to stay behind.

Trainees are encouraged to exception report but as far as KH-B was aware, the department has not received any.

It was acknowledged that the current registrars are particularly enthusiastic.  The panel had concerns that when the department has a different cohort of trainees in the future they may encounter problems fitting the current work patterns into a compliant work schedule.

It was confirmed that the department is working on recruiting a service line lead.  The role attracts 2 PAs and would mean a consultant dropping clinical activity if they were to undertake the role.  The department is in agreement that the role is needed but to date there has been reluctance from individuals to take this on.  In the interim, staffing issues are going to KH-B. 

 

Date of report: 14th February 2018

Author: Jane Bunce/Dr Martin Davis

Job Title: Quality Manager / Head of Quality